[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
EXAMINING QUALITY OF LIFE AND
ANCILLARY BENEFITS ISSUES
=======================================================================
HEARING
before the
SUBCOMMITTEE ON DISABILITY ASSISTANCE AND
MEMORIAL AFFAIRS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
JULY 23, 2009
__________
Serial No. 111-37
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas VERN BUCHANAN, Florida
JOE DONNELLY, Indiana DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
JOHN J. HALL, New York, Chairman
DEBORAH L. HALVORSON, Illinois DOUG LAMBORN, Colorado, Ranking
JOE DONNELLY, Indiana JEFF MILLER, Florida
CIRO D. RODRIGUEZ, Texas BRIAN P. BILBRAY, California
ANN KIRKPATRICK, Arizona
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
__________
July 23, 2009
Page
Examining Quality of Life and Ancillary Benefits Issues.......... 1
OPENING STATEMENTS
Chairman John J. Hall............................................ 1
Prepared statement of Chairman Hall.......................... 34
Hon. Doug Lamborn, Ranking Republican Member, prepared statement
of............................................................. 35
WITNESSES
U.S. Department of Veterans Affairs, Bradley G. Mayes, Director,
Compensation and Pension Service, Veterans Benefits
Administration................................................. 26
Prepared statement of Mr. Mayes.............................. 66
______
Blinded Veterans Association, Thomas Zampieri, Ph.D., Director of
Government Relations........................................... 6
Prepared statement of Dr. Zampieri........................... 40
Bristow, Lonnie, M.D., Chair, Committee on Medical Evaluation of
Veterans for Disability Benefits, Board on the Health of Select
Populations, Institute of Medicine, The National Academies..... 11
Prepared statement of Dr. Bristow............................ 44
Economic Systems Inc., Falls Church, VA, George Kettner, Ph.D.,
President...................................................... 13
Prepared statement of Dr. Kettner............................ 46
National Organization on Disability, Carol A. Glazer, President.. 17
Prepared statement of Ms. Glazer............................. 57
National Veterans Legal Services Program, Ronald B. Abrams, Joint
Executive Director............................................. 5
Prepared statement of Mr. Abrams............................. 39
Paralyzed Veterans of America, Carl Blake, National Legislative
Director....................................................... 3
Prepared statement of Mr. Blake.............................. 35
Quality of Life Foundation, Woodbridge, VA, Kimberly D. Munoz,
Executive Director............................................. 15
Prepared statement of Ms. Munoz.............................. 54
SUBMISSIONS FOR THE RECORD
Sarah Wade, Chapel Hill, NC, statement........................... 70
MATERIAL SUBMITTED FOR THE RECORD
George Kettner, Ph.D., President, Economic Systems Inc., to Hon.
John J. Hall, Chairman, Subcommittee on Disability Assistance
and Memorial Affairs, Committee on Veterans' Affairs, letter
dated July 27, 2009, and attached Extension of Remarks......... 73
Bradley G. Mayes, Director, Compensation and Pension Service,
Veterans Benefits Administration, U.S. Department of Veterans
Affairs, Fast Letter 09-33, to Director, All VA Regional
Offices and Centers, regarding Special Monthly Compensation at
the Statutory Housebound Rate, dated July 22, 2009............. 74
EXAMINING QUALITY OF LIFE AND ANCILLARY BENEFITS ISSUES
----------
THURSDAY, JULY 23, 2009
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Disability Assistance
and Memorial Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. John Hall
[Chairman of the Subcommittee] presiding.
Present: Representatives Hall and Lamborn.
Mr. Hall. Good morning, ladies and gentlemen. The Veterans'
Affairs Disability Assistance and Memorial Affairs Subcommittee
hearing on Examining Ancillary Benefits and Veterans' Quality
of Life (QOL) Issues will now come to order.
I would ask that we all rise for the Pledge of Allegiance.
[Pledge of Allegiance.]
Mr. Hall. Thank you very much.
I am going to defer my statement until after Congressman
Lamborn, our Ranking Member, makes his because he has a double
booking and needs to leave to take care of that business.
So, Mr. Lamborn, you are recognized.
Mr. Lamborn. Yes. Thank you, Mr. Chairman, for taking me
out of order. And I will submit my statement for the record.
I wish I could be in two places at once. This is a vital
topic. But since I cannot, I am going to have to be here only
momentarily so that we can have the quorum and start the
meeting officially.
I do look forward to hearing the written comments from each
witness and I will be looking at those.
Thank you and I know it will be a good hearing.
[The prepared statement of Congressman Lamborn appears on
p. 35.]
OPENING STATEMENT OF CHAIRMAN HALL
Mr. Hall. Thank you, Mr. Lamborn.
This Subcommittee has actively tackled many complex and
complicated issues that have been encumbering the Veterans
Benefits Administration (VBA) and its ability to properly
compensate veterans who file disability claims.
These issues have centered on U.S. Department of Veterans
Affairs (VA) business processes and operations. Today's hearing
will focus on the actual appropriateness of available benefits
in meeting the needs of disabled veterans and their families.
The expressed purpose of VA disability compensation as
outlined in law (38 U.S.C. Sec. 1151) is based upon the average
impairment of earning capacity. This concept dates back to the
1921 rating schedule which had its roots in the then blossoming
Workmen's Compensation Program.
Then, the primary concern was to ensure that the disabled
World War I veterans would not become a burden on their
families or communities when they could no longer perform the
laborious tasks most civilian occupations required at that
time.
Over the years, Congress has added several elements to the
VA compensation package to assist disabled veterans in
procuring shelter, clothing, automotive, employment, vocational
rehabilitation, and in-home assistance.
In its expansion of these benefits, Congress has attempted
to meet disabled veterans' and their families' social and
adaptive needs and not solely their economic needs.
More recently, several commissions and institutions, a few
of whose members we will hear from today, have studied the
appropriateness of VA benefits, including a potential quality
of life loss payment.
They have identified significant challenges in developing
an instrument or rating schedule that could fairly calculate
compensation for the loss of quality of life.
Much of what makes a life of quality is subjective and goes
beyond fulfilling basic human needs or replacing impaired
income.
Furthermore, I realize that there is no amount of money
that can replace a limb or peace of mind. Ensuring that
veterans impaired by amputation, blindness, deafness, brain
injury, paralysis, and emotional distress are afforded the
necessary resources to lead productive, satisfying lives is the
debt a grateful Nation owes these brave souls.
VA has, in fact, attempted to recognize that in order to
make some veterans whole, there is a need to provide additional
compensation that accounts for noneconomic factors, including
personal inconvenience, social inadaptability, and the
profoundness of their disability.
Part of the problem may be that the formula and criteria
used for adjudicating VA ancillary benefits and special monthly
compensation is complex and often confusing to the
beneficiaries themselves. Oftentimes disabled veterans are
unsure of this added benefit, which leads to an inability to
predict or plan for their future based on their VA assistance.
Without transparency, transitioning wounded warriors are at
a severe disadvantage if they cannot count on and predict their
VA benefits package. Having this knowledge could be a big help
to these veterans and more transparency and outreach is
definitely needed in the ancillary benefits area.
I am eager to hear from today's witnesses, many of whom are
experts in the complexities and paradigms for compensating
military-related disabilities.
I am also eager to hear from VA on its late-delivered VBA
response to the Economic Systems (EconSys) quality of life,
earnings loss, and transition payment study, which was mandated
in section 213 of Public Law 110-389.
Our veterans must be returned to their country,
communities, and homes with the tools and resources to rebuild
a life of quality.
So as we go forward, I once again remind all of our
panelists that your complete written statements have been made
a part of the hearing record. Please limit your remarks to 5
minutes so that we may have sufficient time to follow-up with
questions once all of our witnesses have had the opportunity to
testify.
On our first panel, which I would call now to the table, is
Mr. Carl Blake, National Legislative Director for Paralyzed
Veterans of America (PVA); Mr. Ronald B. Abrams, Joint
Executive Director for National Veterans Legal Services Program
(NVLSP); and Mr. Thomas Zampieri, Ph.D., Director of Government
Relations for Blinded Veterans Association (BVA).
Welcome, Mr. Blake, Mr. Abrams, and Mr. Zampieri. It is
good to see you all again. Thank you for coming to testify
before us.
Mr. Blake, you are now recognized for 5 minutes.
[The prepared statement of Chairman Hall appears on p. 34.]
STATEMENTS OF CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR,
PARALYZED VETERANS OF AMERICA; RONALD B. ABRAMS, JOINT
EXECUTIVE DIRECTOR, NATIONAL VETERANS LEGAL SERVICES PROGRAM;
AND THOMAS ZAMPIERI, PH.D., DIRECTOR OF GOVERNMENT RELATIONS,
BLINDED VETERANS ASSOCIATION
STATEMENT OF CARL BLAKE
Mr. Blake. Thank you, Mr. Chairman.
Mr. Chairman, Members of the Subcommittee, on behalf of
Paralyzed Veterans of America, I would like to thank you for
the opportunity to testify today on what we consider a very
important topic, particularly for PVA's membership, that being
ancillary benefits and quality of life issues.
PVA members represent one of the segments of the veteran
population that benefit most from the many ancillary benefits
provided by the VA. Without the provision of benefits such as
special monthly compensation or SMC, specially adapted housing
grant, and the clothing allowance, our members and other
severely disabled veterans would experience a much lower
quality of life and would in many cases be unable to live
independently.
Special monthly compensation represents payments for
quality of life issues such as loss of an eye or limb, the
inability to naturally control bowel and bladder function, or
the need to rely on others for the activities of daily living
like bathing or eating.
To be clear, given the extreme nature of the disabilities
incurred by most veterans in receipt of SMC, we do not believe
that the impact on quality of life can be totally compensated
for. However, SMC does at least offset some of the loss of
quality of life.
PVA believes that an increase in SMC benefits is essential
for our veterans with severe disabilities. Many severely
injured veterans do not have the means to function in an
independent setting and need intensive care on a daily basis.
To support our recommendation, we encourage the
Subcommittee to review the recommendations of the Veterans'
Disability Benefits Commission (VDBC) report.
One of the most important SMC benefits to PVA is aid and
attendance. PVA would also like to recommend that aid and
attendance benefits be appropriately increased. Attendant care
is very expensive and often the aid and attendance benefits
provided to eligible veterans do not cover this cost.
In accordance with the recommendations of the Independent
Budget (IB), PVA also believes that there are some necessary
improvements in the Service Disabled Veterans' Insurance (S-
DVI) and Veterans' Mortgage Life Insurance (VMLI) programs.
We recently supported legislation considered by this
Subcommittee, H.R. 2713, that would increase the maximum amount
of protection from $10,000 to $100,000 and would increase the
supplemental insurance for totally disabled veterans from
$20,000 to $50,000.
Ultimately, we would like to see the Subcommittee consider
legislation that would increase S-DVI to the maximum benefit
level provided by the Servicemembers' Group Life Insurance
(SGLI) and Veterans' Group Life Insurance (VGLI) programs.
The Independent Budget also recommends that VMLI, veterans
mortgage life insurance, be increased from the current benefit
of $90,000 to $150,000. The last time VMLI was increased was in
1992. Since that time, housing costs have risen dramatically,
but the VMLI benefit has not kept pace. As a result, many
catastrophically disabled veterans have mortgages that exceed
the maximum value of VMLI.
Recent hearings have demonstrated how far behind the VBA is
in using information technology in its claims adjudication
process. While we believe that the entire claims process cannot
be automated, there are many aspects and steps that certainly
can.
We have long complained to the VA that it makes no sense
for severely disabled veterans to separately apply for the many
ancillary benefits to which they are entitled. Their service-
connected rating immediately establishes eligibility for such
benefits as the specially adapted housing grant, adapted
automobile equipment, and education benefits. However, they
still must file separate application forms to receive these
benefits. This just makes no sense whatsoever.
Mr. Chairman, one of the subjects that often generates a
great deal of debate when discussing VA compensation benefits
is the consideration of quality of life.
PVA has expressed serious concerns in the past,
particularly during the deliberations of the Veterans'
Disability Benefits Commission and the Dole-Shalala Commission,
with the assertion that the schedule for rating disabilities
are meant to reflect the average economic impairment that a
veteran faces.
Disability compensation is, in fact, intended to do more
than offset the economic loss created by a veteran's inability
to obtain gainful employment. It also takes into consideration
a lifetime of living with a disability and the every-day
challenges associated with that disability. It reflects the
fact that even if a veteran holds a job, when he or she goes
home at the end of the day, that person is still disabled.
There can be no question but that VA compensation includes
a real and significant component that is provided as an
attempted response to the impact of a disability on the
disabled veteran's quality of life. And, yet, we would argue
that compensation could never go too far in offsetting the
impact that a veteran's severe disability has on his or her
quality of life.
PVA would once again like to thank you, Mr. Chairman, for
allowing us to testify and I would be happy to answer any
questions that you might have.
[The prepared statement of Mr. Blake appears on p. 35.]
Mr. Hall. Thank you, Mr. Blake.
Mr. Abrams, you are now recognized for 5 minutes.
STATEMENT OF RONALD B. ABRAMS
Mr. Abrams. Thank you, Mr. Chairman.
NVLSP would like to focus on the quality of life increased
payments under 38 U.S.C. Sec. 1114(s). Essentially SMC(S) is
paid to veterans who have a total disability and have
independent service-connected conditions that amount to 60
percent or more.
A recent decision by the U.S. Court of Appeal for Veterans
Claims (CAVC), the veterans' court, called Bradley v. Peake [22
Vet. App. 280 (2008)] reveals that the VA has unlawfully
limited the impact of this section of the statute possibly as
far back as 1960.
NVLSP believes that while it is good to improve the law, it
is also vitally important to make sure that the VA correctly
adjudicates current claims.
So we say that now VA, with the help of the veterans'
service groups and Congress, should act quickly, promptly,
efficiently to implement the Bradley decision.
Currently a veteran with SMC(S) gets about $320 more a
month than a veteran who has a total rating. That is because
not only do they have one service-connected condition that
would support 100 percent, they have other conditions that also
impact their lives over and above the 100-percent rate.
The problem is that the statute says that the rating is
based on a single condition noted as total, which would include
benefits that are paid because the one condition causes
individual unemployability. However, the VA has limited this to
only conditions that are 100 percent schedular. And they have
been doing this for 49 years. That does not seem right.
In Bradley, the court finally dealt with this issue. This
was a compelling case. He was basically blown up in Vietnam. He
suffered multiple shell fragment wounds from a booby trap. He
is service-connected for 13 compensable scars and 10 separate
muscle group injuries. He also gets service-connection for
Post-traumatic stress disorder (PTSD) at 70 percent.
The VA awarded him individual unemployability (IU) benefits
in 1983. And in 1992, he was granted a 100-percent rating. It
took the VA 13 ratings to get to that level over many years.
The Court did a wonderful job on this case. First, they
said that a veteran can get SMC(S) without a 100-percent
schedular service-connected disability.
Then the CAVC actually said that even if you have 100
percent combined, if it would be better for the veteran to get
IU based on one and then he had a separate combined 60 percent,
they should pay him that because you get more money.
And, finally, they said that the effective date of payment
is when the evidence shows that the veteran would be entitled
without a specific claim. This case is a home run and should
have a major impact.
What we need to do now is to encourage the VA to educate
its regional offices (ROs) and to help the VA implement this.
There are thousands of dollars for many, many veterans out
there and this, of course, will improve their quality of life.
Thank you very much.
[The prepared statement of Mr. Abrams appears on p. 39.]
Mr. Hall. Thank you, Mr. Abrams.
Mr. Zampieri, you are now recognized.
STATEMENT OF THOMAS ZAMPIERI, PH.D.
Mr. Zampieri. Mr. Chairman, Ranking Member, and other
Members of this Committee, we appreciate the opportunity to
testify here before you today on behalf of the Blinded Veterans
Association.
BVA has joined with the veterans service organizations
(VSOs) in awaiting action on recommendations provided by the
Veterans' Disability Benefits Commission that would improve the
benefits and the services for our Nation's wounded and disabled
veterans.
After reviewing the recent 7-month report issued by
Economic Systems, however, BVA has some concerns about some of
the recommendations on quality of life for veterans with
service-connected sensory and other disabilities.
We believe that the complex objective and subjective
instruments for a new payment system will require careful
consideration by Congress along with what is being presented
here today.
Quality of life measurements themselves are not only
objective measures of activities of daily living, but the
subjective concepts of pain levels, negative emotions, social
difficulties, and if not very carefully considered, the latter
could be easily excluded from any determinations of fair
measurements in looking at the impact of quality of life
compensation for our Nation's wounded.
We have some concerns about some sections. One thing that
alarmed us was a statement and some of the graphs that skin,
ear, and eye body systems have the lowest level of quality of
life loss for disabled veterans. I think and hope that you
would also sort of ask what is that coming from.
Mr. Chairman, as fellow veterans who have lost sensory
function could all testify, the reactions to blindness or
deafness are varied. Fear, overwhelming stress and anxiety,
depression, anger, those are just a few of the typical
responses to those sensory losses.
Our degree of independence is dramatically diminished and
our quality of life is completely disrupted and forever
changed. Loss of vision is accompanied by the sudden loss of
freedom to move about safely and independently. We must
constantly learn new ways of coping with and managing our lives
in the absence of vision or sensory losses in our world.
There are amazing new technologies and assistive devices
that have been developed, but those require continued updating
and training. It is not as if someone gets one new technology
device and that is the end of it.
I also want to emphasize, and this is commonly found in
almost any medical articles, if you look at sensory losses, the
one that is the single largest sensory system for all of us is
our vision. Seventy percent of our ability to perceive our
environment comes from vision. So if an individual was blinded,
70 percent of what they are able to tell about where they are,
who they are is gone.
The other major sensory system, of course, which is
frequently affected in the improvised explosive device
explosions from Iraq and Afghanistan, is hearing loss. The VDBC
was faced with a really complex task that for 2 years required
a very difficult analysis of a complex issue when it comes to
quality of life. Along with other Federal agencies, State
governments, and local governments, this is a difficult area.
And I would like to point out that the VDBC said that no
current compensation for the impact of disability on the
quality of life currently exists within the current system.
Many national surveys demonstrated in the past decade since
the passage of the ``American Disabilities Act'' that there has
actually been very little progress made in the employment rates
of the disabled. Among several sources, one being the very
respected Cornell University's Center on Disability Statistics'
annual disability status report, which you can find online,
data indicates that the country's disabled,
noninstitutionalized population of working age adults between
the ages of 21 and 64 still have significantly lower rates of
employment, lower earnings, and lower household incomes across
multiple studies as compared to their nondisabled American
counterparts.
The 2007 Census Bureau survey, for example, found that 60
percent of disabled men between those ages with one disability
were employed, but when looking at individuals with severe
disabilities affecting daily functioning skills, that rate
falls to 32 to 34 percent in multiple different studies despite
improvement in transportation accessibility for those
individuals with disability that affect their ability to do
daily functions. Almost 30 percent of the disabled in this
country still have problems with access to public
transportation.
The American communities survey in 2007 found individuals
with sensory disabilities in that age group of a population
with a median income of $22,000 less than the average
households containing nondisabled members.
And I have multiple other things in the testimony that I
will let you look at rather than try and read through all of
them.
I would also like to point out, though, the National
Council on Disabilities' March 2009 report reveals that the
percentage of disabled Federal workers has actually steadily
declined and that Washington, DC, U.S. Department of Labor has
found that Federal employees with disabilities is actually at
the lowest level in almost 20 years. For those who like to say
that technology is making everything equal and so I have to
argue with that.
I have other things in here that unfortunately due to time
constraints cannot go through all of them. I appreciate the
ability to be able to testify here this morning in front of the
Committee. Hopefully I will be able to answer some of your
questions. Thank you.
[The prepared statement of Dr. Zampieri appears on p. 40.]
Mr. Hall. Thank you, Mr. Zampieri.
I want to thank all of you for your service to our country
and to our country's veterans.
Mr. Zampieri, as you noted in your testimony, eye and ear
injuries have been associated with Traumatic Brain Injury
(TBI), with explosion of roadside bombs in Iraq and Afghanistan
among other battlefields and theaters of combat.
Do you feel that VA has done a sufficient job evaluating
all the face and head trauma completely and accurately to
compensate veterans and to provide them with all necessary
ancillary benefits?
Mr. Zampieri. Thank you for the question.
I think it is actually a concern of ours and probably safe
to say many of the other VSOs that individuals with Traumatic
Brain Injuries (TBI) that have sensory associated symptoms have
a very difficult time in getting their ratings because so many
of those are subjective kind of complaints.
You know, we frequently hear a lot about the problems with
tinnitus, for example. Frequently TBI patients complain of
photophobia, which is extreme sensitivity to light. And those
are very difficult to rate, but those things can have quite an
impact on the individual's ability to function and also their
relationship socially and employment-wise.
And so we are concerned about the way TBI assessments are
done in regards to sensory losses. I know that the VA has put a
lot of effort toward looking at new assessment methods, and
congratulate them for, you know, recognizing this is a serious
problem.
Mr. Hall. In its report, EconSys made policy suggestions
regarding new assistive technologies and disabled veterans who
use them.
Can technology sufficiently replace an actual ability that
would negate the need to compensate the veteran for his or her
loss of earning capacity? Are you aware of any new technologies
that are around the corner and just becoming available that
would substitute for one's natural vision? I am aware of some
for hearing loss, but is there something similar for vision
that you are aware of?
Mr. Zampieri. Thank you for the question.
Yes. Actually, and we are very supportive, and I do not
want it to come out the wrong way here today, by the way, of
VA's efforts at research and new technology. And we commend Dr.
Kuppersmith for his leadership in research and development of
new technologies.
And, for example, the VA does work with the universities
doing research on a brain port device, which holds some promise
of being able to allow part of the brain, the occipital area
that perceives and processes vision, to get input from a camera
and then through, believe it or not, the tongue transmits
images to the occipital area.
But it is certainly in its early stages of research. And I
think those individuals who have been involved in using it will
say that it holds some hope, but it is not going to replace,
you know, natural vision.
And I think individuals with deafness would also say that
the advances made surgically and with new devices for deafness,
you know, are not going to equal what normal sensory input
would be.
Mr. Hall. Thank you. I would have to concur with your
remarks about hearing loss.
Also, the mental health community, both secular and
religious meditation groups and teachers, and so on believe
that. One of the reasons that they teach meditation in a
darkened room is because 70 percent of the input, sensory to
your brain is coming through your eyes, the average person's
vision and ocular nerves. So, it is only natural then that the
loss of that much input is a severe loss indeed.
Mr. Abrams, do you have any further feedback on other SMC
rates besides (S) and the usefulness of these benefits as a
mechanism to compensate veterans for the loss of quality of
life?
Mr. Abrams. I am not sure I am following the question.
Mr. Hall. I am asking if you have any feedback on the other
SMC rates besides the (S)----
Mr. Abrams. Yeah. I think that the Aide and Attendance
(A&A) rate should be bumped up. It is too low. I personally
have a family member in a home and it costs over $90,000 to
$100,000 to put somebody into a home. And home care, if you
need 24-hour care, is hugely expensive. Real A&A is too low. We
need to improve that.
Mr. Hall. Thank you for bringing to our attention the
Bradley decision, which is certainly something that this
Subcommittee and the full Committee will be looking at.
Mr. Abrams. Thank you. That is important and we can help
right now with that.
Mr. Hall. We will be asking you for that help.
Mr. Blake, has the PVA and its fellow Independent Budget
organizations reviewed the EconSys study and its
recommendations regarding quality of life compensation and what
further impressions do you have of that?
Mr. Blake. We have not as a group of organizations, but I
would imagine as we develop the upcoming IB that it will be
something of obvious consideration, particularly given the new
focus on wanting to try to figure out a way to compensate for
quality of life.
The one thing I would suggest is that this is not an easy
task and for four organizations, I think it has already been
discussed here a little bit, trying to figure out a way to make
recommendations on how to adjust quality of life, I am not sure
that any of the four organizations could come to a universal
agreement on the best way to do it because I think at the end
of the day, it is more subjective than objective in trying to
figure out a way to compensate for that.
But I will say since I do not work chiefly on the benefits
side of the IB that I would imagine that it would be one of the
main things that they will look into, yes, sir.
Mr. Hall. Thank you.
Has the PVA studied the impact of in-home ventilator care
and the costs associated with that care? Should there be an
additional rate paid based on ventilator dependence?
Mr. Blake. I cannot say that I am aware that we have
studied it, Mr. Chairman, but I can certainly go back and ask
some of the folks who represent our research folks and see if
they have looked into this issue particularly.
Mr. Hall. Thank you. That would be helpful.
Should there be a partial A&A awarded for veterans who can
perform some of the activities of daily living, but not all of
them?
Mr. Blake. A partial A&A, sir? I do not think there should
be any partial benefit given period. I think the aid and
attendance benefit is a benefit given in whole and that is it.
Mr. Hall. Should there be a new SMC rate created for
cognitive impairments such as for PTSD or TBI?
Mr. Blake. I do not know if it would be a new rate or a way
to reevaluate the current SMC schedule as it is developed and
add that in there. Maybe it needs a new subsection of its own.
I could not speak to that necessarily, sir.
Mr. Hall. Thank you.
How would the PVA recommend that a quality of life payment
be made? Should it be inherent in a new rating schedule or
should it be as an SMC?
Mr. Blake. I do not know that that question has ever been
put before our Board of Directors. I am not sure that we have
ever considered the best way to do it. But I will take it back
to my leadership and see what their thoughts on that question
might be, sir.
Mr. Hall. Would either Mr. Abrams or Mr. Zampieri like to
comment on that question?
Mr. Zampieri. Yes. Appreciate it.
I would be concerned about having it too fragmented with
the determination, you know, because then you make an already
slow process even more complex for the individual veteran who
is trying to figure out why they are making this decision in
the service-connected, economic replacement type payments and
then a separate payment for something else and then another
payment for, you know.
The last thing the VA needs I think at this point could
safely say is something else that is going to add to the
slowing down or cumulative effect of having to deal with all
these various benefits decisions.
Mr. Hall. Good point.
Mr. Abrams.
Mr. Abrams. I think that if it can be determined that
somebody comes back from Iraq, Afghanistan, Vietnam and because
they suffered a blow that cost them a percentage of their
ability to think, they should have an SMC code for that. It is
not any harder than the current SMC codes which some VA raters
find hard. But it is not going to add any more to the
complicated process.
Mr. Hall. Well, thank you.
I want to thank all three of you for your testimony and for
your answers. I am looking forward, as we move forward, to
speaking with you all again. So our first panel, you are now
excused.
We will invite in the changing of the guard our second
panel to join us.
Dr. Lonnie Bristow is the Chairman of the Committee on
Medical Evaluation of Veterans for Disability Benefits, Board
on the Health of Select Populations at the Institute of
Medicine (IOM), the National Academies; Mr. George Kettner,
Ph.D., President of Economic Systems, Inc.; Ms. Kimberly D.
Munoz, Executive Director for the Quality of Life Foundation;
accompanied by Michael Zeiders, President of the Quality of
Life Foundation; and Ms. Carol A. Glazer, President of the
National Organization on Disability (NOD).
Thank you all for joining us today. I would remind you as
always that your full written testimony is entered in the
record and if you can limit yourselves to 5 minutes in oral
testimony, then we will have time for questions.
Dr. Bristow, you are now recognized for 5 minutes.
STATEMENTS OF LONNIE BRISTOW, M.D., CHAIR, COMMITTEE ON MEDICAL
EVALUATION OF VETERANS FOR DISABILITY BENEFITS, BOARD ON THE
HEALTH OF SELECT POPULATIONS, INSTITUTE OF MEDICINE, THE
NATIONAL ACADEMIES; GEORGE KETTNER, PH.D., PRESIDENT, ECONOMIC
SYSTEMS INC., FALLS CHURCH, VA; KIMBERLY D. MUNOZ, EXECUTIVE
DIRECTOR, QUALITY OF LIFE FOUNDATION, WOODBRIDGE, VA;
ACCOMPANIED BY MICHAEL ZEIDERS, PRESIDENT, QUALITY OF LIFE
FOUNDATION, WOODBRIDGE, VA; AND CAROL A. GLAZER, PRESIDENT,
NATIONAL ORGANIZATION ON DISABILITY
STATEMENT OF LONNIE BRISTOW, M.D.
Dr. Bristow. Thank you. Good morning, Chairman Hall----
Mr. Hall. Please push your button so that your microphone
is on.
Dr. Bristow. That helps.
Mr. Hall. Yes. Thank you.
Dr. Bristow. Good morning, Chairman Hall, Ranking Member
Lamborn, and Members of the Subcommittee. I am Lonnie Bristow.
I am a physician, a Navy veteran, a member of the Institute of
Medicine, and a former President of the American Medical
Association. And I am very pleased to appear before you again
to testify about the improvement needed in the disability
benefit system of the VA.
I had the great pleasure and honor of Chairing the
Institute of Medicine (IOM) Committee on Medical Evaluation of
Veterans for Disability Compensation that was established at
the request of the Veterans' Disability Benefits Commission.
The Committee was asked to evaluate the VA's schedule for
rating disabilities and related matters, including the medical
criteria for ancillary benefits.
My task today is to present to you the Committee's
recommendations on improving ancillary benefits, which are in
Chapter 6 of our 2007 report entitled, ``The 21st Century
System for Evaluating Veterans for Disability Benefits.'' And I
also intend to comment on our recommendations concerning
quality of life, which is in Chapter 4 of our report.
Specifically the IOM Committee was asked to comment on the
appropriateness of medical criteria for five specific ancillary
benefits, including vocational rehabilitation and employment
(VR&E) services, automobile assistance, adapted housing grants,
and clothing allowances.
And in each case, the Committee was asked to consider from
a medical viewpoint the appropriateness of the specific
conditions that a veteran is required to have in order to
receive these ancillary benefits.
When we reviewed ancillary benefits, we found that they
were created piecemeal over time. They were not designed as
part of a comprehensive program of services and they are not
systematically updated and, in some cases, not indexed for
inflation. They are not based on an empirical analysis of
veterans' actual needs or actual loss of quality of life. And
except for vocational rehabilitation, there is no evaluation of
their effectiveness in addressing veterans' actual needs or
loss of quality of life.
We also noted that for most benefits, the medical
eligibility criteria require a very high degree of obvious
anatomic impairment and that they are so specific that they may
not include veterans with other impairments that hinder
mobility, such as multiple sclerosis.
I realize that this Committee does not have purview over
vocational rehabilitation, but we concurred with the
recommendation of a 2004 task force on VR&E that was appointed
by VA, which suggested that VA should better coordinate its
health, VR&E, and compensation programs in order to achieve a
more individualized or veteran-centric approach to veteran
services.
The IOM Committee offered four recommendations of its own
for improving ancillary benefits. The first was based on the
lack of data on the need for, or the effectiveness of,
ancillary benefits and, therefore, we recommended that VA
should sponsor research on ancillary benefits and obtain input
from veterans about their needs. Such research could include
conducting intervention trials to determine the effectiveness
of ancillary services in terms of increasing functional
capacity and enhancing health-related quality of life.
Second, since VA offers a number of services that might
benefit a disabled veteran, we recommended that VA and the U.S.
Department of Defense (DoD) should conduct a comprehensive,
multidisciplinary medical, psychosocial, and vocational
evaluation of each veteran applying for disability compensation
at the time of service separation.
Third, we found no medical basis for the current 12-year
limitation on eligibility for vocational rehabilitation (VR)
services. VR might be beneficial after 12 years because of
medical advances or the development of new assistance devices
or new types of work for which veterans with disabilities might
then be trained.
And, fourth, we were concerned about the low rate of
participation in the Vocational Rehab Program and recommended
that VA should develop and test incentive models that would
promote vocational rehabilitation and return to gainful
employment among those veterans for whom this is a realistic
goal.
Concerning loss of quality of life, our report recommended
that it be measured directly. Since quality of life measurement
appropriate for compensation by VA does not exist at this time,
we recommended that VA take a series of steps.
First, VA should develop a quality of life tool based on a
lot of good work that has been done recently, some of it by
VA's own researchers. In fact, VA already uses a quality of
life measurement tool, the SF-36, but it is used in research on
clinical outcomes, not compensation.
So, second, VA should either modify that tool or choose
another it might select to determine if veterans experience an
average loss of quality of life for any specific disabilities
which exceeds the average loss of earnings capacity as measured
by the rating schedule.
Third, if it turns out that veterans experience a serious
loss of quality of life on average for a given condition that
is not highly rated by the rating schedule, then the VA should
compensate for that difference.
In summary, in our report, the main points concerning
ancillary benefits and quality of life are, first, VA should
more systematically research the needs of disabled veterans and
the effectiveness of its ancillary benefit programs in meeting
those needs and make the needed revisions in these programs
based on this research.
Second, VA should assess the individual needs of disabled
veterans at the time of separation from military service and
coordinate the delivery of the services identified by that
assessment.
Third and last, VA should develop a tool to measure the
quality of life of disabled veterans, determine the extent to
which the rating schedule already accounts for loss of quality
of life, and for those disabling conditions in which average
loss of quality of life is worse than the rating schedule
indicates, compensate for those differences.
Thank you, Mr. Chairman.
[The prepared statement of Dr. Bristow appears on p. 44.]
Mr. Hall. Thank you, Dr. Bristow.
Dr. Kettner, you are now recognized for 5 minutes.
STATEMENT OF GEORGE KETTNER, PH.D.
Mr. Kettner. Mr. Chairman, thank you for the opportunity to
appear before you today. I am the President of Economic
Systems, Incorporated and served as the Project Director of a
recent study of loss of earnings and loss of quality of life of
veterans with service-connected disabilities.
We compared veterans with service-connected disabilities to
a match group of nonservice-connected veterans. Service-
connected means that the condition occurred during or was
aggravated by military service. It does not require that the
disability be work related or be caused by conditions in the
work environment.
We found that overall, actual earnings, plus disability
compensation for veterans with service-connected disabilities,
was 7 percent above the earnings of the respective comparison
group without service-connected disabilities.
On average, veterans rated 30 percent or less did not
experience serious wage loss. Approximately 55 percent of 2.6
million veterans receiving disability compensation are rated at
30 percent or less.
Veterans rated 40 to 90 percent ratings experience wage
loss, but their VA disability compensation more than made up
for the loss. For veterans rated at 100 percent, their earnings
and disability compensation was 9 percent less than expected.
We also found considerable differences in earnings loss
across different diagnoses for a given rating level resulting
in serious inequity in the disability payment system.
Several of the most prevalent diagnostic codes are
candidates for changes to the rating schedule because there is
no earnings loss at the 10 percent or 20 percent rating levels.
Examples include arthritis, hemorrhoids, tinnitus, and
diabetes.
We found that mental health disorders in general have a
much more profound impact on employment and earnings than do
physical disabilities. Adjustments to the rating criteria could
overcome much of this disparity but not for those already rated
100 percent unless the benefit amount for the 100-percent
rating was increased as well.
Veterans receiving disability compensation have on average
3.3 disabilities that are rated. VA uses a certain look-up
table for combining individual disability ratings into a
combined degree of disability rating. The earliest known table
dates from 1921 and little has changed since then.
The formulas result in ratings that overcompensate veterans
for loss of earning, particularly when combining multiple
disabilities with low ratings.
Veterans with a combined rating between 60 to 90 percent
who are determined to be unemployable qualify for individual
unemployability benefits or IU benefits. Veterans determined to
be entitled to IU qualify for the same benefit payment amount
as those rated at the 100-percent disability level.
Individual unemployability has increased by almost 90
percent since 2001 with PTSD cases making up one-half of new IU
cases. Forty-four percent where veterans age 65 and older, age
is clearly related to employment, but it is not considered in
determining eligibility for IU. It appears that IU for veterans
approaching or past retirement age is implicitly providing
retirement income or recognition for loss of quality of life
rather than for employment loss.
Special monthly compensation is a series of awards for loss
of limb, organ, or functional independence. SMCs are not
awarded to compensate for average loss of earnings capacity.
Instead they can be viewed as payments for loss of quality of
life.
The amount of SMC monthly payments above the regular
schedule payment for the 100-percent rating ranges from about
$600 to $1,900 for severely disabled veterans. SMC payments are
generally not made for PTSD and other mental health conditions
unless the veteran requires aid and attendance.
Certain SMCs are paid to veterans for assistance with
activities of daily living. For example, SMC(L) provides $618
per month above the normal 100 percent amount and SMC(S) for
housebound veterans provides $302 per month.
Survey results indicate that the monthly cost of hiring
assistance for caregiving ranges from about $500 to $11,000
depending on how many hours of care are provided.
A recent study estimated the lost wages and benefits of
family caregivers of severely injured, active-duty
servicemembers at $2,800 per month. The current amount of the
SMCs for assistance is well below these estimated costs.
The literature generally defines quality of life as an
overall sense of well-being based on physical and psychological
health, social relationships, and economic factors.
We found that QOL loss occurred for veterans at all levels
of disability. We also found that loss of quality of life
increases as disability increases, but there is wide variation
in loss of quality of life at each disability rating.
Putting an economic value on quality of life is subjective
and value laden. Hence, we develop different options for
quality of life loss payments ranging from an average amount of
$100 a month to about $1,000 a month depending on the benchmark
for measuring loss of quality of life.
Examples of benchmarks include veterans' self-assessment,
societal views, awards made by foreign governments, SMC
payments, and IU benefits for veterans over the age of 65.
Before any quality of life benefit is implemented, we
recommend that the current system for rating disabilities be
adjusted to reflect actual loss of earnings to ensure an
overall equitable system. Otherwise, we may be compounding the
inequities that we have in the current system.
Mr. Chairman, I thank you for the opportunity to appear
before you today.
[The prepared statement of Dr. Kettner appears on p. 46.]
Mr. Hall. Thank you, Dr. Kettner.
Ms. Munoz, you are now recognized for 5 minutes.
STATEMENT OF KIMBERLY D. MUNOZ
Ms. Munoz. Thank you.
Chairman Hall and distinguished Members of the
Subcommittee, thank you for inviting the Quality of Life
Foundation to testify today.
As you know, the Veterans Affairs mission statement is
based on the promise that President Lincoln made to America's
Civil War veterans to not only care for them but also in the
event of their death to ensure their widows and orphans were
not forsaken.
We assert that today's equivalent of America's Civil War
widows and orphans includes the families of catastrophically
injured veterans and that they also must not be forsaken. As
such, benefits must reflect the reality that when a veteran is
dependent on a family caregiver, their family becomes dependent
on their benefits.
As a nonprofit organization founded to develop, support,
and implement strategies to improve the quality of life for
those who face limiting barriers, we began researching the
experiences of catastrophically wounded servicemember families
in February of 2008. We published our findings in a report in
April of 2009.
During our research, we heard repeated stories of families'
struggles to receive the benefits their veterans had earned.
The degree of this struggle is reflected in the fact that for
fiscal year 2007, 5 of the largest, most well-known VSOs
reported $75 million in program expenses associated with VA
claims assistance.
It is apparent that VA must reduce the burdensome process
and wait times associated with the receipt of benefits these
families need to rebuild independent and quality lives.
While timely processing is important, it cannot be achieved
at the cost of accuracy. An accurate disability rating based on
relevant eligibility criteria is the key to open doors to
benefits these families desperately need. Special monthly
compensation is one of those.
This compensation is awarded in consideration of the impact
disabilities have on the veteran's independent living function.
However, current eligibility criteria fails to fully consider
cognitive and psychological impairments that also diminish the
veteran's ability to live independently.
For example, a highly functioning veteran with 100 percent
service-connected disability due to a stand-alone Traumatic
Brain Injury who has been left with impaired cognitive,
judgment, and short-term memory capabilities clearly cannot
safely live independently. He requires oversight for activities
like paying bills, cooking, driving, attending medical
appointments, and taking medication.
However, because he has no physical disability, he is
eligible for just one category of special monthly compensation
resulting in approximately an additional $600 a month.
When a family member has left their job to provide that
oversight for their veteran, $600 does not cover that financial
burden.
Simply stated, we believe that if a veteran's service-
connected disability requires a significant level of daily
supervision and assistance, the VA must provide compensation to
fully cover that caregiving expense.
The specially adapted housing grant is another benefit with
eligibility criteria based largely on physical impairments. The
maximum grant is $60,000 and it is intended to only offset the
cost to modify a home. The process is lengthy and as such
prohibits modifications from being completed prior to the
veteran's homecoming.
These grants must be awarded in time to allow the
homeowner, including parent caregivers, to provide a safe and
accessible environment for the day the veteran arrives home.
Additionally, the grants should cover the total cost of the
modification.
The VA provides health care to eligible veterans throughout
the United States via their own facilities and in some
instances through a fee-basis program. However, when VA
facilities do not provide the best option for veterans and
their families, the VA discourages access to private care.
When veteran families choose to pursue health care via the
fee-basis program, the VA should accommodate that choice by
timely issuance of preauthorization and full and timely payment
to non-VA medical providers.
Family caregivers also require health care and many of
them, especially parent caregivers, forfeit their own health
insurance when they leave their job to provide daily care to
their veteran. This loss of coverage results in a lower quality
of life and potentially the inability to sustain caregiving for
the veteran.
The VA must provide health care insurance to those family
members who have forfeited their own insurance to provide care
to their veteran.
In addition to health care, family caregivers require
respite from the demands of 24/7 caregiving. However, respite
eligibility criteria also does not fully consider cognitive and
psychological impairments experienced by those with stand-alone
PTSD or TBI.
For those who do qualify for respite, the VA provides 30
calendar days per year of in-home, 6 hours a day respite.
Families who desire extended respite may place their loved one
in a VA nursing home. Most families are reluctant to exchange
the stress of moving a loved one into a nursing home for a much
needed weekend vacation.
We believe the VA should provide respite to family
caregivers of veterans who require aid and attendance and
should extend the current in-home respite benefit beyond a 6-
hour maximum to include overnight in-home care.
Family caregivers often voice heartfelt concern regarding
the day they become unable to fulfill caregiver
responsibilities and are forced to place their loved one in a
VA nursing home. The VA must invest in long-term, age
appropriate residential care geared to meet the needs of this
generation of traumatically injured veterans.
In conclusion, the Quality of Life Foundation believes our
country's response to the families of severely wounded veterans
must be deserving of their response to their veteran's call of
duty. We must provide compensation, medical care, and long-term
support to allow severely wounded families to rebuild quality
lives, to live with dignity in their homes, and to know that
their sacrifices are appreciated and honored by a grateful
Nation.
The time to study this issue is past. These families are
struggling to sustain caregiving with too few resources. They
do not need nor want a handout. They simply ask for the tools
required to take care of their veteran and their families. We
urge Congress to pass legislation this session that increases
support to family caregivers.
That concludes my testimony and I look forward to answering
any questions you may have.
[The prepared statement of Ms. Munoz appears on p. 54.]
Mr. Hall. Thank you, Ms. Munoz.
Ms. Glazer, you are now recognized for 5 minutes.
STATEMENT OF CAROL A. GLAZER
Ms. Glazer. Thank you, Mr. Chairman and Members of the
Subcommittee.
My name is Carol Glazer and I am the President of the
National Organization on Disability or NOD. We are a 27-year-
old national nonprofit organization that has long worked to
improve the quality of life for people with disabilities by
advocating for their fullest inclusion in all aspects of life.
We are well-known for our Harris polls, which measure
quality of life indicators, including access to health care,
transportation, employment, education, worship, and even
political participation.
And we commend the Subcommittee for looking at quality of
life indicators besides earning capacity in determining
disability ratings and ancillary benefits for our country's
service-disabled veterans.
Today I want to share with you what we are learning from
the early phases of an Army wounded warrior career
demonstration project, which is a privately funded, 4\1/2\ year
demonstration conducted by NOD under a Memorandum of
Understanding with the United States Army and its Army Wounded
Warrior Program.
My observations on quality of life issues for veterans are
derived from scouting reports from the field, from focus groups
over the course of a year with over 200 soldiers and family
members, and through our first year of this demonstration that
is operating in three sites, the Dallas Metroplex, the State of
Colorado, and the State of North Carolina.
In fact, just this morning, I returned from our Colorado
site where I spoke with several officials at Fort Carson,
veterans, family members, and the service providers who work
with these veterans.
Through our demonstration with the Army, our career
specialists ensure that career services and related assistance
are provided, in this case to over 200 soldiers and their
family members. We link these soldiers with existing career
services in their community and in some cases we provide direct
services ourselves where such services are inadequate.
We are demonstrating a model of intensive, proactive, long-
term career support in what will ultimately be a caseload of
several hundred soldiers.
The demonstration has a research component where we will
analyze the results of our model, especially on outcomes
related to education and work. And although this demonstration
is related to education and employment, we believe that the
service model and what we are learning from this demonstration
is going to have applicability across a whole range of quality
of life issues for veterans, especially those that are of
concern to this Committee.
I wanted to share with you a few of the lessons that we are
learning from this early stage. Our demonstration has been in
place for about a year with the U.S. Army.
First observation, a fundamental mismatch. Many of the
supports for veterans are constrained to a reactive service
model placing the burden on veterans and their families to find
and approach agencies. But we find that the most seriously
injured soldiers, especially with cognitive injuries, are not
really able to effectively access these services.
The model we are testing involves proactive support, in
which we actively reach out to veterans who are in our caseload
immediately upon their transition home. We contact them at
least once month either electronically or by phone and we see
them at least twice a year, much more often at the outset of
our work with them.
Our surveys confirm that our veterans find this approach
much more satisfying than those of many other services that are
more reactive in nature.
Second observation, the need to deal with both the veteran
and the family member. As others have stated, the process of
recovering from injury and coming home and coming to terms with
disability is a very complex process that impacts the entire
family. It is our belief that ancillary benefits and services
must be available to veterans and family members.
Third observation unaddressed mental health needs, as
others have noted. More than half of the Army Wounded Warrior
population, which is a group of veterans with a 50 percent or
higher disability rating from the Army, suffers from a primary
diagnosis of PTSD, often combined with Traumatic Brain Injury.
It is not a criticism of the VA to say that the level of
mental health services is simply at this point insufficient to
meet the large and growing demand. We believe that the VA
should supplement the direct services that it provides in
mental health with help from many good, quality community and
other based mental health services.
Four, criminal charges. Several veterans' behavior
associated with PTSD or TBI have resulted in their facing
criminal charges--erratic driving, substance abuse, a whole
range of other behaviors, some of them violent. Those serving
veterans must intervene with the police, with the courts, and
with prosecutors to request that notice be taken of a soldier's
disability and considered as a mitigating factor in charges and
sentencing.
Five, personal and family financial management. Young
veterans often have little experience in managing properly
their family finances and they are in dire financial straits.
There is clearly a need for continuing personal and family
financial management, training, and guidance.
Six, peer support mechanisms. Many veterans and families
are isolated geographically, socially, and psychologically. Our
career specialists employ peer support mechanisms with very,
very good results. We encourage the VA to think about that type
of an intervention as well.
And then education and job skills, we are very heartened by
the new GI benefit structure, but offer a yellow warning light
that these benefits are now so rich in relation to other
benefits that in many cases we believe they may skew decisions
toward a 4-year college for many veterans that could benefit
more appropriately from job training or community college
credentials that are going to be needed to succeed in the labor
market of today and tomorrow.
Finally, the need for flexible work supports. The veterans
and families we serve often have very low incomes and cannot
pay for things like computers or work clothes or other types of
improvements that will help them access the job market. To meet
such needs, we provide small grants, flexible money from what
we call work supports, but we would encourage the VA to
consider that type of very, very flexible funding that can be
administered very quickly in response to needs that arise.
These are just a few of the observations we have drawn from
our demonstration which is now only a year into our model in
Dallas and in North Carolina, it is even younger. We provided
more information to you about the demonstration in our written
comments and we would be happy to provide even more or answer
any questions you have about our model.
Thanks for your invitation.
[The prepared statement of Ms. Glazer appears on p. 57.]
Mr. Hall. Thank you, Ms. Glazer.
Dr. Bristow, in its recommendations on ancillary benefits,
the IOM observed that VA had not surveyed veterans about the
effectiveness of these benefits, so there was a serious lack of
data to evaluate the medical criteria.
Do you think conducting this research would be an important
step before VA could further consider how it might compensate
veterans for the loss of quality of life or to revise the SMC
rates?
Dr. Bristow. First of all, we cannot report on our
Committee's assessment of SMC because that was not a part of
our charge. I can give you a personal observation in a moment.
But certainly on the issue of whether or not additional
research should be done assessing from the veterans, listening
to the veterans themselves as to what their needs are, this is
essential in order to be able to judge the adequacy and
effectiveness of the ancillary benefits program and in order to
be able to subsequently go back and find out how well are these
benefits actually meeting those needs and actually
accomplishing the goal, which would be to increase functional
capacity and to improve to the extent possible the veteran's
mobility and employability.
I would make a personal observation about SMC only to the
extent that SMC as I have seen it seems to have a specific
focus on anatomic loss. And as you have heard already, this
virtually precludes its ability to be effective in use for
conditions such as TBI and PTSD where the disability is largely
neurogolical or psychiatric and not an anatomic or physical
loss.
And so it is terribly important that we actually assess
from the veterans themselves as to what they need and how well
these programs may or may not fit their needs.
Mr. Hall. Thank you, Doctor.
IOM also looked at various veterans' programs from several
other countries.
Would you say that any of them did a better job of
compensating veterans for the loss of quality of life? Which
models, if any, would you recommend and why?
Dr. Bristow. Well, one of the best examples of how you can
effectively and credibly evaluate quality of life and put it
into a compensation model is seen in Canada. We noted that in
Ontario, Canada, the city had a workers' compensation program
that took a very unique approach to the fact that there is a
need to compensate workers not only for their loss of work
capability, earning capability but also for quality of life.
They have 12,000 workers who are disabled. And what they
did was they selected I think it was 76 disabling conditions
such as blindness, such as the loss of a limb, such as stroke,
things of that nature, and they took individuals who had those
76 conditions and made 5 to 6 minute long videotapes in which
they had a therapist question the individual as to how this
disability impacted their lives and allowed the individuals to
demonstrate how they perceive this impacted their lives, things
such as trying to catch a bus, trying to take care of your
laundry, daily services of caring for yourself.
They then took those videos and they showed disabled
workers four to six such videos in a 30-minute period of time,
and asked them, how would you rate your preference for this
condition, making sure that they did not show anyone a video of
the condition they already had, instead always showing them
some other conditions.
The test subjects were then asked to rate each condition on
a preference basis from 0 to 100, 0 being ``this would not
bother me at all,'' on up to 100 being ``I would rather be dead
than have this condition,'' and rates were assigned in this
subjective fashion.
They were able by this methodology to come up with a
credible rating system in which the ``average person'' would be
able to say if I had this condition, this is the impact it
would have on my life, my perception of my will to live, so to
speak.
They then also were able to convert that system with those
percentages to a monetary compensation. And this worked very
effectively there.
It is possible to do. It is possible to measure quality of
life in a way that is credible and reproducible statistically
and to actually convert that assessment into a monetary or
compensation platform.
The VA is close to that with the quality of life instrument
that they are currently using. It would need to be modified.
But were it to be modified to actually allow for preferences to
be indicated, at the IOM we believe that this could serve as a
vehicle for the actual measurements of quality of life that
could be attributed to various conditions and then take a look
to see whether or not that condition's quality of life
assessment matches up reasonably well with what the current
rating schedule is already giving to a veteran.
If it matches up well, fine. But if there is a significant
disparity between the veteran's perception of their quality of
life given this condition as contrasted with what the rating
schedule gives, then we believe that a third step is needed,
which the VA should make some adjustment in its compensation
award to that veteran based on the difference in quality of
life that they are experiencing.
Quality of life, Mr. Chairman, as I am sure you are aware,
is terribly important.
Mr. Hall. Thank you, Doctor.
Dr. Kettner, there has been concern that the data that
EconSys used to base its recommendations upon did not fully
consider all of the veteran population, particularly VA's
largest service-connected cohort, Vietnam veterans.
Can you provide more insight into how you conducted your
study and what you might have done differently if data prior to
1980 were more readily available? How does your study take into
account the demands of the baby boomer generation who are
currently placing the greatest demand on VA?
Mr. Kettner. Okay. Well, thank you for the question.
Our study focused on veterans who were discharged from
military service post-1980. We attempted to look at pre 1980
data, but uncovered that the pre 1980 data was not adequate for
purposes of our study. We could not get sufficient data on
certain human capital characteristics and, therefore, we
decided that the best approach to take would be to focus on the
post-1980 group.
This post-1980 group is also relevant from the point of
view that if you are going to grandfather the current payments
for veterans already in the system, you want to look forward to
the future on how you would set forth payments for veterans
entering the system in the future. Then we think it is
appropriate from a methodological point of view to focus on the
post-1980 veterans.
[Dr. Kettner subsequently provided additional remarks in
response to Mr. Hall's question, which appears on p. 73.]
Mr. Hall. Thank you.
The study also found that VA has 54 possible combinations
of SMC codes, which apply different degrees of compensation.
Are these combinations adequate to improve a
catastrophically disabled veteran's quality of life or does the
VA need to reassess the SMC awards that for the most part have
been in place since the Civil War?
Mr. Kettner. Okay. Well, the quick answer to your question
would be by and large the SMCs are not adequate. We found
overall that while with the regular schedule, there may be
overcompensation, when it gets to the 100 percent rating level
and the SMCs, generally speaking, there is undercompensation.
In particular, you can view SMCs as expounding into two
parts, one part for implicit quality of life payment and
another part for the aid and attendance. We know that for aid
and attendance, the SMCs are not adequate. They fall quite a
bit short on that account.
The SMC veterans are rated at 100 percent and we know from
our earnings loss analysis that they are not adequately
compensated for their loss of earnings.
The component of quality of life is much more subjective,
but in general, our own judgment would be that the SMC veterans
need more attention and more compensation than the regular
schedule veterans who are rated below 100 percent.
Mr. Hall. You also noted that the rating schedule needs to
be updated for mental disorders and PTSD especially. Veterans
with mental disabilities are below income parity and the report
suggests that the 10-percent rating begin at 30 percent and
subsequent adjustments upward. However, that would still not
solve the equity problem at the 100 percent.
You also noted the lack of SMCs for mental disabilities.
Could the addition of an SMC for mental disorders bring these
veterans to parity?
Mr. Kettner. That would certainly help, but the SMCs are
intended not to replace loss earnings. So there is still that
shortfall in replacing earnings loss for veterans at 100
percent rating, including those that have PTSD.
Mr. Hall. Thank you.
Ms. Munoz, I understand from your report that families of
severely wounded warriors deplete their savings and retirement
accounts, go bankrupt, remortgage homes, lose jobs, along with
other problems.
What would you estimate the average family spends to meet
the needs of their wounded warrior that the Government does not
reimburse them for undertaking?
Ms. Munoz. Well, it varies widely because some families
have assistance to get the benefits that they need from VA and
they have to use less out-of-pocket funds to get the services
their veteran needs.
Other families who may have not had the guidance from
perhaps a VSO or who do not have the education in our country,
maybe they have moved here from another country and they do not
speak our language, it is hard for them to run through all the
rules and regulations and applications. And so they have a
difficult time accessing the benefits that they need.
There was a study that was released by the Center for Naval
Analysis (CNA) that estimated 19 months of lost income of
around 2,000 some odd dollars, I think, for a total of $36,000
average loss per family of catastrophically injured
servicemembers.
That is their income loss, which is not necessarily
answering your question of how much do they spend out of pocket
to get the services, but it is a figure that has been widely
reported.
Mr. Hall. Thank you.
What additional factors do you think VA should specifically
consider when it adjudicates aid and attendance or housebound
rates?
Ms. Munoz. One of the key questions is can the veteran keep
themselves safe from the hazards of daily living. There are
many other questions related to a body part function or a loss
of a body part, but buried deep in there is can the veteran
keep themselves safe from the hazards of daily living.
For those who have Post-traumatic stress disorder and
stand-alone TBI, I believe that that is a key to determining
whether or not that veteran needs aid and attendance. The aid
and attendance can also vary in terms of do you need physical
aid and attendance or do you need oversight.
So one package of aid and attendance does not meet the
needs of every single veteran.
Mr. Hall. It seems to me that a judgment about the safety
of the veteran living independently is similar to a judgment
that one would have to make about an Alzheimer's patient, for
instance, and families that go through that difficult time when
they realize that a stove or an electric socket is no longer a
safe thing for this adult family member to be handling alone.
Ms. Munoz. Some of the family members have suggested
specially adapted equipment be included in the grants available
for home modifications like stoves that automatically turn off
after a certain amount of time or other appliances that
consider short-term memory loss for some of the Traumatic Brain
Injury veterans.
Mr. Hall. And what else do you think, Ms. Munoz, could VA
do to improve the quality of life of disabled veterans and
their families?
Ms. Munoz. It sounds simple, but I know it is very
difficult, and that it makes it easier for families to get what
they need. Any time you look at title 38 and try to determine,
well, what is this veteran eligible for or how do I go about
it, it is so hard to know who is eligible for what.
One family caregiver told me the story of, you know, we
thought we were eligible for respite care and then when we
called, my son's rating was not high enough or the SMC code was
not the right code. So they work very hard then to find out,
well, how do I get that code. And that is a backward way to
work a system.
You need to find out what does that veteran need, much like
you suggested, what is the need of that veteran and what is the
need of that family so that they can live safely and live
independently, not how do we get you pigeonholed into the right
code so you get the services that that code offers.
Mr. Hall. Thank you.
Ms. Glazer, in the program that you operate with the Army,
what kind of feedback have you had from soldiers and their
families regarding their VA benefits?
Ms. Glazer. We are serving soldiers in two ways. One is we
are collecting data about the demographics and then all the way
through from the services they get all the way through to their
career, pursuing a job and then advancing in their career.
We are also serving them by administering direct
questionnaires that are done in person. What we hear is that
among the services that they are accessing not only from the
VA, from the Department of Labor, some of the other public
agencies, as well as even some of the community supports that
the services that we are providing them, they rank very, very
highly, higher than the others.
And we believe that is because it is such an intense,
proactive model where we are actually going out and finding
them and we are staying in touch with them and we are taking
them by the hand when they go into a job interview or walking
in with them. Once they get a job, we are staying with them and
staying with the employer after they become employed.
So in summary, we are finding that they do appreciate these
services. They do not always feel that they have the
wherewithal to go out and get them which is typically the way
the VA process works. They benefit much more greatly from
somebody going out and finding them.
Mr. Hall. Does your organization work with all disabled
people?
Ms. Glazer. Yes, we do.
Mr. Hall. How would you say that the VA compensation
program compares to other programs? Are there other benefits
that could be added to the VA package that would improve or
enhance a disabled veteran's quality of life?
Ms. Glazer. Well, if you just think about cash benefits and
then medical benefits, their cash benefits are much richer for
a veteran because a veteran might be getting Social Security
disability income or even supplemental security income (SSI) in
addition to the VA benefits that they are receiving. TRICARE
and VA offer some of the best health care around.
So I think in terms of comparing benefits for a civilian to
benefits for somebody in the military, those benefits tend to
be richer than for civilians.
Having said that, the benefit system both on the civilian
side as well as on the military side does tend to be skewed
away from work very frequently. Work and career are a focus of
NOD. And what you find is that when a veteran is getting a
combination of disability pay, there could be veterans'
benefits, just regular cash benefits. That same veteran might
also be getting Social Security Disability Insurance. And then
if you layer on top of that accessing the new GI Bill, which
provides not only books and tuition but also a $1,400 a month
housing allowance, that combination of benefits tends to be
very, very, very rich.
And, unfortunately, what we find is it often skews the
decision away from work for a veteran who would otherwise
become a productive, contributing member of their society and
their community. And sometimes, frankly, it is irrational to
make a decision to go back to work and forsake some of those
cash benefits that you are receiving from a combination of the
military and the civilian benefits that you are entitled to.
Mr. Hall. Thank you.
Incarcerated veterans have had their VA benefits reduced or
terminated.
Do you think that Veterans' Courts could help facilitate
keeping more veterans involved in the VA system so veterans do
not fall deeper into poverty or homelessness upon their
release?
Ms. Glazer. Yes, we do. We think it is a very important
model that bears close scrutiny. A number of States are now
adopting these courts. Not only do they divert a veteran out of
the prison system and provide alternatives to incarceration,
but often they have specially trained magistrates who really
understand the mental health conditions that are driving many
veterans to do things that they would not otherwise do, whether
it is substance abuse or domestic violence or you name the kind
of abhorrent behavior that is a result of mental health
problems.
And with specially trained magistrates who really
understand--I just came back from Fort Carson. There is
actually a two-star General retired who is now becoming a
magistrate in the veterans' court in the State of Colorado
which is, in fact, leading the Nation in veterans' courts.
Besides having specially trained magistrates, they often
have collocated on the site of the court a whole range of
support services, whether it is housing or mental health
services or places where you can go and, in fact, get your VA
benefits. The concept of a veterans' court, we believe, has a
lot of promise in keeping people out of the court system, out
of the justice system, and more productively engaged.
Mr. Hall. Last, other countries provide veterans receiving
compensation with financial planning services and advisors.
Is that something you think the VA should do when a veteran
receives an initial award?
Ms. Glazer. Absolutely. We find that a lot of these young
men and women do not really know how to budget, how to plan for
the future, how to save money.
Those particularly who are getting Traumatic
Servicemembers' and Veterans Group Life Insurance (TSGLI),
which is a one-time only cash payment of $100,000 with a 100
percent disability rating, what many of these young men and
women do is they will go out and buy a house and mortgage to a
level that they really cannot afford or they will go out and
buy a fancy car. If they had a little bit of financial literacy
support, that money would be used much more wisely, not only
the TSGLI, but, of course, all the other benefits they are
getting.
Mr. Hall. Thank you, Ms. Glazer.
Thank you to all of our panelists, Drs. Bristow and
Kettner, and Ms. Munoz. Your testimony has been very helpful to
us. We will now excuse you from your duty here and wish you a
good day. Thank you again for your work.
Our third panel is now invited to come to the witness
table, Mr. Bradley G. Mayes, Director of Compensation and
Pension Service for the Veterans Benefits Administration of the
U.S. Department of Veterans Affairs; accompanied by Mr. Thomas
Pamperin, Deputy Director of Policy and Procedures,
Compensation and Pension Service for the VBA; and Mr. Richard
Hipolit, Assistant General Counsel of the Office of General
Counsel for the U.S. Department of Veterans Affairs.
Gentlemen, welcome. It is always good to see you here and
to hear what you are doing for our Nation's veterans. We know
you are working hard to sort through these complex problems.
Your written testimony as always is entered into the record, so
feel free to use your 5 minutes however you choose.
Mr. Mayes, you are now recognized.
STATEMENT OF BRADLEY G. MAYES, DIRECTOR, COMPENSATION AND
PENSION SERVICE, VETERANS BENEFITS ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY THOMAS PAMPERIN,
DEPUTY DIRECTOR, POLICY AND PROCEDURES, COMPENSATION AND
PENSION SERVICE, VETERANS BENEFITS ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; AND RICHARD HIPOLIT, ASSISTANT
GENERAL COUNSEL, OFFICE OF GENERAL COUNSEL, U.S. DEPARTMENT OF
VETERANS AFFAIRS
Mr. Mayes. Thank you, Mr. Chairman. Thank you for inviting
me to speak today on the timely and important issues related to
providing compensation for quality of life loss to our Nation's
disabled veterans.
Definitions of quality of life loss vary widely and may
focus on aspects of an individual's physical and mental health
or may address an individual's overall satisfaction associated
with life in general.
The Institute of Medicine traces the concept back to the
Greek philosopher Aristotle's description of happiness. Then
they go on to provide a definition that encompasses the
cultural, psychological, physical, interpersonal, spiritual,
financial, political, temporal, and philosophical dimensions of
a person's life.
A more succinct definition utilized by EconSys refers to an
individual's overall sense of well-being based on physical and
psychological health, social relationships, and economic
factors.
The most recent study of quality of life loss by EconSys
titled, ``Study of Compensation Payments for Service-Connected
Disabilities, Earnings and Quality of Life Loss Analysis,'' was
released in September 2008.
VA tasked EconSys with analyzing potential methods for
incorporating a quality of life loss component into the current
rating schedule and with estimating the cost for implementing
these methods.
The EconSys study proposed three options that could be
utilized by VA. The first and simplest method would be to
establish statutory quality of life loss payment rates based on
combined degrees of disability. EconSys has estimated that
additional annual program costs for implementing this method
range from $10 billion to $30.7 billion.
A second optional method proposed by EconSys would key
quality of life loss payment amounts to the medical diagnostic
code of the primary disability as well as to the combined
percentage rate of disability. EconSys estimated that this
method would result in annual program costs of $9 billion to
$22.2 billion.
A third option proposed by EconSys would involve an
individual assessment of each veteran for quality of life loss
by both a medical examiner and a claims adjudicator. Estimates
for this method range from $10.5 billion to $25.7 billion.
Implementing a disability rating system that compensates
for quality of life loss would involve at least two major
challenges for VA as we have heard today. The first would be to
accurately and reliably determine whether and to what extent a
disabled veteran suffers from quality of life loss. The second
would be to establish equitable compensation payments for
varying degrees of quality of life loss, which is arguably the
more difficult of the two challenges.
Most of the organizations that have provided input to VA on
quality of life loss have stated that VA has a number of
special benefits that implicitly if not expressly compensate
for quality of life loss such as ancillary benefits, special
monthly compensation, and total disability based on individual
unemployability.
Special monthly compensation and ancillary benefits are
provided to veterans in addition to compensation paid on the
basis of the schedular rating assigned to service-connected
disabilities.
The ancillary benefits to which these organizations refer
are intended to provide assistance to veterans with special
needs resulting from exceptional disabilities. They include
assistance with purchasing of an automobile or other
conveyance, obtaining the adaptive equipment necessary to
ensure that a veteran can safely operate the vehicle, acquiring
housing with special features, adapting a residence or
acquiring an already adapted residence, and, finally, providing
an annual clothing allowance.
These benefits are described in more detail in my written
statement which was submitted for the record.
Through this testimony we are attempting to outline some of
the issues and challenges that VA would face if authorized to
provide quality of life loss compensation. If VA is to provide
quality of life loss compensation consistent with the proposed
options in the EconSys study, statutory changes would be
required.
Additional administrative costs for training VA personnel
and reconfiguring VA computer systems, as well as the cost for
providing additional benefits to veterans would be
considerable. The implications for adopting such a policy are
significant for VA.
This testimony also illustrates how, in addition to
compensation provided under the rating schedule. VA provides
special monthly compensation, ancillary benefits, and extra
schedular ratings to veterans with certain service-connected
disabilities, which multiple studies have recognized as
existing tools to promote the quality of life of veterans.
As always, VA maintains its dedication to fairly and
adequately serving disabled veterans who have sacrificed for
our country.
Mr. Chairman, this concludes my testimony and I would be
pleased to answer any questions you or the Subcommittee might
have on this very important subject.
[The prepared statement of Mr. Mayes appears on p. 66.]
Mr. Hall. Thank you, Mr. Mayes.
Speaking for the Subcommittee, it appears that VA has
basically not accepted, at this point, any of the options
presented by the EconSys study. If that is the case, then what
does the VA propose to do about loss of earnings, special
monthly compensation, quality of life, and a transition
payment? Is there an approach in the works?
Mr. Mayes. The EconSys study, the Veterans' Disability
Benefits Commission, and Institute of Medicine recommended that
VA periodically review the current rating schedule to ensure
that the schedule serves as an effective proxy for average lost
earnings, which is the intent of our disability compensation
program.
We have done that four times in our history that I am aware
of: in 1956 with the Bradley Commission, the ECVARS study in
1971, the Center for Naval Analyses study that was done for the
VDBC, and the EconSys study.
Generally, CNA found that we were on par with average lost
earnings. EconSys found that we were within, I believe, 2
percentage points of average earnings in the 0 to 30 percent-
range of combined degree of disability and above par, in other
words, earnings plus VA compensation were above par up to the
100 percent rate. We were below par at the 100-percent rate.
We have two recent studies that are somewhat different. One
thing they both found was that for mental disorders, we are
below par. So what are we doing?
I believe we do need to take those recommendations to heart
and institute a periodic validation of the schedule across
diagnostic codes. Further, we are in the process of evaluating
our criteria for setting the disability compensation rate for
veterans suffering from mental disorders, including Post-
traumatic stress disorder.
Those are a couple of things that we are doing right now
that I believe both studies recommended.
Mr. Hall. In your spare time? What did you think of Dr.
Bristow's description of the Ontario evaluation system? Is that
something you were aware of before?
Mr. Mayes. We were aware of it. I believe that was
described in the IOM's report, if my recollection serves me
correctly.
EconSys also came up with a construct for arriving at an
amount to equate to certain levels of loss in quality of life.
That construct was based on the average annual payout for loss
in quality of life in Canada.
Both studies took a look at that, and it certainly sounds
like a reasonable approach. All studies that I am aware of have
taken a look at a certain cohort of the population, in this
case, disabled veterans, and tried to make a comparison between
that cohort and the nondisabled veteran population. There are a
number of ways of doing that.
Mr. Hall. Thank you.
You have already partially answered this question, I think,
but veterans have complained that the application for A&A is
very focused on ambulation and activities related to standing,
walking, and balance, which for arm amputees or for brain
injuries might not be applicable.
When was the last time that the VA reviewed the A&A
application and exam criteria? Has consideration been given to
revising it's A&A criteria to give consideration to these other
disabilities and levels of need?
Mr. Mayes. Consideration has been given. We are considering
revising the eligibility criteria for the higher level of aid
and attendance. That would be aid and attendance at the R2
level. The R2 level provides a monthly benefit amount of a
little over $7,600.
So the real issue, and it has been raised here today at
this hearing, is how you reach veterans who have significant
cognitive impairment, and we certainly are taking a close look
at that.
Do you, Dick or Tom, want to add anything to that?
Mr. Hipolit. Yes. I think it is accurate that we are
considering various approaches to how we might better serve
those veterans through the aid and attendance allowance.
Now, there are various levels of aid and attendance. Of
course, we can pay aid and attendance under the (L) rate. That
is a less generous benefit. But then for veterans who have more
serious disabilities and also have requirements for aid and
attendance at various levels, we can pay a greater benefit.
And we are assessing whether there needs to be improvements
in eligibility for the greater benefit for veterans with
cognitive disabilities.
Mr. Hall. Can a veteran, Mr. Hipolit, you can answer this
if you like, can a veteran receive a partial A&A award if they
can perform some activities of daily living but not all?
Mr. Hipolit. There are basically fixed aid and attendance
rates; there is not a half rate for aid and attendance. You
have to meet that criteria for aid and attendance. There are
various factors we consider. So we look at a total picture when
we consider eligibility for aid and attendance.
Mr. Hall. We also asked one of the earlier witnesses, and I
do not want to add another level of complication to the system,
but I am just curious if a veteran who can perform some
essential activities but not all, if there was a usefulness or
a rationale for a partial award for A&A.
Mr. Pamperin. Congressman Hall, we would like to emphasize
that we did relatively recently look at the TBI rating
criteria, which had previously been limited to a 10-percent
evaluation for subjective complaints only and published after
two summits on TBI and a lot of comments from everybody over
our proposed rule a new TBI regulation that does allow for a
100-percent evaluation, which now gets you at least to the
potential for the aid and attendance at the L level.
Mr. Hall. Thank you.
The VA notes that several studies dating back to 1956 have
identified veterans with mental disabilities as being below
income parity with their peers.
Why has it taken this long for VA to address this disparity
and what steps is the VBA taking to address this serious
compensation discrepancy besides the review of the rating
schedule for mental disorders? Can something be done more
immediately for our veterans?
Mr. Mayes. Mr. Chairman, with the conflicts in Iraq and
Afghanistan, we were seeing veterans coming back suffering from
Traumatic Brain Injury. We knew that our evaluation criteria
and the rating schedule were not adequate to address the number
of servicemembers that we were seeing coming back with
disabilities.
As Mr. Pamperin said, we undertook an effort to update and
put in place a system to properly evaluate veterans suffering
from these disorders.
The way we went about that, I think, was very successful.
We engaged the veterans' health community, Veterans Health
Administration (VHA), DoD, and stakeholders from the private
sector to learn about Traumatic Brain Injury and the
classifications of the disorder. Then we incorporated that
learning into what I think is a very meaningful regulation that
is helping veterans. I am very proud of that occurring on our
collective watch here.
What we want to do is replicate that approach for mental
health. The Institute of Medicine looked closely at PTSD. They
did at least two studies, I believe, for the Veterans'
Disability Benefits Commission. So we have information there.
But we wanted to engage the medical community again to answer
some critical questions for us so that when we write a new
regulation serving as the proxy for lost earnings, we get it
right.
We are working with the VHA right now to host a summit
similar to what we did with the TBI regulation, and we will
invite those stakeholders to participate and help us learn.
Then we will set about crafting a new regulation that I think
will do a better job.
You combine that with periodically validating the
effectiveness of our regulations, the rating schedule, and I
think we can begin to do a better job for veterans.
Mr. Hall. Well, I appreciate that. And I know our veterans
will as well.
Some veterans have noted that they must go to a Veterans
Affairs Medical Center to apply for the clothing allowance. For
some retirees using TRICARE, this is an inconvenience.
Why is the clothing allowance no longer adjudicated as an
inferred benefit by the RO?
Mr. Mayes. That was an attempt by us to make the process a
little bit more streamlined. Veterans were going to medical
centers for treatment. The medical centers were, for example,
prescribing medications that would soil clothing, clothing that
would then serve as the basis for entitlement for a clothing
allowance award.
Those applications were coming into VBA and to our VA
Regional Offices, and then we were asking VHA to certify that
the disability warranted the award of benefits.
What we were trying to do was eliminate some hand-offs and
allow VHA to make that award at the time that they are
delivering the services.
Mr. Hall. That makes sense in a lot of cases. I do not know
whether some flexibility might be a good idea or not in the
case of those veterans who are used to TRICARE, but just a
thought.
If EconSys has already mapped the ICD9 codes, wouldn't this
standardization with other medical models, including DoD and
private providers, make it easier for raters to match treatment
records and diagnoses to claimed disabilities?
Mr. Mayes. I do not know that it would make it easier for
our decision makers. What it would have the potential to do is
to allow us to do some data mining and compare our evaluations
with, for example, information out there on treatment since the
coding would be similar.
Our decisionmakers, though, are required to review all of
the evidence at the time they render a decision because we do
not want to disadvantage a veteran by missing a piece of
evidence. So we look at all of the medical evidence, whether
that be treatment records, exam reports, or psychiatric
treatment records. Then they are going to match that up against
the schedule to determine the level of severity.
It would allow us to look a little bit more after the fact
once we have assigned the evaluations.
Tom, do you want to add anything to that?
Mr. Pamperin. The question has been raised a number of
times about ICD9, and it is a very complex system of over
10,000 codes. But we do see the merit in cross-referencing with
ICD9. What we are proposing to do is to retain our current
numbering system and add a new field for service-connected
disability at the back end of what the ICD9 is that was
assigned. That way, you can compare apples to apples in terms
of doing research.
But that would be, I think, far less difficult to do than
to completely overhaul the rating schedule with a new numbering
system, which then would drive major modifications to computer
systems, whereas if you just put another field into the
service-connected numbering system, I think you achieve the
objective.
Mr. Hall. Mr. Mayes, can you further explain how the VA
would go about reviewing ancillary benefits to determine where
additional benefits such as assistive devices may be
appropriate to improve a veteran's quality of life? What do you
envision a benefits package as such would look like?
Mr. Mayes. I heard the previous panel, and the design
initially for ancillary benefits I do not believe was to per se
compensate for lost quality of life, but really to meet needs
that were identified by veterans suffering from severe
disabilities, for example, the clothing allowance and the
automobile grant, the home adaptation grant.
As those needs change, and I heard two panelists previously
say this we need to evolve. An example would be veterans who
are suffering from severe burn injuries; they are surviving
today when they possibly did not survive in previous conflicts
because of advances in health care. So we need to adjust.
We have worked on modifying the eligibility criteria for
the specially adapted housing grant to accommodate veterans
suffering from severe burn injuries.
Those are the kinds of things we need to do. I think we
need to take a look at the automobile grant. It is currently
$11,000. We are taking a look at that to see if that is meeting
the needs of veterans to help offset the cost of the purchase
of an automobile.
We need to continually do that, and I am going to take that
away from today's hearing.
Mr. Hall. Thank you.
Two more questions, Mr. Mayes, and I think we may actually
have our first hearing that is not interrupted by a vote.
Mr. Mayes. The one that went to about 8:30 that night----
Mr. Hall. I am sorry.
Mr. Mayes [continuing]. Will stick in my memory forever.
Mr. Hall. Well, we all remember that one.
Do you have a rough estimate at this point of the
percentage of returning OEF/OIF veterans who are suffering from
TBI?
Mr. Mayes. Do you have that, Tom?
Mr. Pamperin. We will get the exact number for you. But
when we revised the TBI regulation, I believe the total number
of people in the system from all wars who had a service-
connected diagnostic code was about 12,000.
TBI is not in the top ten list of returning veterans filing
claims for benefits. I cannot honestly say where it is, but we
can easily get that number for you.
Mr. Mayes. We will provide that for the record, Mr.
Chairman.
[The VA subsequently provided the following information:]
L Nine thousand two hundred sixteen living veterans
discharged on or after September 11, 2001, are service-
connected for TBI. Based on Department of Defense data from May
31, 2009, and VA records of veteran-reported Global War on
Terror (GWOT) service through July 31, 2009, approximately
1,135,000 living Veterans had GWOT service.
Mr. Hall. Thank you.
Has the VA considered revising its policies on the SMC(S)
rate as suggested by Mr. Abrams in light of the Bradley v.
Peake decision?
Mr. Mayes. Interestingly enough, we sent policy guidance
out yesterday on that. This is a case where the court
interpreted a longstanding regulation interpreting a statutory
requirement. The court held that our interpretation was overly
restrictive. It is binding on VA, and we are going to
administer the housebound benefit at the (S) rate per the
court's decision.
Dick, did you want to elaborate on that?
Mr. Hipolit. Yes. I think that is correct. We have actually
recognized in our regulation for some time that you could get
the (S) rate for a single disability found to be totally
disabling, based on individual unemployability plus an
additional disability of 60 percent or more. That may not have
been applied consistently across the board.
We do recognize the court's decision. We are working to
implement it. Guidance is going out now. We are also looking at
whether we need to amend our regulations to further incorporate
changes in our system.
Mr. Hall. Could you supply this Subcommittee with a copy of
the guidance that you just referred to that you sent out
yesterday, please?
Mr. Mayes. Sure.
[The VA subsequently provided Fast Letter 09-33, to
Director, All VA Regional Offices and Centers, regarding
Special Monthly Compensation at the Statutory Housebound Rate,
dated July 22, 2009, which appears on p. 74.]
Mr. Hall. And we are also still curious to see the Booz
Allen Hamilton report.
Mr. Mayes. As soon as that is cleared, Mr. Chairman, we
will get it over to the Hill.
[The Booz Allen Hamilton report entitled, ``Veterans
Benefits Administration Compensation and Pension Claims
Development Cycle Study,'' dated June 5, 2009, is being
retained in the Committee files.]
Mr. Hall. Okay.
Mr. Mayes. It is still in draft. I checked before I came
over.
Mr. Hall. Well, thank you very much. We are looking forward
to that as well.
Thank you for the work that you are doing.
I would like to remind the Members that they have 5
legislative days to revise and extend their remarks.
Thank you for the work that you are doing. I know it is a
terribly busy, complex time, and we here in Congress keep
making more requests and adding to your workload and to VA's
workload, which is already impressive and staggering. But, we
are all pulling, I think, pulling the oars in the same
direction and trying to better the care, treatment, and quality
of life of our veterans who have served this country.
So, thank you for your statements today, your insight, and
your opinions.
This hearing stands adjourned.
[Whereupon, at 11:55 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. John J. Hall, Chairman,
Subcommittee on Disability Assistance and Memorial Affairs
Good Morning Ladies and Gentleman:
The Subcommittee on Disability Assistance and Memorial Affairs of
the House Committee on Veterans' Affairs' hearing on, ``Examining the
Ancillary Benefits and Veteran's Quality of Life Issues'' will now come
to order.
I ask that you please rise for the Pledge of Allegiance.
This Subcommittee has actively tackled many complex and complicated
issues that have been encumbering the Veterans Benefits
Administration's ability to properly compensate veterans who file
disability claims. These issues have majorly centered on VA business
processes and operations. Today's hearing will focus on the actual
appropriateness of available benefits in meeting the needs of disabled
veterans and their families.
The expressed purpose of VA disability compensation as outlined in
38 United States Code Section 1155 is based upon the average impairment
of earning capacity. This concept dates back to the 1921 Rating
Schedule, which had its roots in the blossoming workman's compensation
programs. Then, the primary concern was to ensure that disabled World
War I veterans would not become a burden on their families or
communities when they could no longer perform the laborious tasks most
civilian occupations required at that time. Over the years, Congress
has added several elements to the VA compensation package to assist
disabled veterans procure shelter, clothing, automotive, employment,
vocational rehabilitation and in-home assistance. In its expansion of
these benefits, Congress has attempted to meet disabled veterans and
their families' social and adaptive needs, and not solely their
economic needs.
In recent years, several commissions and institutions--many of
whose members we will hear from today--have studied the appropriateness
of VA benefits including a potential quality of life loss payment. They
have identified significant challenges in developing an instrument or
rating schedule that could fairly calculate compensation for the loss
of quality of life. Much of what makes a life of quality is subjective
and goes beyond fulfilling basic human needs or replacing impaired
income. Furthermore, I realize that there is no amount of money that
can replace a limb or peace of mind. Ensuring that veterans impaired by
amputation, blindness, deafness, brain injury, paralysis, and emotional
distress are afforded the necessary resources to lead productive,
satisfying lives is the debt a grateful Nation owes these brave souls.
VA has in fact attempted to recognize that in order to make some
veterans whole, there is a need to provide additional compensation that
accounts for non-economical factors, including personal inconvenience,
social inadaptability and the profoundness of the disability. Part of
the problem may be that the formula and criteria used for adjudicating
VA ancillary benefits and special monthly compensation is complex and
often confusing to the beneficiaries themselves. Often times, disabled
veterans are unsure of this added benefit, which leads to an inability
to predict or plan for their future based on their VA assistance.
Without transparency, transitioning wounded warriors are at a severe
disadvantage if they cannot count on and predict their VA benefits
package. Having this knowledge could be a big help to these veterans
and more transparency and outreach is definitely needed in the
ancillary benefits area.
I am eager to hear from today's witnesses many of whom are experts
in the complexities and paradigms for compensating military related
disabilities. I am also eager to hear from VA on its late-delivered VBA
Response to the EconSys Quality of Life, Earnings Loss and Transition
Payments study as mandated in Section 213 of P.L. 110-389. These
veterans must be returned to their country, communities, and homes with
the tools and resources to rebuild a life of quality.
I now yield to Ranking Member Lamborn for his Opening Statement.
Prepared Statement of Hon. Doug Lamborn, Ranking Republican Member,
Subcommittee on Disability Assistance and Memorial Affairs
Thank you Mr. Chairman,
I welcome our witnesses to this hearing to discuss the important
issues of ancillary benefits and quality of life.
It is a terrible tragedy when one of our Nation's servicemembers
are severely injured, and no amount of compensation can ever make up
for the immeasurable sacrifice they have made in defense of our
country.
It is these veterans with whom we should be most concerned, and
every effort should be expended to ensure that they are able to lead
lives that are as close to normal as possible.
I am particularly concerned about veterans in need of Aid and
Attendance.
Much discussion has taken place recently with regard to family
caretakers and what services should be available for them.
In my opinion, care for severely disabled veterans is the sole
responsibility of the government that sent them to war, and zero burden
should be placed on veterans' family members.
Obviously, many of our veterans' family members WANT to be there to
care for their injured soldier, and that is wonderful if it is by
choice, but it should never be out of necessity.
Compensation paid to the severely injured servicemembers should be
more than adequate enough to obtain services necessary to meet the
needs of daily living.
I look forward to our witnesses' testimony and working with Mr.
Chairman Hall to address any shortcomings that might be revealed as a
result of these proceedings.
Thank you, I yield back.
Prepared Statement of Carl Blake, National Legislative
Director, Paralyzed Veterans of America
Mr. Chairman and Members of the Subcommittee, on behalf of
Paralyzed Veterans of America (PVA) I would like to thank you for the
opportunity to testify today on the ancillary benefits provided by the
Department of Veterans Affairs (VA) and how they impact the quality of
life issues that veterans must deal with. PVA appreciates the efforts
of this Subcommittee to address the varying needs of our veterans,
particularly veterans with severe disabilities, such as spinal cord
injury. We hope that addressing these particular issues will better
benefit today's veterans and the veterans of tomorrow.
PVA members represent one of the segments of the veteran population
that benefit most from the many ancillary benefits provided by VA.
Without the provision of benefits such as Special Monthly Compensation
(SMC), the Specially Adapted Housing (SAH) grant, and the Clothing
Allowance, our members, and other severely disabled veterans, would
experience a much lower quality of life and would in many cases be
unable to live independently. With these thoughts in mind, we will
focus our statement on some of the key ancillary benefits that PVA
members receive, improvements that might be made, and the relationship
quality of life has to these benefits.
Also, we would like to encourage the Subcommittee to review the
final report of the Veterans' Disability Benefits Commission (VDBC)
released in October 2007. The VDBC conducted one of the most thorough
evaluations of ancillary benefits, as well as the entire VA claims
process, ever completed. PVA tended to agree with many of the
recommendations included in the VDBC report, particularly as it relates
to improving ancillary benefits and addressing quality of life issues.
Special Monthly Compensation (SMC) and Aid and Attendance Benefits
Special Monthly Compensation represents payments for ``quality of
life'' issues, such as the loss of an eye or limb, the inability to
naturally control bowel and bladder function, the inability to achieve
sexual satisfaction or the need to rely on others for the activities of
daily life like bathing, or eating. To be clear, given the extreme
nature of the disabilities incurred by most veterans in receipt of SMC,
we do not believe that the impact on quality of life can be totally
compensated for; however, SMC does at least offset some of the loss of
quality of life.
PVA believes that an increase in SMC benefits is essential for our
veterans with severe disabilities. Many severely injured veterans do
not have the means to function in an independent setting and need
intensive care on a daily basis. Many veterans spend more on daily
home-based care than they are receiving in SMC benefits. This can place
a significant financial strain on these veterans and often results in
them being forced to opt for institutionalization.
To support our recommendation, we encourage the Subcommittee to
review the recommendations of the VDBC report. As explained by the
VDBC:
Veterans with catastrophic disabilities and their families
face many challenges that make it harder for them to maintain a
reasonable standard of living and compete with their peers. SMC
adjustments help protect the health and welfare of severely
disabled, service-connected veterans and their families.
However, after considering the studies conducted by IOM
(Institute of Medicine) and CNAC (Center for Naval Analysis)
and other information, the Commission concluded that there are
some instances, such as Aid and Attendance, in which the level
of SMC is inadequate to offset the burden placed on veterans by
their disabilities.
In the VDBC report, Recommendation 6.1 states that ``Congress
should consider increasing special monthly compensation where
appropriate to address the more profound impact on quality of life.''
PVA supported that recommendation then, and we continue to advocate for
this important change.
One of the most important SMC benefits to PVA is Aid and Attendance
(A&A). PVA would like to recommend that Aid and Attendance benefits
should be appropriately increased. Title 38 U.S.C. establishes
eligibility for Aid and Attendance benefits. Furthermore, 38 CFR sets
the conditions for receipt of Aid and Attendance benefits as follows:
(1) they (the veteran) cannot keep themselves ordinarily clean and
presentable, (2) they cannot dress and undress themselves, (3) they
frequently need adjustment of special prosthetic or orthopedic
appliances, which by reason of the particular disability cannot be done
without aid, (4) they cannot feed themselves due to the loss of
coordination of upper extremities or extreme weakness, (5) they cannot
attend to the wants of nature, (6) they have physical or mental issues
that prevent them from avoiding the hazards or dangers of daily life.
Attendant care is very expensive and often the Aid and Attendance
benefits provided to eligible veterans do not cover this cost.
As an example, a particular PVA member who lives in Florida
incurred a spinal cord injury while serving in Vietnam. He was shot
through the neck and his spinal cord was severed at the C2/C3 level
resulting in quadriplegia. In order to operate his power wheelchair, he
has to use a ``sip-and-puff'' mechanism. Fortunately, his mother
provided most of his attendant care to him throughout his adult life. A
couple of years ago, his mother passed away, and he has no other
immediate family to take care of him. He is now paying for a full-time
attendant, but his cost for attendant care far exceeds the amount he
receives as an SMC-Aid and Attendant beneficiary at the R2 compensation
level (the highest rate available).
Finally, PVA would like to suggest that the Veterans Benefits
Administration (VBA) should develop experts who deal expressly in SMC
benefits. The complex nature of this particular component of VA
compensation can be overwhelming for many claims rating specialists who
work secondarily on SMC. With in-house experts who deal specifically
with SMC cases, the VA could more accurately and efficiently decide
these claims. In order to promote this demonstrated need, PVA has
prepared a Guide for Special Monthly Compensation (SMC) that has been
adopted by the VA for use when training ratings specialists. This
information has been included on the VA's intranet. The PVA Guide has
also been distributed through VBA's Special Monthly Compensation
training. We would also suggest that the claims process could likewise
benefit from specialized staff members who deal strictly with radiation
claims and claims of former prisoners of war.
Specially Adapted Housing Grant and Adaptive Automobile Assistance
In recent years, Congress has taken significant steps to improve
the Specially Adapted Housing grant program. Unfortunately, less has
been done to improve Adaptive Automobile assistance. These two benefits
in particular are keys to a veteran living an independent life.
PVA is pleased that Congress recently made significant improvements
to the Specially Adaptive Housing benefits provided by the VA to
severely disabled veterans. These changes were incorporated into P.L.
110-289, the ``Housing and Economic Recovery Act of 2008.'' The new
housing law makes an appropriate increase in the maximum dollar amount
for the Specially Adaptive Housing (SAH) Grant. That amount is
increased to $60,000. The last increase was in 2003, when it was
increased to $50,000 from $48,000. Construction materials cost for
single family homes in recent years has increased approximately 16
percent (U.S. Bureau of Labor Statistics). The new law also makes an
adjustment to the maximum amount each year based on the residential
home cost-of-construction index. This needed increase was recommended
in The Independent Budget, co-authored by Paralyzed Veterans of
America, Disabled American Veterans, Veterans of Foreign Wars, and
AMVETS.
The law allows for the VA to pay for home improvements and
structural alterations for members of the Armed Forces that incur a
severe disability and who would otherwise qualify for the SAH grant as
a veteran. In the past, active duty servicemembers had to be discharged
from military service to apply for the SAH benefit. This new change in
the law allows a servicemember who will not return to active duty
because of a service-connected disability, to make the necessary
alterations to their home while waiting for their final discharge.
Additionally, the law allows an individual that qualifies for the home
modification grant, to use that grant to modify the home of a family
member while residing with that family member (known as Temporary
Residence Adaptation). It is common for a servicemember that has
suffered a traumatic injury to live with family members during their
rehabilitation and a period afterward.
Unfortunately, few eligible claimants have taken advantage of the
Temporary Residence Adaptations (TRA) grant, which are limited to
$16,000 and counts against the SAH allowance of $60,000. In a recent
report, the Government Accountability Office (GAO Report GAO-09-637R
June 15, 2009) found that only nine recipients have used the grant
since the change in law and suggested that the low usage may be
improved if the grant were a stand alone program. We believe Congress
should consider this option.
One of the common injuries associated with service in Operation
Enduring Freedom and Operation Iraqi Freedom is severe burns. This
change in law for the overall SAH program will allow individuals that
have suffered severe burns to use the Specially Adaptive Housing Grant
for necessary modifications in their home environment. These
modifications could involve expensive air filter systems and electronic
temperature controls for the home.
We would encourage the Subcommittee to further examine some of the
recommendations included in the FY 2010 Independent Budget regarding
the adaptive housing benefits. Specifically, The Independent Budget
calls for establishing a grant for adaptation of a second home when a
veteran chooses to replace his or her current adapted home. The
Independent Budget also calls for an increase in the grants for
adaptation of homes for veterans living in family owned temporary
residences from the current $14,000 to $28,000 for veterans with a
total and permanent service-connected disability and from $2,000 to
$5,000 for veterans with service-connected blindness.
As previously mentioned, we are concerned that the automobile grant
and adaptive automobile assistance has not kept pace with the current
market. Currently, the automobile grant provides $11,000 toward the
purchase of a new car for severely disabled veterans. However, in 2008,
the average cost of a new car was $28,500. When the automobile grant
was first created by Congress, it covered the full cost of a new
vehicle. In 1946, the benefit covered 85 percent of the cost of a new
vehicle; today the grant only covers 39 percent of the cost. The
Independent Budget recommends that the grant be increased to 80 percent
of the cost of a new vehicle ($22,800) and be indexed annually based on
the rising cost of living.
Service-Disabled Veterans' Insurance and
Veterans' Mortgage Life Insurance
In accordance with the recommendations of The Independent Budget,
PVA also believes that there are some necessary improvements in the
Service-Disabled Veterans' Insurance (SDVI) and Veterans' Mortgage Life
Insurance (VMLI). With regards to the SDVI benefit, The Independent
Budget for FY 2010 recommended that the insurance benefit be increase
from $10,000 to $50,000. However, we recently supported legislation--
H.R. 2713--considered by this Subcommittee that would increase the
maximum amount of protection from $10,000 to $100,000, and would
increase the supplemental insurance for totally disabled veterans from
$20,000 to $50,000. Ultimately, we would like to see the Subcommittee
consider legislation that would increase SDVI to the maximum benefit
level provided by the Servicemembers' and Veterans' Group Life
Insurance (SGLI/VGLI) programs. We also believe that the premium waiver
for 100 percent total and permanent service-connected veterans should
be automatic, rather than require an unnecessarily long application
process for the waiver.
The Independent Budget also recommends that VMLI be increased from
the current benefit of $90,000 to $150,000. The last time VMLI was
increased was in 1992. Since that time, housing costs have risen
dramatically, but the VMLI benefit has not kept pace. As a result, many
catastrophically disabled veterans have mortgages that exceed the
maximum value of VMLI.
Expediting Provision of Benefits
Recent hearings have demonstrated how far behind the VBA is in
using information technology in its claims adjudication process. While
we believe that the entire claims process cannot be automated, there
are many aspects and steps that certainly can. We have long complained
to the VA that it makes no sense for severely disabled veterans to
separately apply for the many ancillary benefits to which they are
entitled. Their service-connected rating immediately establishes
eligibility for such benefits as the Specially Adapted Housing grant,
adaptive automobile equipment, and education benefits. However, they
still must file separate application forms to receive these benefits.
That makes no sense whatsoever.
Moreover, certain specific disabilities require an automatic rating
under the disability ratings schedule. For example, it does not take a
great deal of time and effort to adjudicate a below knee single-leg
amputation. An advanced information technology system can determine a
benefit award for just such an injury quickly. We believe that it is
time for the VA to automate consideration of ancillary benefits and
specific ratings disabilities that are generally automatic.
Quality of Life
Mr. Chairman, one of the subjects that often generates a great deal
of debate when discussing VA compensation benefits is the consideration
of quality of life. PVA has expressed serious concerns in the past,
particularly during the deliberations of the Veterans' Disability
Benefits Commission and the Dole-Shalala Commission, with the assertion
that the schedule for rating disabilities is meant to reflect the
average economic impairment that a veteran faces. Disability
compensation is in fact intended to do more than offset the economic
loss created by a veteran's inability to obtain gainful employment. It
also takes into consideration a lifetime of living with a disability
and the every day challenges associated with that disability. It
reflects the fact that even if a veteran holds a job, when he or she
goes home at the end of the day, that person is still disabled.
Seriously disabled veterans have the benefit of many adaptive
technologies to assist with employment. But these technologies do not
help them overcome the many challenges presented by other events and
activities that unimpaired individuals can participate in. Most, if not
all, spinal cord injured veterans no longer have the ability to
conceive children with a loved one. They cannot perform normal bowel
and bladder functions or bathe themselves. They cannot play ball with
their children or carry them on their shoulders. Severely disabled
veterans suffer from potential negative stereotypes due to disability
in all aspects of their lives.
There can be no question but that VA compensation includes a real
and significant component that is provided as an attempted response to
the impact of a disability on the disabled veteran's quality of life.
And yet, we would argue that compensation could never go too far in
offsetting the impact that a veteran's severe disability has on his or
her quality of life.
Mr. Chairman and Members of the Subcommittee, PVA would once again
like to thank you for the opportunity to provide our views on ancillary
benefits and quality of life issues. We look forward to working with
you to improve these benefits.
Thank you again. I would be happy to answer any questions that you
might have.
Prepared Statement of Ronald B. Abrams, Joint Executive Director,
National Veterans Legal Services Program
MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
Thank you for the opportunity to present the views of the National
Veterans Legal Services Program (NVLSP) on ancillary VA benefits and
veterans' quality of life issues.
NVLSP is a nonprofit veterans service organization founded in 1980.
Since its founding, NVLSP has represented thousands of claimants before
the Board of Veterans' Appeals and the Court of Appeals for Veterans
Claims. NVLSP is one of the four veterans service organizations that
comprise the Veterans Consortium Pro Bono Program, which recruits and
trains volunteer lawyers to represent veterans who have appealed a
Board of Veterans' Appeals decision to the CAVC without a
representative. In addition to its activities with the Pro Bono
Program, NVLSP has trained thousands of veterans service officers and
lawyers in veterans benefits law, and has written educational
publications that thousands of veterans advocates regularly use as
practice tools to assist them in their representation of VA claimants.
The VA, under 38 U.S.C. Sec. 1114 and 38 CFR Sec. 3.350 has a level
of monetary benefits, described as Special Monthly Compensation (SMC).
SMC benefits are paid in addition to the basic rates of compensation
payable under the Schedule for Rating Disabilities. SMC is paid to
compensate veterans for service-connected disabilities such as loss of
use of a hand or a foot, impairment of the senses, loss of vision or
hearing, and for combinations of severely disabling service-connected
disabilities. While the basic rates of compensation are predicated on
the average reduction in earning capacity, special monthly compensation
benefits are based on noneconomic quality of life issues such as
personal inconvenience, social inadaptability, or the profound nature
of the disability.\1\
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\1\ VA Gen. Coun. Prec. 5-89 (Mar. 23, 1989).
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A recent decision by the United States Court of Appeals for
Veterans Claims (CAVC or Court) reveals that the VA has unlawfully
limited the impact of a section of 38 U.S.C. Sec. 1114. The Department
of Veterans Affairs, the veterans service organizations and the
Congress should act now to implement this CAVC decision.
The statute involved, Section 1114(s), mandates increased benefits
for veterans who are so unlucky as to have a service-connected
disability rated as total, and suffer from additional service-connected
disability or disabilities independently ratable at 60 percent or more.
This benefit is usually called SMC(s).
Currently, a veteran entitled to SMC(s) without dependents is paid
$320 more per month than a veteran entitled to a total evaluation
($2,993 as opposed to $2,673). The idea behind this benefit is that a
veteran who has a service-connected condition that causes total
disability and has significant other disabilities should be paid more
than a veteran who just has the one disability.
The problem is that for many years the VA implemented Section
1114(s) with a regulation that unlawfully limited the beneficial impact
of the statute. The regulation, 38 CFR Sec. 3.350(i)(1), requires a
veteran to have one service-connected disability rated as 100 percent
disabling to be considered for SMC(s) benefits. This regulation, 38 CFR
Sec. 3.350(i)(1) states:
[T]he special monthly compensation provided by 38 U.S.C. 1114(s)
is payable where the veteran has a single service-connected disability
rated as 100 percent and, has additional service-connected disability
or disabilities independently ratable at 60 percent, separate and
distinct from the 100 percent service-connected disability and
involving different anatomical segments or bodily systems.
The language of the statute, however, requires total disability
based on a single condition--not a single disability that qualifies for
a 100 percent schedular evaluation. In other regulations, the VA has
acknowledged that a service-connected disability that causes impairment
of mind or body which is sufficient to render it impossible for the
average person to follow a substantially gainful occupation is a total
disability. See 38 CFR Sec. Sec. 3.340(a), 4.15, 4.16(a).
In Bradley v. Peake,\2\ the Court of Appeals for Veterans Claims
(CAVC) finally dealt with this issue. This veteran sustained multiple
shell fragment wounds from a booby trap in Vietnam. He is service-
connected for thirteen compensable scars and 10 separate muscle group
injuries. He is also entitled to compensation benefits for Post-
traumatic stress disorder (PTSD).
---------------------------------------------------------------------------
\2\ 22 Vet. App. 280, (2008).
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The veteran was granted total disability based on individual
unemployability (TDIU) from March 25, 1983, until June 8, 1992, and
then he was granted a 100 percent combined rating from June 8, 1992.
Between 1971 and 2006, the VA made thirteen different adjudications to
come to the above conclusions.
The Board of Veterans' Appeals (BVA or Board) denied Mr. Bradley's
claim for SMC(s) and he appealed that decision to the CAVC. The CAVC
held that:
Section 1114(s) does not limit ``a service-connected
disability rated as total'' to only a schedular rating of 100 percent--
it includes a disability that would support the grant of TDIU.
When a veteran has several service-connected conditions
that combine to a 100 percent evaluation, if the veteran would be
monetarily advantaged by a having just one service-connected condition
support a total TDIU rating and the veteran has other service-connected
conditions that combine to 60 percent, the VA is obligated to rate the
case to maximize the benefits that can be paid to the veteran. This is
true because under 38 CFR Sec. 3.103(a) the VA is obligated to render a
decision which grants every benefit that can be supported in law.
Because SMC benefits must be granted when a veteran
becomes eligible without need for a separate claim,\3\ any effective
date must be based on that point in time when the evidence first
supported an award of SMC, which may be well before the veteran raised
this issue. See 38 U.S.C. Sec. Sec. 5110(a), 1114(s); 38 CFR
Sec. 3.400(o).
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\3\ Akles v. Derwinski, 1 Vet.App. 118, 121 (1991).
The Bradley decision should have a major impact both on current
claims and claims that have been previously adjudicated. Many severely
disabled veterans should receive significant retroactive payments.
The positive impact of Bradley will improve the quality of life for
those veterans who are unfortunate enough to suffer from several severe
service-connected disabilities. In addition, now the VA, upon request,
will have to readjudicate Bradley type claims and pay increased
benefits from the date the evidence first supported an award of SMC(s).
We hope that the VA will take it upon itself to encourage its raters to
review previous rating for these potential retroactive benefits.
The Bradley decision gives the VA the opportunity to quickly
improve the financial situation of many veterans. Therefore, we have
contacted the VA and asked them to consider amending certain sections
of Adjudication Procedures Manual M21-1 MR that may be interpreted as
requiring a single schedular 100 percent rating as a requirement for
SMC(s).\4\ In addition we have asked that the VA to re-rate cases that
it recognizes as having the potential for increased benefits under the
holding in Bradley.
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\4\ M21-1 MR Part IV, Subpart II, Chapter 2, par. 56a.
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That completes my testimony. I would be pleased to answer any
questions the Members of the Subcommittee may have.
Prepared Statement of Thomas Zampieri, Ph.D.,
Director of Government Relations, Blinded Veterans Association
INTRODUCTION
Chairman Hall, Ranking Member Lamborn, and Members of the House
Veterans' Affairs Subcommittee on Disability Assistance and Memorial
Affairs:
On behalf of the Blinded Veterans Association (BVA), thank you for
this opportunity to present our testimony today regarding veterans'
ancillary benefits and quality of life issues affecting them.
BVA was founded in 1945 and Congressionally chartered in 1958 as
the only Veterans Service Organization (VSO) exclusively dedicated to
serving the needs of our Nation's blinded veterans and their families.
The organization's governing body and members are proud of BVA's
continuing advocacy of the important benefits and health care issues
affecting them.
BVA has joined with other VSOs in awaiting action on
recommendations provided by the Veterans Disability Benefits Commission
(VDBC) that would improve the benefits and services for our Nation's
wounded. After reviewing the recent 7-month report issued by Economics
Systems, Inc. (Econsys), however, BVA questions some of the
recommendations on Quality of Life for veterans with service-connected
sensory disabilities. As this Subcommittee is already aware, VDBC was
created by Public Law 108-136. With the assistance of the Institute of
Medicine and many other organizations, appointed commissioners spent
more than 2 years reviewing extensively current VA benefits and
compensation for disabled veterans. Its final report made clear that
the current system required fundamental changes, one of which was the
mechanism used in determining benefits affecting Quality of Life
payments.
BVA is concerned that Econsys presented this research in order to
develop a Quality of Life measurement tool based on the 7-month time
frame on reporting. We believe that the complex objective and
subjective ``instruments'' for a new payment system will require more
consideration by Congress than what is being presented here today.
Quality of Life measurements themselves are not only objective measures
of Activities of Daily Living (ADL), but the subjective concepts of
pain levels, negative emotions, and social difficulties and if not
carefully considered, the latter could easily be excluded from
determinations of fair measurement in looking at the impact of Quality
of Life compensation for service-connected disabilities. We strongly
refute the statement on Page 22 of the Econsys report that ``the lowest
level of Quality of Life loss for disabled veterans was for skin, ear,
and eye body systems.'' We believe that Members of Congress would also
question such a claim.
BLINDED VETERANS' QUALITY OF LIFE
Mr. Chairman, as fellow veterans who have lost sensory function
could all testify, the reactions to blindness and disability are
varied. Fear, overwhelming stress and anxiety, depression, and anger
are just some of the typical responses to the loss of vision. Our
degree of independence is dramatically diminished and our quality of
life completely disrupted and forever changed. Loss of vision is
accompanied by the sudden loss of freedom to move around safely and
independently. In order to overcome the limitations imposed by vision
loss, it has been necessary for us to undergo the type of continuous
and comprehensive rehabilitation that is always changing as we adapt to
new challenges--and as the field of rehabilitation and technology
evolve.
We must constantly learn new ways of coping with and managing our
lives in the absence of vision as these changes in our world bring with
them the requirement for more training and education in new methods and
techniques in order to optimize their relevance for us personally. It
would be wrong to think that once a veteran has received some training
that the support and current benefits rating system assistance needed
is entirely sufficient. Impact on Quality of Life from the catastrophic
loss incurred must be considered. Blinded veterans have been successful
in adapting to adversity in large part through the support and
assistance received from families and also through the benefits and
services provided by VA Blind Rehabilitation Service programs and a
variety of VA benefits. BVA found this statement in the Econsys report
``That consensus on a definition of overall QoL still eludes many
researchers. QoL is a multi-dimensional construct that is typically
defined on the basis of the specific form of the research.''
Please consider, Mr. Chairman, that the process of recovery from
any tragic or traumatic event is characterized by a period of grieving
followed by rehabilitation and restoration. Substantial changes are
normally required as a result of such shattering events before a new
and productive life can be discovered. Similar to the grief experienced
by those who have experienced any type of catastrophic event, blinded
veterans also must grieve their loss of vision. The late Father Thomas
Carroll, a recognized expert in the field of blindness and
rehabilitation after World War II, wrote that people who lose their
vision must first grieve for the death of the sight itself. Grieving is
a very individualized process that lacks definite time limits. Only as
the grieving process ends is the individual ready to engage in
rehabilitation. Perception plays the one major role in an individual's
ability to live life. Although all five of our body's senses play a
significant role, the visual system is critical to perception,
providing more than 70 percent of human sensory awareness of everything
we know, with hearing being another critical component of our sensory
awareness. Considering that hearing losses and visual impairments are
two common sensory losses that have also occurred from Improvised
Explosive Devices (IED) in Iraq and Afghanistan, we cannot
overemphasize the importance of assessing them carefully in the process
of rating such sensory injuries common with Traumatic Brain Injuries.
Vision also provides information about environmental properties. It
allows individuals to act in relation to such properties. In other
words, perceptions allow humans to experience their environment and
their Quality of Life in order to live within it. Individuals perceive
what is in their environment by a filtered process that occurs through
a complex, neurological visual system. With various degrees of visual
loss come greater difficulty to clearly adjust and see the environment,
resulting in increased risk of injuries, loss of functional ability,
and unemployment. Impairments range from losses in the visual field,
visual acuity changes, loss of color vision, light sensitivity
(photophobia), and loss of the ability to read and recognize facial
expressions. Complete blindness is considered by VA to be a
catastrophic loss of a body system in determining service-connected
benefits.
CURRENT SYSTEM REVIEW
VDBC was faced with a complex task that has confronted all levels
of local, State, and Federal Government agencies trying to regulate
disability ratings over many decades. Their comprehensive findings
included the recommendation that VA should develop Quality of Life
compensation. On February 26, 2008, before this Committee, VDBC
Chairman Terry Scott testified that ``there has been an implied but
unstated congressional intent to compensate disabled veterans for
impairment of quality of life due to their service-connected
disabilities.'' The attempt to determine the validity of the current
rating and disability compensation systems for economic loss is
appropriate but VDBC found ``no current compensation for the impact of
disability on the quality of life.'' The Veterans Benefits
Administration (VBA) does not adequately compensate a veteran who has
suffered from a significant life-altering disability that impacts daily
activity and functioning.
Veterans who cannot be classified as permanent service-connected
disabled should indeed be considered as such on the basis of Quality of
Life. Assessments should be done on impact regarding their ability to
perform daily activities. BVA feels strongly that the soldiers, airmen,
sailors, or marines who have developed blindness or another
catastrophic disability should all be rated and treated equitably and
with the appropriate support needed in the processing of their claims,
both for economic loss as well as Quality of Life losses. A system in
which one severely disabled veteran receives a lower percentage of
compensation for an injury than that of another veteran will be viewed
as unfair and add to an already existing perception that the system is
adversarial for some veterans.
Many national surveys demonstrate that in the past decade, since
the passage of the Americans with Disabilities Act, very little
progress has been made in the employment rates of the disabled. Among
several sources, one being the respected Cornell University Centers on
Disability Statistics Annual Disability Status Report for FY 2007
(www.disabilitystatistics.org), data indicate that the country's
disabled non-institutionalized population of working adults age 21-64
still have significantly lower rates of employment, lower earnings, and
lower household income than the non-disabled when comparisons are made
using several disability types. Examples of such research findings
follow:
The 2007 Census Bureau's survey found that 60.1 percent
of disabled men between ages 21-64 and with one disability were
employed. When reviewing data on those with a severe disability
affecting daily functioning skills, the rate is only 32 percent.
Despite improvements in transportation accessibility,
levels of participation in social, cultural, and commercial activities
have not increased measurably during the past decade and 30 percent of
the disabled in rural regions of the country have no access to public
transportation.
The Survey of Income and Program Participation (SIPP)
found that, in 2007, 24.7 percent of working age adults who were
limited in their ability to work lived at or below the poverty level.
Some 22.1 percent with a sensory disability lived at or below that
level.
Census Bureau American Community Survey (ACS) in 2007
found that individuals with a sensory disability age 16-64 in the
general population lived in households with a median income $22,600
lower than that of average households containing non-disabled members.
From FY 1996 to FY 2005, the total Federal workforce
increased by more than 78,000 employees. The total represents a net
increase of about 3 percent. During that same time period, the number
of Federal employees with targeted disabilities decreased from about
30,000 to approximately 25,000. The drop represents a net decrease of
16 percent.
The National Council on Disabilities' March 2009 Report
reveals that the percentage of workers has declined steadily since 1994
and is now at its lowest level in two decades. Even with ADA and other
attempts to increase disability participation in the workforce, public
discrimination and negative attitudes toward those with disabilities
persist in the workforce environment.
The claim has been made in recent times that emerging technology
has made access to employment and independent living for the disabled
easier than ever before. We believe evidence strongly suggests that
this is not the case. According to National Council on Disability (NCD)
Chairperson John R. Vaughn, the United States already has in place a
string of Federal laws and regulations designed to guarantee various
levels of access to telecommunications products and services. He states
further that such service nevertheless leaves gaps in coverage and are
rapidly becoming outdated as the analog technologies upon which they
were premised are being substituted with technologies that are
digitally and Internet-based. As Congress, the Federal Communications
Commission, and other Federal or State agencies take on the daunting
task of defining regulatory measures that will govern the deployment of
these next generation communication technologies, Mr. Vaughn believes
that they should include safeguards to ensure that individuals with
disabilities not be left behind. Representative Ed Markey (D-MA-7)
introduced H.R. 3101 to help individuals with sensory difficulties deal
with problems of access to new technology. BVA cautions that while
advances in technology for the blind help with some daily activities,
they do not replace the overall losses in Quality of Life experienced
while trying to perform all of life's routine but vitally important
functions.
Too many potential and actual accessibility barriers to new
technologies already exist. Section 508 compliance has even been a
problem for VA. Our blinded and visually impaired veterans working as
Field Service Representatives, have, for example, had problems using
the information technology system as it relates to benefits and filing
claims. Inaccessible user interfaces on consumer equipment, lack of
interoperable and reliable text transmissions, and obstacles to video
and web programming all threaten the ability of individuals with
functional limitations to gain equal access to these products and
services. Legislative and regulatory actions are needed to eliminate
such barriers and to safeguard future access to modern communications
and information technologies and services, regardless of the form
(text, video, or voice) and nature of the transmission media (i.e.,
Public Switched Telephone Network [PSTN]; Internet Protocol [IP];
wireless, cable, satellite, copper wire, fiber-optic network; dial-up
or high speed) over which such information or communication travels.
While technology may be constantly changing with the intent to benefit
work environments universally, the results are not always equal or even
similar. We request that this perspective be included when considering
such complex issues as the catastrophically disabled veteran's
individual Quality of Life compensation.
Representatives Edolphus Towns (D-NY-10) and Cliff Stearns (R-FL-6)
recently introduced The Pedestrian Safety Enhancement Act of 2009 (H.R.
734) with 124 co-sponsors. The proposed act mirrors legislation
introduced in the 110th Congress. The Pedestrian Safety Enhancement Act
would require the Department of Transportation to research and
ultimately set forth a minimum sound standard that must be met by
hybrid and electric vehicles so that blind and other pedestrians may
travel safely and independently in urban, rural, and residential
environments. For the blind disabled, emerging new technology in many
cases presents dangers in the pedestrian environment of crossing
streets. This factor is definitely a Quality of Life factor for blinded
veterans. BVA very much appreciates Mr. Stearns' leadership especially
on this issue. BVA has also found complaints from the deaf and blind
with warning systems failing during natural disasters and barriers to
accessing shelters for the disabled in these disasters as examples of
QoL fear for those seriously disabled.
CONCLUSIONS
Mr. Chairman and Members of this Subcommittee, the Blinded Veterans
Association would appreciate inclusion of the following issues in your
list of changes as VA moves forward in attempting to compensate
service-connected veterans suffering catastrophic injuries as result of
their service to our Nation. It is essential that physical health,
psychological health, social relationships, and economic situations be
considered as these benefits changes occur.
1. The quality, timeliness, accuracy, and consistency of the
disability rating system and scale should be improved to include
Quality of Life for catastrophically disabled veterans as defined by
VA. Both objective and subjective measurements should be included.
Recommendations should consider factors such as education level of the
disabled veteran and the impact of the veteran's injuries on the
caregivers. In short, physical health, psychological well-being, social
relationships, and economic situations are all essential aspects of
Quality of Life that must be adequately included in a measurement tool.
2. Blinded veterans must experience a seamless transition from the
DoD to the VA disability rating of benefits. Accomplishment of this
objective requires that DoD and VA complete the integration of medical
computer health records systems. It also requires that the continuum of
health care and benefits processing be done efficiently--through a
special office of compliance if necessary.
3. Benefits and services should be provided to collectively
compensate for the negative consequences of service-connected
disability on average earning capacity, the ability to engage in normal
life activities, and Quality of Life. They should not establish a dual
compensation system that further fragments the disability claims
process.
4. The VDBC's ``Institute of Medicine 21st Century System for
Evaluating Veterans for Disability Benefits'' and other studies have
found that those with Post-traumatic stress disorder and Traumatic
Brain Injury need new and updated scientific methods for determining
benefits. This would involve an advisory Committee, which would include
stakeholder representatives within VBA, to ensure transparency in this
evolving process. Multiple reports reference problems for TBI and PTSD
veterans not receiving benefits appropriate for their service connected
injuries or mental health problems.
Prepared Statement of Lonnie Bristow, M.D., Chair, Committee on
Medical Evaluation of Veterans for Disability Benefits, Board on the
Health
of Select Populations, Institute of Medicine, The National Academies
Good morning, Chairman Hall, Ranking Member Lamborn, and Members of
the Committee. My name is Lonnie Bristow. I am a physician and a Navy
veteran. I am a member of the Institute of Medicine and have served as
the president of the American Medical Association. I am pleased to
appear before you again to testify about improving the disability
benefits system of the Department of Veterans Affairs (VA).
I had the great pleasure and honor of chairing the Institute of
Medicine (IOM) Committee on Medical Evaluation of Veterans for
Disability Compensation, which was established at the request of the
Veterans' Disability Benefits Commission and funded by the Department
of Veterans Affairs. The IOM was established in 1970 under the charter
of the National Academy of Sciences to provide independent, objective
advice to the Nation on improving health.
The Committee I chaired, which reported in 2007, was asked to
evaluate the VA Schedule for Rating Disabilities and related matters,
including the medical criteria for ancillary benefits. My task today is
to present to you the Committee's recommendations on improving
ancillary benefits, which are in Chapter 6 of our report, A 21st
Century System for Evaluating Veterans for Disability Benefits. I will
also comment on our recommendation concerning quality of life, which is
in Chapter 4 of the report.
Medical Criteria for Ancillary Benefits
The Veterans' Disability Benefits Commission asked the Committee to
focus on the appropriateness of medical criteria for five specific
ancillary benefits available to veterans being compensated for service-
connected disabilities. These were:
1. Vocational rehabilitation and employment (VR&E) services,
2. Automobile assistance and adaptive equipment,
3. Specially adapted housing grants,
4. Special housing adaptation grants, and
5. Clothing allowances.
The Committee was asked to consider, from a medical viewpoint, the
appropriateness of the specific conditions that a veteran is required
to have in order to receive these ancillary benefits. For example,
assistance in purchasing a specially adapted automobile or other
vehicle requires
loss, or permanent loss of use, of one or both feet; or
loss, or permanent loss of use, of one or both hands; or
permanent impairment of vision in both eyes with a
central visual acuity of 20/20 or less in the better eye with
corrective glasses, or central visual acuity of more that 20/200 if
there is a field defect in which the peripheral field has contracted to
such an extent that the widest diameter of visual field has an angular
distance no greater than 20 degrees in the better eye.
To qualify for assistance in purchasing a specially modified home,
a veteran must have a permanent and total service-connected condition
or conditions due to
the loss or loss of use of both lower extremities, such
as to preclude locomotion without the aid of braces, crutches, canes,
or a wheelchair; or
the loss or loss of use of both upper extremities, such
as to preclude use of the arms at or above the elbows; or
blindness in both eyes, having only light perception,
plus loss or loss of use of one lower extremity, or
the loss or loss of use of one lower extremity together
with residuals of organic disease or injury, or the loss or loss of use
of one upper extremity, which affects the functions of balance or
propulsion as to preclude locomotion without the aid of braces,
crutches, canes, or a wheelchair.
These medical eligibility criteria are very specific and require a
very high degree of impairment. They are so specific that they may not
include veterans with somewhat different impairments that hinder
mobility, such as multiple sclerosis.
Assessing Ancillary Benefit Criteria
When the Committee reviewed ancillary benefits, we found that they
were
created piecemeal over time.
not designed as part of a comprehensive program.
not systematically updated and, in some cases, not
indexed for inflation.
not based on an empirical analysis of veterans' actual
needs or loss of quality of life.
not evaluated for their effectiveness in meeting
veterans' needs or loss of quality of life (except for VR&E).
In 2004, a VA-appointed task force on VR&E recommended that VA
coordinate its health, VR&E, and compensation programs to achieve a
broader, more integrated approach to assisting veterans move from
military to civilian life. The task force suggested a more
individualized approach including
continuing and systematic medical examinations of
veterans for better informed career and employment decisions;
early, routine functional capacity assessments by
vocational experts for both disability compensation and rehabilitation
decisions; and
a change from a sequential series of required steps to a
more individualized sequence taking into consideration the veteran's
education, vocational rehabilitation, and compensation needs.
The Committee agreed with these recommendations--and the veteran-
centered concept of service delivery underlying them--and added some
recommendations of its own.
IOM Recommendations for Improving Ancillary Benefits
The Committee offered four recommendations for improving ancillary
benefits.
The lack of data on the need for or effectiveness of
ancillary benefits made it impossible for the Committee to assess the
appropriateness of the medical criteria requirements. The eligibility
requirements were not based on research relating needs to rating level
or type of impairment, so it is possible that the benefits could be
changed to serve veterans better or to address other needs.
Accordingly, we recommended that ``VA should sponsor research on
ancillary benefits and obtain input from veterans about their needs.
Such research could include conducting intervention trials to determine
the effectiveness of ancillary services in terms of increased
functional capacity and enhanced health-related quality of life.''
In addition to obtaining data on the mitigating effects
of each type of benefit on functional limitations, work disability, and
quality of life, a better approach to assessing the needs of individual
veterans is needed. The Committee concluded that ``An assessment of
health care and rehabilitation needs should be performed in conjunction
with the assessment of compensation needs, so that the veteran will
benefit from all services VA provides to help veterans with
disabilities succeed in civilian life . . . The assessment should also
include the need for education, vocational rehabilitation, and other VA
ancillary services and benefits, which, together, could enhance a
veteran's ability to succeed in civilian life.'' Specifically, we
recommended that ``VA and the Department of Defense should conduct a
comprehensive multidisciplinary medical, psychosocial, and vocational
evaluation of each veteran applying for disability compensation at the
time of service separation.''
There is no medical basis for the current 12-year limit
on eligibility for vocational rehabilitation services, although there
may be administrative convenience or fiscal control reasons. Some
employment and training needs may not adhere to a 12-year deadline. For
example, emerging assistive and workplace technologies (e.g.,
computing) may provide training or retraining opportunities for
veterans with disabilities through continuing education of various
kinds. New types of work may also emerge for which veterans with
disabilities could be trained. Advancements in medical knowledge and
breakthroughs in medical technology also do not abide by a 12-year
limit. The Committee recommended that ``The concept underlying the
extant 12-year limitation for vocational rehabilitation for service-
connected veterans should be reviewed and, when appropriate, revised on
the basis of current employment data, functional requirements, and
individual vocational rehabilitation and medical needs.''
Finally, the Committee was concerned about low rate of
participation in the VR&E program. For example, in FY 2005, about
40,000 veterans applied for VR&E services and were accepted. But
160,000 veterans began receiving benefits for service-connected
disabilities that year, and the pool of those potentially eligible from
prior years is much larger. Also, in recent years, between a quarter
and a third of the participants had not completed the program. We
concluded that VA should explore ways to increase participation in this
program, and we recommended that ``VA should develop and test incentive
models that would promote vocational rehabilitation and return to
gainful employment among veterans for whom this is a realistic goal.''
IOM Recommendation on Compensating for Loss of Quality of Life
The Committee did not view the ancillary benefits that it was asked
to review as a form of compensation for loss of quality of life. We
considered them as services to improve functional mobility and
employability.
Rather than consider if and to what degree that benefits such as
adapted housing and automobiles, or Special Monthly Compensation, help
to compensate for loss of quality of life, the Committee recommended
that quality of life be measured directly. Then, if it is found that
veterans experience an average loss of quality of life for a given
disability that exceeds the average loss of earning capacity as
measured by the Rating Schedule, we recommended that VA compensate for
the additional loss.
We noted that VA already uses a quality of life measurement tool,
the SF-36, in research on clinical outcomes. We cited a quality-of-life
methodology used on injured workers in Ontario, Canada, that found that
impairment ratings systematically underpredicted the loss of quality of
life that workers associated with certain disabilities. We said some
additional work would have to be done by VA to adapt the SF-36 or
Canadian or possibly some other quality of life tool for veterans'
compensation purposes. If such a tool could be developed, and we
believe that it could be, VA could use it to determine average quality
of life of veterans with different disabilities, relative to
nondisabled veterans. If it turns out that veterans experience a
serious loss of quality of life for a condition that is not highly
rated by the Rating Schedule, then VA should compensate for the
disparity.
Conclusions
In summary, the main points of our report A 21st Century System for
Evaluating Veterans for Disability Benefits concerning ancillary
benefits and quality of life are:
1. VA should more systematically research the needs of disabled
veterans and the effectiveness of its ancillary benefit programs in
meeting these needs and make needed revisions in these programs based
on this research.
2. VA should assess the individual needs of disabled veterans at
time of separation from military service and coordinate the delivery of
the services identified in the assessment.
3. VA should develop a tool to measure the quality of life of
disabled veterans, determine the extent to which the Rating Schedule
already accounts for loss of quality of life, and--for disabling
conditions in which average loss of quality of life is worse than the
Rating Schedule indicates--compensate for the difference.
Prepared Statement of George Kettner, Ph.D., President,
Economic Systems Inc., Falls Church, VA
Mr. Chairman and Members of the Subcommittee, thank you for the
opportunity to appear before you today to present my views on the
effectiveness of ancillary benefits and ways that VA can improve the
quality of life for disabled veterans. I present the major results of
Economic Systems' Study of Compensation Payments for Service-Connected
Disabilities completed last year for VA.
VA Disability Compensation Rating System
The VA Disability Compensation Program provides monthly benefit
payments to veterans who become disabled as a result of or coincident
with their military service. Payments generally are authorized based on
an evaluation of the disabling effects of veterans' service-connected
physical and/or mental health impairments. Monthly payments are
authorized in percentage increments from 10 percent ($117 in 2008) to
100 percent ($2,527 in 2008). The process for determining ratings for
disability compensation benefits uses the VA Schedule for Rating
Disabilities (VASRD) to assign the level of severity of the
disabilities.
The VASRD contains over 700 diagnoses or disability conditions,
each of which may have up to 11 levels of medical impairment. The
lowest level of impairment starts at 0 percent then increases in 10
percent increments up to a maximum of 100 percent. Disability
compensation, as determined by the VASRD, is intended to replace
average impairment in earnings capacity.
Eligibility requires that a determination be made that the
condition is a service-connected disability. Service-connected means
that the condition occurred during or was aggravated by military
service or, for chronic conditions, became evident within 1 year of
discharge from the military. It does not require that the disability be
work-related or be caused by conditions in the work environment. In
this regard the VA Disability Compensation Program combines elements of
both disability insurance voluntarily provided by employers and
workers' compensation programs mandated by Government.
Claimants with a combined rating between 60 to 90 percent who are
determined to be unemployable solely as a result of service-connected
conditions qualify for IU. Claimants determined to be entitled to IU
qualify for the same benefit payment amount as those rated at the 100
percent disability level. Conditions or circumstances that result in
the claimant not being employable override the medical impairment
rating. IU is similar to the Social Security Disability Insurance
(SSDI) program in that both provide payments because the beneficiary is
deemed to be unemployable.
Special Monthly Compensation (SMC) is a benefit paid in addition to
or instead of the VASRD-based benefits. Examples include: loss of or
loss of use of organs, sensory functions, or limbs; disabilities that
confine the veteran to his/her residence or result in the need for
regular aid and attendance; a combination of severe disabilities that
significantly affect mobility; and the existence of multiple,
independent disabilities each rated at 50 percent or higher.
We were asked by VA to address three major areas in our analysis:
earnings loss resulting from service-connected disabilities, the impact
of those disabilities on quality of life, and a possible transition
benefit for veterans engaging in VA's vocational rehabilitation and
employment program. In many ways, all three areas bear on this
hearing's focus on ancillary benefits and quality of life. Some of our
most significant findings relate to the following topics:
Adequacy of Disability Compensation
Disabilities Without Earnings Loss
Additional Diagnostic Codes
Earnings Loss for Veterans with Post-traumatic stress
disorder (PTSD), Other Mental Health Disorders, and Traumatic Brain
Injury (TBI)
Methodology Used to Calculate Combined Degree of
Disability
Individual Unemployability Benefits
Special Monthly Compensation
Quality of Life Payment Options
Transition Benefit Options.
Adequacy of Disability Compensation
A crucial part of the loss of earnings analysis is determining the
wages that the veteran would have received if he or she had not
experienced a service-connected disability (SCD). The estimates of
these potential earnings depend on tracking the actual earnings of
individuals in a comparison group who did not have SCDs but who were
otherwise matched to the disabled veterans on personal characteristics.
The personal characteristics used to match the disabled veterans and
the veterans without SCDs were age, gender, education at the time of
entry into the service, and status as an officer or enlisted person
when discharged from active duty. The analysis of loss of earnings was
primarily based on comparisons of the earnings in 2006 of veterans with
SCDs and without SCDs as provided to the study by the Social Security
Administration.
We found that overall, veterans with service-connected disabilities
have earnings plus disability compensation 7 percent above their
average expected earnings. The average was higher at each rating level
except at the 100 percent rating level where the combined earnings and
compensation was 9 percent less than expected. On average, veterans
with a 30 percent or less combined disability rating did not experience
serious wage loss. Approximately, 55 percent of 2.6 million veterans
receiving disability compensation in 2007 were rated at 30 percent or
less. Earnings losses for veterans with 40 percent to 90 percent
combined rating did have wage losses, but their VA disability
compensation more than made up the loss. In contrast, actual earnings
losses plus disability compensation for veterans with 100 percent
combined rating fall short of average expected earnings by about 9
percent. In 2007, 9.1 percent of veterans receiving disability
compensation had a combined rating of 100 percent, up from 7.5 percent
in 2001.
On the other hand, we found considerable differences in earnings
loss across different diagnoses for a given rating level, resulting in
serious inequity in the payment system. For example, for veterans with
a 50 percent combined rating, the range was from no earnings losses for
genitourinary or endocrine medical conditions to over 40 percent
earnings losses for non-PTSD mental conditions. Veterans with PTSD,
Other Mental Disorders, and infectious diseases experience greater
earnings losses than veterans diagnosed with other medical conditions
rated at the same level.
One factor that is important to understanding the results of our
earnings analysis is that it concentrates on veterans discharged since
1980. Our results, therefore, differ from the previous study conducted
by CNA Corporation for the Veterans' Disability Benefits Commission as
that study included veterans discharged before 1980. Our study does not
include veterans of World War II, Korea, and Vietnam (relatively few)
because they are largely past or approaching retirement age and because
data on their essential demographic and human capital characteristics
are not available for analysis. We believe that this focus on more
recent veterans is more appropriate for policy considerations for the
future. More detailed discussion of the differences between our study
and the study for VDBC is provided later.
Disabilities without Earnings Loss
In addition to examining the broad comparisons cited above, our
analysis identified several diagnostic codes that are candidates for
changes to the Rating Schedule because the impact of these conditions
on earnings is not commensurate with the level of the rating. In
particular, for several of the most prevalent diagnostic conditions,
there is no earnings loss at the 10 percent or 10 percent to 20 percent
combined rating levels. Examples of these diagnoses include: arthritis;
lumbosacral strain; arteriosclerotic heart disease; hemorrhoids; and
diabetes mellitus. The 10 percent rating for these conditions could be
adjusted to zero to reflect that no earnings loss occurs at this level
for these conditions.
Additional Diagnostic Codes
We were asked to identify diagnostic codes that could be added to
the over 700 existing codes in the Rating Schedule. Analogous codes are
currently used in 9 percent of all cases. By sampling 1,094 cases in
which analogous codes were used, we identified 33 ICD-9 codes that were
used often enough to warrant addition to the Rating Schedule. These
include disturbance of skin sensation, mononeuritis of lower limb, and
unspecified hearing loss.
PTSD, Other Mental Disorders, and TBI
Our analysis and previous studies conducted by the Bradley
Commission in 1956, the Economic Validation of the Rating Schedule in
1972, and the Veterans' Disability Benefits Commission in 2007, are
consistent in finding that mental health disorders in general have a
much more profound impact on employment and earnings than do physical
disabilities. We found that earnings loss for PTSD is 12 percent for
veterans rated 10 percent and up to 92 percent for those rated 100
percent. For other mental disorders, the earnings loss is 14 percent
for those rated 10 percent and 96 percent for those rated 100 percent.
Earnings loss for TBI rated 100 percent is similar at 91 percent.
A policy option for consideration is to adjust the VA Schedule of
Rating Disabilities to eliminate rating PTSD at 10 percent and use the
rating criteria for 10 percent to rate 30 percent, 30 percent to 50
percent, 50 percent to 70 percent, and combine the criteria for 70
percent and 100 percent at 100 percent. We note that this will not
eliminate the deficiency at 100 percent; these veterans will still be
receiving less in disability compensation and earnings combined than
their expected level of earnings. We also note that these changes,
especially if also made for mental health disorders in general, would
have a significant impact on the issue of Individual Unemployability
(IU). Veterans whose primary diagnosis is PTSD made up 32 percent of IU
cases on the rolls in 2007 and 47 percent of new IU cases during the
period 2001-2007. Including PTSD with all mental disorders, 44 percent
of IU cases on the rolls in 2007 were mental disorders and 58 percent
of new IU cases from 2001-2007 had mental disorders. Since the criteria
for rating mental disorders at 100 percent require veterans to be
unemployable, it is not clear why veterans with mental disorders who
are unemployable are not rated 100 percent instead of IU.
Methodology Used to Calculate Combined Degree of Disability
VA has used certain formulas over the years to assign a Combined
Degree of Disability (CDD) when veterans have more than one rated
service-connected disability. Veterans receiving disability
compensation have on average 3.3 disabilities that they are rated for.
The earliest known formula dates from 1921 and has changed very little
since then. The CDD determines the amount of the disability
compensation payment. The table below provides examples of how various
individual ratings are combined using the four formulas. The formulas
do not take into account the types of disabilities being combined.
----------------------------------------------------------------------------------------------------------------
Rating Schedule 1921 1930 1933 1945 to Present
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Two 10% Ratings 19 19 20 20
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Three 10% Ratings 28 19 30 30
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Four 10% Ratings 37 19 30 30
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Five 10% Ratings 46 19 40 40
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One 30% and four 10% 58 58 50 50
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One 70% and four 10% 82 82 80 80
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A claimant who has three disabilities with each disability rated at
10 percent, receives a combined rating of 30 percent. A veteran with
two service-connected disabilities, one rated 60 percent and one rated
10 percent, receives compensation only at the 60-percent rate. The
effect of combining additional ratings gives greater weight to multiple
10 percent ratings at the low end of the scale. The effect of
additional 10 percent ratings is diminished if the primary diagnosis
has a high rating. Having multiple low ratings increases the payment
dramatically for a veteran whose primary diagnosis has a low rating; it
has a negligible or much smaller effect for veterans who have a single
condition with a high rating such as 80 percent or more.
In our analysis we found that actual earnings, on average, were
higher for veterans with more disabilities at a given rating level such
as 30 percent. This paradoxical result suggests that the rating for the
first medical condition captures most of the impact of the veteran's
overall medical conditions on his or her potential earnings. The
ratings for the second, third, or additional medical conditions
increase the CDD but the additional conditions do not further affect
the veteran's earning capacity. The formula for combining disabilities
results in ratings that over compensate veterans for lost earnings.
An option to the current single lookup table is to replace it with
tables that reflect specific combinations of different disabilities.
The tables could be programmed for ease of use rather than manually
applied as is the current practice.
Medical science has established for many years that certain
diseases are prevalent together, examples of which include PTSD and
major depressive disorder, and diabetes and cardio-vascular diseases.
It is quite likely that there are many diseases that are present
together in individuals and that they cause a greater impact on the
individual's earning capacity than would be the case with multiple
unrelated minor ailments. Analysis of the impact of multiple diseases
or disabilities would result in an enhanced approach to ratings for
combinations of diagnoses.
Individual Unemployability Benefits
The number of IU cases has grown from about 101 thousand in
September 2001 to 190 thousand cases in September 2007, an increase of
almost 90 percent. PTSD cases constituted about one-third of the IU
cases in 2007 and one-half of new IU cases between 2001 and 2007.
Forty-four percent of the IU cases in 2007 were for veterans age 65 and
older; 64 percent for veterans age 55 and older.
Although age is clearly related to employment, it is not considered
in IU determinations. While IU is not intended for veterans who
voluntarily withdraw from the labor market because of retirement, new
awards are often made to veterans who are near or past normal
retirement age for Social Security. In light of these circumstances it
appears that IU determinations are made for veterans approaching or
past retirement age based on providing retirement income or in
recognition of loss of quality of life rather than for employment loss.
IU determinations depend on decisions about substantially gainful
employment. In order to further facilitate the decisionmaking process
for IU determinations, a work-related set of disability measures would
be worth assessing. Consideration of this could supplement the medical
impairment criteria in the VASRD.
An option for consideration would be for VA to adopt a patient-
centered, work disability measure for IU evaluations. As with the
current IU evaluation, assessments would address the individual's work
history but also consider other factors including motivation and
interests. Work disability evaluations would include relevant measures
of impairment, functional limitation, and disability. Particular care
should be taken to include measures of physical, psychological, and
cognitive function. Assessments would evaluate the individual in the
context of his or her total environment.
Special Monthly Compensation
SMCs are a series of awards for anatomical loss or loss of
functional independence. These awards are evaluated outside of the
Rating Schedule. SMCs are known by the letter designations K, L, M, N,
O, P, R, and S. SMC K is the only award that can be made to veterans
who are rated less than 100 percent and can be awarded one, two, or
three times with each award $91 per month (2008 rates) in addition to
the amount paid for the Combined Degree of Disability rating. As of
December 1, 2007, there were 188,747 veterans receiving SMC K awards.
SMCs other than K are paid instead of the amount payable for 100
percent ratings, not in addition to the amount paid for 100 percent
ratings. Since SMCs are not awarded with the intent of compensating for
average loss of earnings capacity, they can be thought of as payments
for the impact of disability on quality of life.
SMC for Assistance
Four different SMCs can be paid to veterans for assistance: L, S,
R1, and R2. SMC L can be awarded either for loss of or loss of use of
limbs or organs or to veterans rated 100 percent without such loss if
they are in need of regular Aid and Attendance; in other words, if they
need assistance with activities of daily living. In 2007, 48 percent of
13,928 veterans receiving SMC L were receiving that award because they
needed assistance, rather than for loss of or loss of use of organs or
limbs. SMC S can also be awarded to veterans rated 100 percent if they
are housebound but do not meet the required level of assistance for SMC
L. SMC R1 and R2 are awarded to catastrophically injured veterans,
primarily to those with spinal cord injuries, who need the highest
levels of assistance. The table below depicts the number of veterans
receiving SMCs other than K and the amount of the award that is above
the normal amount paid to veterans rated 100 percent without SMC. Thus,
if a veteran receives SMC L for assistance, the veteran is receiving
only $618 per month above the normal 100 percent amount; and a veteran
receiving SMC S for housebound is receiving only $302 above the 100
percent amount.
In 2007, 45,773 veterans received SMC L, S, R1, or R2 for
assistance and $30,506,362 above the amount paid for the 100 percent
rating. This was an average of $660 per month.
Special Monthly Compensation Rates Compared with Schedular 100% Rating
----------------------------------------------------------------------------------------------------------------
Increased
SMC Code Veteran Alone Amount for Amount for Number of Monthly
100% or O/P SMC Veterans Benefit
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Quality of Life
----------------------------------------------------------------------------------------------------------------
L $3,145 $2,527 $618 5,355 $3,309,390
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L\1/2\ $3,307 $2,527 $780 1,887 $1,471,860
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M $3,470 $2,527 $943 1,839 $1,734,177
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M\1/2\ $3,709 $2,527 $1,182 1,650 $1,950,300
----------------------------------------------------------------------------------------------------------------
N $3,948 $2,527 $1,421 477 $677,817
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N\1/2\ $4,180 $2,527 $1,653 250 $413,250
----------------------------------------------------------------------------------------------------------------
O/P $4,412 $2,527 $1,885 2,661 $5,015,985
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Total 14,119 $14,572,779
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Assistance
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L $3,145 $2,527 $618 4,944 $3,055,392
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L\1/2\ $3,307 $2,527 $780 1,742 $1,358,760
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S $2,829 $2,527 $302 31,361 $9,471,022
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R1 $6,305 $4,412 $1,893 5,576 $10,555,368
----------------------------------------------------------------------------------------------------------------
R2 $7,232 $4,412 $2,820 2,151 $6,065,820
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Total 45,773 $30,506,362
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Source: Department of Veterans Affairs, Special Monthly Compensation, 12/1/07
Using the results of surveys conducted by the National Alliance for
Caregiving and the American Association of Retired Persons and by the
Veterans' Disability Benefits Commission, we estimated monthly costs of
hiring assistance ranging from $520 for 8 hours of caregiving per week
to $10,800 for full time, around the clock 24/7 care. The CNA Corp.
issued a report for the Department of Defense in September 2008 on the
average earnings and benefits loss of caregivers of seriously wounded,
ill, and injured active duty servicemembers and estimated those losses
as $33,500 annually or $2,800 per month. Regardless of which estimates
are used, the current amount of the SMCs for assistance is well below
either the cost of hiring such care or of the lost earnings and
benefits of family caregivers.
Quality of Life Payment Options
Our review of the literature led us to define quality of life (QOL)
for veterans as an overall sense of well-being based on physical and
psychological health, social relationships, and economic factors. Our
in-depth analysis of the data from the Veterans' Disability Benefits
Commission's survey of more than 21,000 disabled veterans found that
QOL loss occurred for veterans at all levels of disability and all 40
diagnostic codes for which sufficient responses were available. We also
found that loss of QOL increases as disability increases, but it does
not increase as sharply as disability does, and that there is wide
variation in the loss of quality of life at each disability rating. QOL
is an individualized perception, and people adjust to disability. About
one-half of those individuals with severe disabilities report high
degrees of life satisfaction.
The quality of life loss analysis paralleled the earnings loss
analysis in many regards. In particular, we found that veterans
receiving Individual Unemployability benefits and those receiving SMC
payments report mental and physical QOL loss significantly greater than
for other service-connected veterans. Fewer severe disabilities are
associated with a greater loss of quality of life than a greater number
of less severe conditions at a given level of combined disability.
Three broad options were presented to VA for implementing a QOL
payment:
1. Statutory rates for QOL payments by combined degree of
disability
2. Separate, empirically based normative rates for QOL loss
3. Individual clinical and rater assessments plus separate
empirically-based rates for QOL loss.
All three options would require periodic surveys to assess QOL
impact. Option 3 would be the most complex and costly to implement and
would require clinical and rater assessments each time a claim is
filed. Options 1 and 2 would not be subject to veteran appeal if
Congress approves the rate scale. However, before any QOL options are
implemented, the criteria and benefits contained in the VA Schedule for
Rating Disabilities should be adjusted to reflect actual lost earnings
or average actual lost earnings, to ensure an overall equitable system.
Payment rates for QOL would have to be set by policy or statute and
placing an economic value on QOL would be subjective and value laden.
Options that use empirical data are provided in our report as examples
of how such rates could be established. The monthly amounts depicted in
the options range from $99 to $974. Volume III of our report contains
an extensive description of the findings of the QOL analysis and of the
possible rationale or basis for setting the amounts.
Foreign countries that award QOL payments link them closely to
impairment and consider the circumstances of the individual veteran.
QOL payments are considered the primary disability benefit and earnings
loss payments are made only for actual earnings loss or a specified
loss of earnings capacity. A veteran in Canada, for instance, must
demonstrate inability to work in order to receive an earnings loss
payment in addition to a QOL payment and must complete 3 years of
vocational rehabilitation that results in unemployment before receiving
ongoing earnings loss payments.
VA could structure its disability benefits like the foreign
programs so that they are based primarily on QOL. QOL could be inferred
from impairment, or it could be measured directly, with earnings loss
paid only when an actual earnings loss occurred. The systems used in
both the United Kingdom (UK) and Canada pay QOL in lump sum payments
and have several low rating levels for QOL payments. While making QOL
payments in all 15 of its ratings, the UK system does not pay for
earnings loss in the 4 lowest ratings of its 15-point rating scale. The
Canadian schedule increases proportionally. In 2008, after the 10
percent rating, each 5 percent rating increase in Canada has a payment
increase of $12,909. The UK payments do not increase with a
multiplicative constant. For instance, the highest payment is $565,000,
the second highest payment is $399,000, the third highest is $228,000.
The lowest pain and suffering payment in UK is $2,080. These payment
schedules reflect society's view that severe disability merits very
high QOL payments and low levels of disability merit recognition
payments. These benchmarks suggest great flexibility for VA in
establishing payment levels.
Although our study focused on monetary compensation for QOL, the
literature review and the analysis of the survey data indicates that
greater QOL is supported by a strong family or social network and that
employment is associated with a better quality of life. QOL of service-
connected veterans may be improved by programs aimed at family members
to help them to understand and support the disabled veteran, through
case management directed to the holistic needs of the veteran, and
employment assistance programs.
Our earnings analysis found that on average veterans' earnings plus
disability compensation exceeds the expected earnings level by 7
percent. There are exceptions such as for mental health and TBI and
those rated 100 percent where earnings plus compensation is
significantly less than expected earnings. Some SMC payments can be
thought of as payment for QOL. Taken together, a judgment could be made
that veterans are currently compensated for QOL.
Transition Benefit Options
Disabled veterans face a number of living expenses during their
transition to civilian life before and during their participation in
the VA Vocational Rehabilitation and Employment (VR&E) Program.
Providing transition assistance payments offset the foregone cost
of earnings (time spent in rehabilitation and not working), which in
turn increases the likelihood of entry and completion of
rehabilitation. Providing transition assistance benefits to caregivers
and family members could reduce the levels of stress and depression for
veterans and caregivers, which in turn could raise the overall quality
of life for both the patient and family members and caregivers.
Providing and aligning financial incentives with successful completion
of specific rehabilitation tasks could increase the likelihood that
patients enter and successfully complete rehabilitation.
In order to estimate what an appropriate level of transition
benefit should be, we selected housing, food, and transportation
expenses to comprise a core group of living expenses that one would
expect a living expense benefit to cover. We also considered additional
``menu items'' such as apparel and services, health care (for
dependents of disabled veterans not rated 100 percent), personal care
products and services, household operations, and child care. Based on
statistical analysis of average living expenses, the core living
expense option would be $1,898 for the veteran alone or $2,981 for a
veteran with two dependents. This includes the average monthly housing
allowance paid by DoD in the 11 most populous veteran population
centers, the same rates that would be paid under the Chapter 33
Education program. The payment for additional expenses would be $511
for the veteran alone or $935 for a veteran with two dependents. A new
transition benefit would be in lieu of the current subsistence
allowance and precede start of permanent disability compensation
benefit. The 2007 monthly subsistence allowance was $521 (no
dependents) and $761 (two dependents).
We identified several groups of veterans who could be eligible for
such payments based on medical discharges, severity of disability, and
time since discharge. The possible eligibility groups would range from
a small group consisting of severely injured/ill who are medically
discharged with ratings of 70 percent or higher who enter
rehabilitation within 2 years of discharge, to a much larger group that
would include all veterans currently eligible for VR&E. The most
limited option would include 3,400 applicants per year and the most
inclusive option would include approximately 29,000 each year.
Methodology Differences with the Previous Study
As discussed previously, our methodology differed in significant
ways from the approach taken by the CNA Corp. in 2007 for the Veterans'
Disability Benefits Commission. Our study focused on service-connected
and non service-connected veteran populations discharged since 1980.
Data from the Defense Manpower Data Center is reliable for veterans
discharged since that time and provides important demographic or human
capital characteristics for individuals such as education level at time
of entry into the military, gender, and officer or enlisted status.
These characteristics can be used to ensure that the observed
differences in earnings are due to the service-connected disabilities
and not some demographic differences.
The study for VDBC also used earnings data for non service-
connected veterans from the Current Population Survey (CPS) which were
self reported, in comparison with the actual earnings of service-
connected veterans discharged prior to 1980. We conducted a thorough
analysis of the CPS data and concluded that it was not reliable for
this purpose for several reasons. Self-reported earnings are not as
accurate as actual Social Security Administration data and the CPS
sample has 50 percent fewer veterans than the general population. Post
1980 veterans have better health, fewer limitations from disabilities,
and higher rates of employment. Thus we focused on comparing earnings
of veterans discharged since 1980. We obtained actual earnings data
from the Social Security Administration on the entire population of
1,062,809 service-connected disabled veterans discharged since 1980 and
a demographically selected sample of 432,947 non service-connected
veterans also discharged since 1980. These two populations were
compared to determine the impact of service-connected disabilities on
earnings. Actual earnings were compared, thus avoiding the use of
survey data. A detailed explanation of why CPS data is not reliable for
this comparison is provided in Volume III of our report. We believe
that this comparison of veterans discharged since 1980 enables policy
makers to focus more on veterans that VA rates today and will be rating
in the future.
Another difference between our analysis and the CNA analysis was
that we conducted a more detailed analysis of rating levels using the
entire range of rating levels (10 percent through 100 percent, in 10
percent increments) while CNA used four groupings of ratings (10
percent, 20-40 percent, 50-90 percent, and 100 percent). We did this so
as to be able to analyze all ten rating levels individually. We also
used individual diagnostic codes to the maximum extent possible within
the restrictions on release of individual-level data. The over 700
codes in the Rating Schedule were grouped into 240 similar diagnoses so
as to avoid the possibility of individual veterans being identified. In
contrast, the CNA study aggregated veterans into the 15 body systems
with PTSD the only individually analyzed diagnosis. We also placed
emphasis on analysis of veterans receiving Special Monthly Compensation
and Individual Unemployability. Finally, we used 2006 earnings without
estimating lifetime earnings while CNA used 2004 earnings to estimate
lifetime earnings. We obtained annual earnings for veterans since 1951
but time constraints prevented including this information in our
analysis as we would have preferred.
Concluding Remarks
In closing, our study completed last year provides a great deal of
information on the adequacy of disability compensation and ways in
which the program can be improved to better serve veterans. There are
clear indications that overall the amount of compensation exceeds the
average expected earnings loss yet it is inadequate for mental health
and for those rated 100 percent. The methodology used to assign the
overall combined degree of disability, and hence the amount of
compensation paid, results in over compensating many veterans,
especially at the lower rating levels. There are several diagnoses that
either do not result in loss of earnings or the rating is higher than
necessary. It could be concluded that quality of life is somewhat
compensated by the amount compensation exceeds expected earnings loss
and by some SMC payments. SMC payments for assistance are not equal to
either the cost of hiring assistance or the lost earnings and benefits
of family caregivers.
While the findings cited in this testimony provide accurate and
reliable information upon which to base policy decisions, the time
frame for that study (7 months) did not permit a thorough analysis of
certain aspects of the disability compensation program and of the
inter-related nature of the findings. We would recommend that
additional analyses be conducted. Restrictions intended to safeguard
the privacy of individuals prevented the Social Security Administration
from providing earnings at the individual veteran level. This meant
that we could not analyze the impact on earnings of combinations or
comorbidities of disabilities. We have discussed this issue with the
Social Security Administration and believe a methodology could be used
that safeguards the privacy of individuals yet enables such analysis.
Additional demographic or human capital characteristics could be
analyzed in future studies to ensure that the impact on earnings is not
due to factors such as education level at discharge, military
occupational series, or Armed Forces Qualification Test scores. Also,
consideration of such factors as time in service, period of service,
and timing of diagnosis could shed additional light on the impact of
disability on earnings.
In addition to analysis of earnings at the individual veteran
level, earnings and quality of life results should be integrated so as
to see the overall impact of disability on veterans. This could include
assessing how comorbidities and the timing of the diagnoses as
indicated by the date of original service-connected disability impact
earnings and QOL. A technique called shadow pricing could also be used
to measure the economic impact on quality of life.
Mr. Chairman, I thank you for the opportunity to appear before you
today and would welcome any questions you or the Subcommittee Members
may have.
Federal contracts relevant to the subject of this hearing: Study of
Compensation Payments for Service-Connected Disabilities, February
2008-September 2008, $3.2 million; Evaluation of VA's Vocational
Rehabilitation and Employment Program, September 2008-September 2010
(ongoing), $2.9 million. Both contracts are with the Department of
Veterans Affairs.
Prepared Statement of Kimberly D. Munoz, Executive Director,
Quality of Life Foundation, Woodbridge, VA
Chairman Hall, Ranking Member Lamborn and distinguished Members of
the Subcommittee--thank you for inviting the Quality of Life Foundation
to testify today regarding the quality of life impacts the Department
of Veterans Affairs has on Veterans and their families. We offer our
testimony as a loud and clear voice for the severely wounded family,
who along with their veteran, faces lifelong physical, emotional, and
financial challenges as a result of service to country.
The Quality of Life Foundation does not receive grants or contracts
from the Federal Government.
We are a small not-for-profit organization with a mission to
develop, support, and implement strategies that improve the quality of
life for those who, through no fault of their own, face limiting
barriers. Our first initiative was launched in February 2008 shortly
after a chance meeting between our President, Michael Zeiders, and the
spouse of a severely injured Marine. After hearing her compelling story
of the challenges she and her family faced as she left her home, job
and children behind to provide bedside care to her wounded Marine and
then took the heavy responsibility of transitioning her family from an
active duty military life to community-based living, Mr. Zeiders knew
this family represented the very population his Foundation was formed
to serve.
As a result, he launched the Wounded Warrior Family Care Project
and assigned staff to research the experiences of severely wounded
servicemember families and the resources they rely on to help them
recover from such a traumatic loss. Eight months of research culminated
in the publication of the Wounded Warrior Family Care Report in April
2009. The report clearly defined the population reviewed, their unique
support needs, existing resources, and a comprehensive Model of Support
from the moment the family is notified of their loved one's injury,
through inpatient care, to after they transition to home-based care.
Quality of Life shared the report with leaders of the Department of
Defense, the Department of Veterans Affairs, other not-for-profit
organizations (including veterans' service organizations), and the
Senate and House Committees on Veterans Affairs. In fact, a copy was
sent to every Member of this Subcommittee in April.
The Veterans Affairs Mission Statement is based on a pledge
President Lincoln made to America's Civil War Veterans during his
second inaugural address--``To care for him who shall have borne the
battle and for his widow and his orphan.'' This promise gave Civil War
era military members peace of mind that in the event their lives were
lost in the line of duty, and they were no longer able to provide for
their families, that our country would step in to fill that void.
Today's equivalent of America's Civil War widows and orphans
includes families of catastrophically injured veterans who can no
longer care for themselves nor provide for their families.
As such, catastrophically injured veterans' benefits must reflect
the reality that when a veteran is dependent on their family for his/
her daily living needs, that family's quality of life then becomes
dependent on the veterans' benefits. Our country, in addition to
providing care for severely disabled veterans, must also address the
quality of life impact that veteran's injuries have on the family.
During our research, we heard repeated stories of family caregivers
struggling to learn about the compensations, services and programs
provided by the VA, and which, if any, their veteran was eligible for.
We also heard of many families applying for benefits, waiting months to
receive a determination on their application, then submitting appeals
before finally receiving the resources they desperately needed to
provide daily care for their veteran.
Their experiences are telling and highlighted by a quick analysis
of IRS 990 data for FY 2007 of 5 of the largest, most well known
Veterans' Service Organizations. That review revealed an aggregate
annual program expense of over 75 million non-profit dollars to provide
claims assistance to veterans.
The VA must reduce the burdensome process and wait times associated
with the receipt of benefits and services required by families who are
striving to rebuild independent, quality lives after their veteran has
endured catastrophic disability associated with his/her service-
connected injuries.
Disability Ratings
While timely processing is important, it cannot be accomplished at
the expense of accuracy. Assigning an accurate and timely initial
determination regarding the veteran's disability rating is critical to
the overall well-being of the veteran and family.
The disability rating is the eligibility key required to open doors
to additional, ancillary benefits required by families to rebuild
quality lives after devastating injury.
The following provides our comments regarding how some of the most
critical ancillary benefits can be improved to increase the quality of
life for severely wounded veterans and their families.
Special Monthly Compensation
If the initial disability rating is accurate, most severely injured
veterans will be awarded additional Special Monthly Compensation (SMC)
in consideration of the impact physical disabilities have on their
ability to function. However, for those whose disability is primarily
cognitive or psychological [i.e., Traumatic Brain Injury (TBI) or Post-
traumatic stress disorder (PTSD)]--SMC fails to fully compensate for
the requirement these veterans have for Aid and Attendance.
Within SMC, there are 9 broad categories--7 of which are based
solely on physical impairments (k,m,n,o,p,q,s), leaving only 2
categories based on cognitive or psychological impairments (l,r). This
method of coupling eligibility to a body part, does not fully consider
the range of impact TBI or PTSD has on a veteran's ability to function
independently and the resulting dependency on a family member (or hired
help) to provide daily Aid and Attendance.
For example, a veteran with a 100 percent service-connected
disability rating for a stand-alone Traumatic Brain Injury who is
highly functioning on a physical level (i.e., able to walk, talk,
dress, and perform activities of daily living) but has impaired
cognitive, judgment, short-term memory, and emotional-control
capabilities; is eligible for just one category of SMC, SMC-L. This
category allows an additional monthly compensation of approximately
$650. When a family member has left their job to provide the Aid and
Attendance required to keep this veteran safe from harm, or has hired
an attendant to provide that oversight, $650 simply does not cover the
additional financial burden borne by the family. The only other
category which considers cognitive or psychological impairments is SMC-
R, a category that also requires extreme physical impairments.
SMC must fully consider the complete range of impact TBI and PTSD
have on the veterans' ability to function independently and safely. If
a veteran's service-connected disability (physical, cognitive, or
psychological) results in the inability to function safely and
independently and thus requires a significant level of daily
supervision and/or assistance, SMC must be awarded to cover the full
expense required to provide the appropriate level of Aid and Attendance
to the veteran.
Specially Adapted Housing Grants
The Specially Adapted Housing Grant (SAH) also has eligibility
criteria based primarily on physical impairments and is available to
veterans with injuries that preclude them from locomotion.
The application processing time for the SAH is lengthy and as a
result, prohibits home modifications from being completed prior to the
veteran's homecoming. Families who have spent months away from home to
provide bedside care to their loved one should not return to an
environment that does not meet the disabled veteran's needs.
In addition, when grants are approved, the maximum allowable is
$60,000--an amount used across the Nation, without any adjustment in
consideration of regional cost of living factors. The grant is intended
to offset the cost of the modification as opposed to covering the cost
of the modification.
Another hurdle faced by veterans who do not own their own home, but
instead are living in the home of a family caregiver (i.e., a parent),
is that they must acquire a fee simple interest in the home to be
eligible for the SAH maximum grant. This creates another bureaucratic
burden for already strapped family members.
The grant is meant to offset the cost to modify a house to meet the
veteran's new accessibility needs with no consideration to how that
modification may affect the needs of other family members. For example,
if a home is modified to enlarge a bathroom and bedroom to meet a
disabled veteran's needs--and that modification results in the loss of
a bedroom or bathroom from the rest of the family--the family bears a
hardship.
SAH grants must be awarded in time to allow the homeowner to modify
the home to provide a safe and accessible environment for the veteran's
arrival; must cover the total actual cost to modify the home; and the
modification must be completed in a manner that meets the other
residing family members' needs.
Health Care
Veteran Health Care
The VA provides excellent health care to eligible veterans
throughout the United States via their Veterans Integrated Service
Networks (VISNs) and Fee-Basis Program, predominately through the
VISNs. There are instances when VA facilities do not meet the needs of
the veteran and their families--for example, a veteran may require a
specialist to perform a certain surgery, or a private physical therapy
clinic may be closer to the family home, or higher quality
rehabilitation care may be available for a brain-injured veteran. In
these instances, two hurdles exist for families to pursue the best
approach for them. The first is that the VA strongly discourages
families from pursuing medical care outside of the VA system and is
hesitant to issue the required preauthorization for fee-basis care. The
second is that some medical providers are unwilling to provide care to
veterans for fear of insufficient payment from the VA Fee-Basis
Program.
The quality and ease of access to veteran health care affects the
whole family. When the veteran and family desire to pursue care outside
of the Veterans Affairs Health Administration to obtain higher quality
care for the veteran and reduce the burden associated with obtaining
care far from home, the VA should accommodate the veteran and their
family by facilitating access to Fee-Basis services. In addition, VA
must ensure they pay Fee-Basis medical providers in a full and timely
manner.
Family Member Health Care
Non-dependent family caregivers (i.e., a parent or a sibling) often
forfeit employer-sponsored health coverage when they leave their job to
provide daily care for their loved one. This loss of coverage often
leads to diminished wellness and acute medical care, resulting in a
lower quality of life and potentially the inability to sustain care
giving for the veteran.
The VA should provide health care insurance to those family members
who have forfeited their health care insurance to provide care to their
veteran.
Respite Care
Respite care is intended to give family caregivers a break from the
demands of 24/7/365 care giving. Similar to the eligibility criteria
for Special Monthly Compensation, respite care eligibility does not
fully consider non-physical impairments experienced by those veterans
with stand-alone TBI or PTSD, and as such, precludes their families
from receiving services associated with this benefit.
The VA currently provides an annual respite benefit of up to 30
calendar days. In-home respite care is available from VA-approved
providers for up to 6 hours per day. A 6-hour respite, while better
than nothing, is very brief considering the 24/7/365 responsibility of
caregivers. Additionally, for families who desire overnight respite
care (perhaps to allow for a vacation or to receive inpatient medical
care), their only VA-provided option is to place their loved one in a
VA-approved residential care facility. Most veterans and their families
are extremely reluctant to utilize institutional care, strongly
preferring the dignity of receiving care in the comfort of home, the
security of familiar surroundings, and the receipt of one-on-one care.
Families simply choose to forego respite care when institutional care
is their only option.
VA should provide respite care for all veterans who require a
caregiver and should extend the current in-home respite benefit to
include overnight care to allow veterans to stay in their own homes
when family caregivers take the respite they need.
Long-Term Care Planning for Severely Disabled Veterans
Family caregivers for severely disabled veterans face a daunting
concern when it comes to planning for the day they are unable to
provide the care their loved one needs. While severely disabled
veterans are certainly eligible for VA-provided long-term care,
existing facilities and staff are oriented more toward the care of
chronic and age-related illnesses as opposed to the ``signature
injuries'' (TBI and PTSD) of this generation of severely wounded
veterans. Families need long-term care options that meet their loved
ones needs.
VA should invest in long-term, age-appropriate residential care
that is geared to meet the needs of OEF/OIF traumatically injured
veterans.
Beneficiary Travel
VA currently pays eligible veterans 28\1/2\ cents per mile traveled
to receive medical care and certain VA-required examinations. However,
they deduct $15.54 per round trip (deductibles not to exceed $46.62 per
month). Families of severely injured servicemembers are already
strapped for time and money and should not be further burdened by fuel
and auto maintenance expenses associated with long distance travel to
VA facilities.
VA should provide mileage reimbursement based on standard GSA rates
and eliminate the deductible.
Conclusion
The Quality of Life Foundation believes it is the moral and ethical
obligation of our Nation, Government and private citizen alike, to care
for veterans and families who, through service to country--have
sacrificed for us all. The veteran certainly faces the most personal
challenge, that of living every day with severe disabilities resulting
from their wounds and must be provided with the very best medical,
rehabilitative and long-term care to restore independence and quality
to their lives. We must remember that their family members also face
lifelong emotional, physical and financial challenges as a result of
this traumatic injury.
Our country's response to severely wounded families must be
deserving of their sacrifices. We must provide compensations, medical
care, and long-term supports to allow families to rebuild quality
lives, to live comfortably and with dignity in their homes, and to be
secure in the knowledge that their sacrifices are appreciated and
honored by a grateful Nation.
Prepared Statement of Carol A. Glazer,
President, National Organization on Disability
Mr. Chairman, Members of the Committee: I am Carol Glazer,
President of the National Organization on Disability, or NOD. I was
pleased to accept your invitation to testify before your oversight
hearing on ``Examining Ancillary Benefits and Veterans Quality of Life
Issues.''
NOD is a 27-year old national nonprofit organization that has long
worked to improve the quality of life of people with disabilities by
advocating their fullest inclusion in all aspects of life. We are one
of only three so-called ``cross-disability'' organizations working to
improve the quality of life for all of America's 54 million people with
disabilities.
Over our nearly 30-year history, we've worked with scores of
communities across the country to help them improve the quality of life
for their citizens with disabilities and honor those that do it well.
The World Committee on Disability has honored countries that do the
same with an award presented by the Secretary General of the United
Nations.
We're perhaps best known for our Harris polls, which have tracked
various quality of life indicators through statistically valid sampling
of 1,000 people with disabilities. For more than 20 years, the Harris
Interactive firm's researchers have tracked everything from access to
health care, to transportation, degree of optimism about the future,
social interactions with friends and community, religious
participation, and even voting.
Needless to say, the gaps in these quality of life indicators
between people with and without disabilities remain very wide,
notwithstanding gains we've made through the ADA and other policy
reforms in the last 10 to 20 years. Among these indicators, it should
be no surprise that economic self sufficiency displays the greatest
gap. People with disabilities suffer a poverty rate that is three times
the national average and our Harris polls have reported a 67-percent
rate of unemployment, a number that's remained virtually unchanged
since the end of WWII.
For this reason, the NOD board, led by our Chairman, former
Secretary of Homeland Security Tom Ridge, has decided that for the next
5 years NOD will devote the bulk of our resources to promoting economic
self sufficiency among America's 33 million working-age people with
disabilities. Within this focus, we are working on helping the most
severely injured veterans returning from Iraq and Afghanistan become
productive, contributing members of their communities by entering or
resuming careers upon their transition home. (We have other programs in
this arena, described in more detail in Attachment 1.)
We highly commend your Subcommittee for taking an honest appraisal
of the way in which ancillary benefits are adjudicated, disability
ratings are determined, and the kinds of ancillary benefits that can
help soldiers who've been injured in service of their country resume a
high quality of life upon their transition home.
Today, I want mainly to share with you what we are learning from
the early phases of our Army Wounded Warrior Career Demonstration
Project (AW2 Careers). While this demonstration is focusing on helping
the most severely injured soldiers in the Army's AW2 Program access
careers upon transitioning home, the model we are piloting has
applicability to a broad range of services beyond those devoted to
increasing economic self sufficiency. It is a model that deals not only
with veterans but with their families. We strongly believe that the
population of severely injured servicemembers, like the rest of the
country's people with disabilities, faces a very complex recovery
process that affects a family over a prolonged period and requires an
array of services and supports for it to gain a semblance of a good
quality of life.
Our AW2 Careers Demonstration is an entirely privately funded
initiative conducted by NOD under a Memorandum of Understanding with
the U.S. Army and its Army Wounded Warrior Program. Today, NOD Career
Specialists ensure that career services and other assistance are
provided to over 150 soldiers, veterans, and their families\*\ in the
Dallas Metroplex and the States of Colorado and North Carolina. We link
soldiers/veterans and family members to existing career services in the
community--or provide them directly ourselves where such services are
inadequate.
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\*\ We will henceforth mainly use ``veterans'' to represent all of
those served by AW2 and AW2 Careers--Regular Army, Reserve, or National
Guard soldiers who mainly veterans separated from active duty, though
in some cases still on active duty or still in the Reserves or Naional
Guard--and their family members.
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I want to proceed directly to address the Subcommittee's interest
in the benefits for and quality of life issues of our veterans. Let me
stress that to understand fully what I will present it is important to
know something about the nature of both the Army's Wounded Warrior
Program and of the NOD AW2 Careers Demonstration. Brief descriptions of
both (and of NOD) are in Attachment I and I urge those not familiar
with these programs to read Attachment I before proceeding here.
Finally, Attachment II is a one-page summary of AW2 Careers outcomes
and progress to date, drawn from our evaluation records.
My observations on the benefits and quality of life issues of our
veterans are in the nature of ``scouting reports from the front,'' so
to speak. They derive from a year of preparatory study (including focus
groups with over 200 veterans), project design, project set up, and
just over 1 year of the planned 3 years of field operations. Moreover,
they are subject to confirmation by a comprehensive external evaluation
that we have commissioned whose full results will be available at the
end of March 2012.
That caveat should be balanced against the fact that these
observations derive from the considered judgments of the NOD Career
Specialists now providing direct career services to our caseload of
veterans as well as those of us in NOD management who have designed and
now manage the project. All of us have considerable experience in
disability, career development, employment and training, human
services, and/or personnel services and issues.
So, let me begin by noting that many of the most severely injured
OEF/OIF veterans would have died in previous wars. Battlefield
medicine, however, has advanced to the point that their lives endure
but are frequently deeply impaired in both the physical and mental
realms. Many observers still expect many of these veterans to live out
lives in dependency, but we at AW2 and NOD strongly believe that most
of these young men and women can become ``independent, contributing
members of their communities.'' (the Army's admirable vision for its
AW2 soldiers/veterans) by returning to school and some form of work.
We, the Nation that placed these young men and women in harm's way,
need to see this situation as an opportunity to learn ``what works'' to
do that.
This, indeed, is the purpose animating AW2 and NOD's AW2 Careers.
It is important to note, however, that many of the challenges facing
these veterans will not be surmounted quickly or easily. The effort
must be long term in nature.
1. A Fundamental Mismatch: Seriously Injured Veterans and Reactive
Agencies: Sometimes by design and more often from funding limitations,
many of the government, and, indeed, private programs in place to help
veterans returning from Iraq and Afghanistan are constrained to a
reactive service model, only responding when a veteran seeks services
and thus placing the burden on veterans to find and approach the
agencies. But we find that the most seriously injured veterans with
whom we work are not really able to effectively access services from
reactive agencies.
Many veterans, especially the most severely injured who often
also suffer from cognitive disabilities, do not know the benefits to
which they are entitled, which agencies offer them, and how to approach
them.\**\ Further, many are isolated, geographically, socially, and/or
psychologically. Their needs call for an entirely different service
model--in our view along the lines of what we are testing in AW2
Careers. That model is to actively reach out to the veterans and ensure
their needs are being met. The terms NOD uses to describe our service
model are ``pro-active, intensive, and prolonged case management
relationships'' with the veterans being served. It is important to note
that few, if any, other government agencies and or private veterans'
service organizations can employ the service model adopted by AW2 and
AW2 Careers.
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\**\ The Army Career and Alumni Program (ACAP) briefing syllabi for
soldiers departing active duty are comprehensive and thorough, but many
veterans report that they didn't get these briefings or understand them
or remember them. Some may have been diverted by their injuries--or
simply young enough to not pay attention to seemingly remote matters
until they become very proximate, back home.
---------------------------------------------------------------------------
When a soldier is going through the Army Board process leading
to medical discharge--or shortly thereafter--that soldier, if s/he
meets AW2 admission criteria regarding severity of injury, is, in
effect, automatically enrolled as a ``member'' of AW2. His/her name is
added to a caseload list of an Army Advocate (and later, where
applicable, an NOD Career Specialist) serving the geographical region
that soldier calls home. That Advocate and Career Specialist are
charged with finding that soldier/veteran; establishing a close,
supportive relationship; and ensuring s/he gets the benefits and
services due her/him.
In NOD's case, we require Career Specialists to contact
``their'' veterans at least once a month, usually electronically (but
including face-to-face meetings early on and, later, once every 6
months, often by getting in their cars and going to see the veteran at
home, where we get a much fuller picture of his/her situation). We do
not sit in our offices and wait for a veteran to knock on our door.
Further, we have early indicators and even some evidence that
this service model is much better received by the veterans.
Anecdotally, it is clear that the close NOD Career Specialist outreach
relationships have lifted some veterans out of their isolation and
immobility and started them re-engaging in both their lives and
careers. These relationships have also resulted in spouses and children
moving forward on career paths. This is reflected in early survey
results, including the below veterans' ratings of satisfaction with
``how helpful'' the services to date of various agencies have been:
------------------------------------------------------------------------
A Lot Some A Little Not at All
------------------------------------------------------------------------
NOD Career Specialist 61% 30% 7% 2%
------------------------------------------------------------------------
AW2 Advocate 56% 29% 14% 2%
------------------------------------------------------------------------
One Stop Center 29% 29% 29% 14%
------------------------------------------------------------------------
Voc Rehab & Empt 28% 48% 20% 4%
------------------------------------------------------------------------
ACAP 16% 43% 39% 11%
------------------------------------------------------------------------
Other Agencies 0% 67% 33% 0%
------------------------------------------------------------------------
Finally, we acknowledge that the AW2/AW2 Careers service model
is more expensive than office-based, reactive models. To this we
respond that our final evaluation is likely to confirm our early
operating judgment that this model works more effectively, certainly
for this population of most severely wounded veterans. Moreover, a
broadly based cost-benefit analysis should weigh direct program costs
against the benefits of reduced dependency costs, increased tax
revenues from veterans' earnings, reduced costs for shelters and
imprisonment, more successful marriages and parenting, and the
restoration of self-confidence from a veteran's again an ``independent,
contributing member of his/her community.''
2. The Need to Deal with both the Veteran and the Family: The
process of recovering from injury and coming to terms with disability
is a complex process that is all consuming not only for the veteran but
the entire family. Retired parents may have to become caregivers to a
veteran. Spouses whose job it was to take care of the children and
household find them-selves suddenly in the role of caregivers to the
veteran and/or even family breadwinners. Children may have to come to
grips with a parent they no longer recognize. Investing in support for
spouses, parents of veterans, and veterans' children who are drawn into
this process is, in our view, a necessary and cost effective investment
that the VA must consider as it administers ancillary benefits. And
these benefits must be as flexible as are many of the benefits
available through VR and E.
3. Unaddressed Mental Health Needs: More than half the AW2
population, including those in AW2 Careers, suffers from primary
diagnoses of Post-traumatic stress disorder or Traumatic Brain Injury,
with many having both, often along with other injuries. But the
behavioral/mental health concerns do not stop there. Many veterans
suffer depression or other mental health issues (including violent or
suicidal ideations) that require appropriate mental health services
(especially including marital/family counseling). But, we find that
these needs are largely unaddressed and can impede career progress by
contributing to veterans' dropping out of education or training or
losing a job. It is not a criticism of the VA to say that despite its
efforts to expand such services, it simply isn't able to adequately
service these needs. Sometimes the veteran denies these needs; or finds
the local VA has no or limited mental health services or they are not
close enough; or does not like what they perceive as the VA's reliance
on problematic medications (not uncommon in other populations using
psychotropic medications), with only limited therapy. We feel that the
VA should supplement its direct mental health services by mobilizing
and applying mental health services from other local agencies that are
anxious to be helpful to veterans but need to be recruited, supported,
and trained to do so.
4. Criminal Charges: We have encountered several situations where
some behaviors associated with PTSD/TBI have resulted in veterans
facing criminal charges (e.g., erratic driving, substance abuse,
violence, including family abuse, etc.). It is hard to help a veteran
stay on a career path when s/he is in court or jail. We have examples
of our Career Specialists intervening with police, prosecutors, or the
courts to request that notice be taken of the soldier/veteran's
disability and considered as a mitigating factor in charges or
sentencing. This has sometimes resulted in remanding the soldier/
veteran to treatment rather than incarceration. There is need for all
agencies serving this population to intervene in such circumstances,
bringing these factors to the consideration of such local authorities.
(Indeed, one of our Career Specialists has led the effort in his part
of his State to create a ``Veterans Court'' to which criminal charges
against soldiers or veterans are referred for disposition taking such
factors into account.)
5. Personal/Family Financial Management: Young veterans often have
little or no experience or knowledge of properly managing family
finances, despite ACAP and other Army training thereon. Our Career
Specialists frequently find veterans in dire financial straits
requiring emergency advice, training, and assistance. There is clearly
a need for continuing personal/family financial management training and
guidance.
6. Peer Support Mechanisms: The fact that so many of our veterans/
families are isolated geographically, socially, and psychologically has
led our Career Specialists to try various peer meetings and other peer
supports, often with heartening results. Our sense is that this needs
broader application.
7. Inadequate Education and Job Skills: We have not been surprised
to find that many of our veterans lack the education credentials and
job skills needed to succeed in the labor markets of today and the
foreseeable future. Our response is to urge veterans to use the
education and training benefits available to them to upgrade their
credentials on either or both fronts. Many have responded positively.
But others working with these veterans need to adopt the same emphasis.
8. The Need for Flexible Work Support Funds: The soldiers,
veterans, and family members we serve frequently have very limited
incomes. In addition, they face the need to spend modest amounts of
money on things that can advance their career prospects--or impede them
if such expenditures are not possible. These needs include things like
tuition payments where Federal educational benefits are delayed and the
veteran cannot afford payments up front. Or, books, work clothes,
computer repairs or software, travel expenses for a job fair or
interview, license or other work related fees, and more. To meet such
needs, we provide small grants from our work support funds that can
facilitate career progress.
Next Steps:
As indicated above, our sense is that our model of services is
highly promising and that its early indicators confirm this. But, we
think we should take this developmental and testing phase further to
generate firmer results, outcomes, and lessons.
The present model of three sites over three operating years was
devised three or so years ago, early in the then understandably chaotic
period of our Nation becoming aware of the challenge and opportunity of
responding to these severely wounded returning veterans--and of the
initially chaotic and understaffed period of establishing the AW2
program. The private sector then stepped forward, with an impressive,
welcome, but still limited support of our demonstration program.
Our sense, as experienced operators of demonstration projects, is
that the present pilot project, while important as a source of early
lessons, is nonetheless too limited. Three sites are too few; 3 years
are too few. Far better in terms of both serving more people but more
important in generating more reliable data to support lessons learned,
would be more sites for more time. We feel that expanding our present
three sites to 5 instead of 3 years would yield important dividends in
lessons learned and confirmed. Moreover, expanding the number of sites
would yield similar dividends. Hence, we argue for up to nine
additional sites, or a dozen in all.
Moreover, additional sites would allow clusters of sites to focus
on potentially important themes. For instance, we would envision a
cluster including concentrated mental health services; another
including concerted advice to employers on both ways to accommodate the
needs of disabled veterans in order to be productive and ways to
``sculpt'' or structure job requirements to the same end; yet others
emphasize peer group supports. Then, too, some or all of the additional
sites should provide career services to the severely disabled veterans
from all DoD uniformed services. To these ends, we seek Congressional
and agency support as well as the continuation of private funding.
Thank you for your invitation and attention.
__________
Attachment I to Testimony of Carol A. Glazer: Brief descriptions of
NOD, of the Army's Wounded Warrior Program (AW2), and of
NOD's AW2 Careers Demonstration Project.
The National Organization on Disability
The mission of the National Organization on Disability (NOD) is to
expand the participation and contribution of America's 54 million men,
women, and children with disabilities in all aspects of life. NOD was
established in 1982 with the goal of inclusion for people with
disabilities. It was a key player in the passage of the Americans with
Disabilities Act (ADA) in 1990 and the placement of the statue of
Franklin Delano Roosevelt in a wheelchair in the Nation's Capital.
With offices in New York City and Washington, DC, NOD works
nationally in partnership with international, national, and local
organizations. NOD has earned respect for its work as an advocate,
program developer, and provider of the field's most important research
on the status of Americans with disabilities (the NOD/Harris Surveys).
NOD provides direct services to clients only as a part of demonstration
programs aimed at developing new approaches and scaling up those that
work.
NOD focuses on economic self-sufficiency for people with
disabilities. Our most significant projects are AW2 Careers as
described below and Start on Success (SOS), a student internship
program that transitions young people with disabilities into the
workforce and helps prepare special education students--especially from
racial or ethnic minorities and low-income, urban families--for
competitive employment.
Despite a primary focus on education and employment, NOD remains
vigorously involved in the wider range of concerns affecting people
with disabilities, including those that arise at the moments of
greatest vulnerability. NOD/Harris Surveys reveal that 56 percent of
people with disabilities do not know whom to contact in the event of a
disaster. NOD's Emergency Preparedness Initiative (EPI) promotes the
inclusion of people with disabilities in emergency preparedness
planning and response by participating in emergency planning exercises,
hosting conferences and by providing information, technical assistance,
and other resources to emergency planners, first responders, disability
advocates, and people with disabilities.
NOD is the only disability organization with credentialed personnel
experienced in emergency management and disability issues.
The U.S. Army Wounded Warrior Program (AW2)
At this writing, the U.S. Army Wounded Warrior (AW2) Program\***\
assists close to 5,000 of the most severely injured soldiers and
veterans of the wars in Iraq/Afghanistan. To be ``in'' AW2, a soldier/
veteran must have one or more severe physical disabilities (e.g.,
burns, blindness, amputations, spinal cord injuries), often combined
with Post-traumatic stress disorder (PTSD) and/or Traumatic Brain
Injury (TBI).
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\***\ Several years ago, then Secretary of Defense Donald Rumsfeld
ordered all uniformed services to establish programs for severely
wounded members that would aggressively facilitate their obtaining the
services and benefits they need, including when medically separated
from active duty. The Army's AW2 Program is the largest of these.
---------------------------------------------------------------------------
Assistance is provided by a cadre of over 135 ``Advocates,'' Army
employees or contractors who are stationed around the country with
caseloads averaging 37. Advocates are counselors, advisors, navigators,
case managers, and, yes, advocates with respect to the many and often
confusing benefits and services available to and needed by such
soldiers and veterans. The Advocates' mission is to pro-actively
facilitate soldiers/veterans' receipt of the supports and services they
need to become ``contributing members of their communities,'' the
Army's admirable vision for those in the AW2 caseload. The Advocates
are charged with staying engaged with veterans for ``as long as it
takes.'' (Family members are also served.)
A culminating step to this goal is sometimes for AW2 soldiers/
veterans to return to active duty, or, more commonly, to leave active
duty and resume or enter civilian careers as veterans, where one of
their options is to resume or enter civilian careers.
But civilian career development is a specialized activity that the
Army and its Advocates have little experience with and limited time to
devote to. To develop and learn what approaches the Army could most
effectively use to assist severely disabled AW2 soldiers and veterans
to move forward on their career paths, the AW2 Program and the
nonprofit NOD concluded a Memorandum of Understanding (MOU) in 2007 for
a public/private collaboration under which NOD would assist AW2 in
advancing the careers of the soldiers/veterans it serves (including
their family members, as well).
NOD's activities with AW2 under this MOU have had two major
focuses: First, NOD drafted a Field Manual on Careers: Education,
Training, and Work for the AW2 Advocates. This primer on career goals
and services will shortly be promulgated to AW2 field staff as official
guidance for their work on the careers front. Our major project is the
AW2 Careers Demonstration Project, the focus of my testimony today. AW2
Careers is a pilot project whose lessons are to be transferred to AW2
both during the project and at its scheduled completion in 2012, when
AW2 plans to assume full responsibility for career services and may
conduct them in large part on the basis of the demonstration's
experiences.
AW2 Careers
NOD's AW2 Career Demonstration Program is a 4\1/2\-year\****\ pilot
project (now just into its second full operating year) under which NOD
has placed one or more NOD Career Specialists in three locations (the
Dallas, Texas, Metroplex; Colorado Springs, serving the State of
Colorado; and Fayetteville, serving the State of North Carolina),
where, over a 3-year period, they team with the local Advocates,
concentrating on career development for soldiers, veterans, and family
members who are ready for such services.
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\****\ This comprises several months for planning and start up,
over 3\1/2\ years for site operations on a staggered startup basis, and
several months to finalize the project's evaluation and promulgate its
findings.
---------------------------------------------------------------------------
Operational Model
Like the Advocates, the Career Specialists employ a pro-active,
intense, prolonged case management model helping the veterans think
about and explore career options; obtain education, skill, aptitude,
and interest assessments; devise resumes and career plans; acquire
additional education and training; enter into work of various kinds
(full- or part-time, paid or volunteer, for nonprofit, for-profit, or
governmental employers--or self-employment as entrepreneurs or
individual contributors); and advance in that work once so engaged.
They do this by finding and linking veterans/families to relevant
career services locally or providing the services themselves where
local resources are inadequate.
The AW2 career process is represented by the flow chart below,
through all or some of which will move an AW2 veteran/family member.
This is not necessarily a linear, forward only, process. Some veterans
may backtrack to an earlier cell, to plan a different career or go to
college, etc. Some may both work and go to school at the same time--or,
may volunteer while working and/or in school. Career planning may be
preparation for work or school and/or may occur while working or in
school. Note, too, that Career Specialists ``stick with'' veterans
after job placement for the full duration of the project.
[GRAPHIC] [TIFF OMITTED] 51876A.001
A goal of a Career Specialist is to assist the veteran to move as
far and as quickly through these cells as possible during the project's
duration. Job placement is not the only criterion of success; equally
important is motion forward. A closely linked goal is to learn ``what
works'' to help the veteran move from step to step (see evaluation,
below).
Some veterans have already, on their own, entered school or at
work, but many are in cell #1 and are our prime target population. They
may be still in outpatient rehabilitation, still too injured to
consider career steps at this time. Or, they may still be adjusting to
the home environment and family situation; content to live on benefits
at this time; discouraged from trying and not making progress; or just
not ready or interested at this time. Many need time and encouragement
to move forward.
Others are dispersed across the other cells of the flow chart.
Wherever they find the veterans, our Career Specialists find and
establish relations with them, assess their needs, and assist them in
moving forward. Attached is our most recent statistical status and
progress report as of the end of June 2009.
NOD has undertaken this Careers Demonstration mindful that it must
utilize, not duplicate, other resources with the mission of assisting
wounded veterans. In AW2 Careers local sites informal collaborators
include the public agencies serving disabled veterans (Department of
Labor and its VETS and ``Real Lifelines'' programs; the Veteran's
Administration Vocational Rehabilitation and Employment offices; and
the Social Security Administration offices); private nonprofit
Veteran's Service Organizations (including Disabled American Veterans,
VFW, Paralyzed Veteran's Association, AMVETS and American Legion) and a
host of new voluntary organizations operating both nationally and
locally, such as the Wounded Warrior Project and Yellow Ribbon Fund,
that have formed since September 11th. The roster of such collaborators
varies from site to site.
In addition, NOD is collaborating with the nonprofit, foundation-
funded Give an Hour network, which stimulates local mental health
providers to donate, gratis, an hour of mental health services per week
to returning Iraq/Afghanistan veterans needing such services. Give an
Hour advises both AW2 Advocates and NOD Career Specialists on how to
make appropriate mental health interventions when needed, and assists
in providing such services where appropriate.
Evaluation
The Economic Mobility Corp. (Mobility), a nonprofit organization
led by Mark Elliott, a workforce development specialist who helped
design the program, is responsible for conducting the program
evaluation. AW2 Careers' two main goals: 1) developing effective ways
to help veterans achieve better employment and education outcomes; and
2) using what we learn to inform the military and the helping
professions and agencies about how best to assist such severely
disabled veterans meet career goals.
A final evaluation after the completion of Year 3 will report on:
1) how effectively the program is implemented at each site; 2) the
extent to which the initiative increases the level and quality of the
employment and educational services that veterans and their families
receive; 3) what employment and educational outcomes veterans/families
achieve after receiving program services; and 4) what career supports
or other factors were most helpful in generating such outcomes.
Funding
NOD designed AW2 Careers to be privately funded (to enable quick
actions devoid of bureaucratic impediments) with national funders
supporting the national office's management, technical assistance,
evaluation, and communication/promotional activities, and local funders
supporting each site. At present, AW2 Careers is supported by 17
national and local foundations and two private corporate donors. These
funders (counting grants provided and renewals that are likely) support
93 percent of the present 4\1/2\-year project budget of $4.6 million.
NOD is seeking to fill the remaining gap through additional support
from present and other potential funders.
Attachment II: AW2 Careers Status Report as of June 30, 2009
------------------------------------------------------------------------
TX CO NC All
------------------------------------------------------------------------
Number of Soldiers/Veterans on the Careers 61 49 50 160
Caseload as of June 30
------------------------------------------------------------------------
Current Status of Soldiers/Veterans
------------------------------------------------------------------------
Currently employed,\1\ in education or 37 29 21 87
training and/or volunteering
------------------------------------------------------------------------
Engaged in career planning 32 22 20 74
------------------------------------------------------------------------
Still on active duty 1 2 9 12
------------------------------------------------------------------------
Engaged in career planning 0 2 7 9
------------------------------------------------------------------------
Currently not on active duty, employed, in 16 16 20 52
education/training or volunteering
------------------------------------------------------------------------
Engaged in career planning 8 12 17 37
------------------------------------------------------------------------
Status not confirmed (Soldier/Veteran not 7 2 0 9
contacted or status not recorded)
------------------------------------------------------------------------
Outcomes Achieved After Receiving Services
------------------------------------------------------------------------
Soldiers/Veterans who ever achieved any 17 20 4 41
outcome after receiving services \2\
------------------------------------------------------------------------
Soldiers/Veterans who achieved any outcome 0 0 1 1
in June 2009
------------------------------------------------------------------------
Soldiers/Veterans currently in an outcome 17 19 4 40
achieved after receiving services
------------------------------------------------------------------------
Family members currently in an outcome 2 0 1 3
achieved after receiving services
------------------------------------------------------------------------
Employment among Soldiers/Veterans
------------------------------------------------------------------------
Ever employed in a civilian job since on the 24 22 11 57
caseload
------------------------------------------------------------------------
Currently employed in a civilian job \3\ 20 19 11 50
------------------------------------------------------------------------
Ever obtained a civilian job after receiving 6 14 1 21
services \4\
------------------------------------------------------------------------
Obtained a civilian job in June 2009 0 0 1 1
------------------------------------------------------------------------
Currently in a civilian job obtained after 6 12 1 19
receiving services
------------------------------------------------------------------------
Education Among Soldiers/Veterans
------------------------------------------------------------------------
Ever attended education/training since on 21 12 10 43
the caseload
------------------------------------------------------------------------
Completed education or training 0 1 0 1
------------------------------------------------------------------------
Currently attending education or training 19 10 10 39
------------------------------------------------------------------------
Ever started education/training after 8 6 2 16
receiving services
------------------------------------------------------------------------
Started education/training in June 2009 0 0 0 0
------------------------------------------------------------------------
Currently in education/training begun after 8 5 2 15
receiving services
------------------------------------------------------------------------
Volunteering among Soldiers/Veterans
------------------------------------------------------------------------
Ever volunteered since on the caseload 9 6 6 21
------------------------------------------------------------------------
Currently in a volunteer activity 9 6 5 20
------------------------------------------------------------------------
Ever started a volunteer activity after 5 3 1 9
receiving services
------------------------------------------------------------------------
Started a volunteer activity in June 2009 2 0 0 2
------------------------------------------------------------------------
Currently in a volunteer activity begun 5 3 1 9
after receiving services
------------------------------------------------------------------------
Contact Since the Start of the Demonstration
at Each Site
------------------------------------------------------------------------
Soldiers/Veterans ever contacted 55 47 50 152
------------------------------------------------------------------------
Soldiers/Veterans who ever received a 53 40 48 141
service or referral
------------------------------------------------------------------------
Soldiers/Veterans seen in person from 42 20 39 101
December 2008 through June 2009 \5\
------------------------------------------------------------------------
Family members who ever received a service 24 0 6 30
or referral
------------------------------------------------------------------------
Contact in June 2009
------------------------------------------------------------------------
Soldiers/Veterans contacted (service, 30 2 30 62
referral or follow up)
------------------------------------------------------------------------
Soldiers/Veterans who received a new 25 0 25 50
service or referral
------------------------------------------------------------------------
Soldiers/Veterans who had follow up or 24 2 10 36
update contacts
------------------------------------------------------------------------
Soldiers/Veterans where contact attempted 14 1 4 19
but not made
------------------------------------------------------------------------
Soldiers/Veterans seen in person 3 1 14 18
------------------------------------------------------------------------
Family members who received a service, 24 0 5 29
referral or follow up
------------------------------------------------------------------------
\1\ Includes civilian jobs only.
\2\ 5 Soldiers/Veterans achieved 2 outcomes: 4 are employed and in
education; 1 is employed and volunteering.
\3\ Currently employed means the last employment assessment entered
indicates that the Soldier/Veteran is employed. However, most
assessments were entered months ago, and ``current'' does not indicate
that the status was verified in the current month. The same applies to
the education assessments and volunteer information.
\4\ The 20 Soldiers/Veterans have obtained a total of 23 jobs since
receiving services.
\5\ December 2008 is when CSs started tracking whether contacts were in
person, by phone or by email.
Prepared Statement of Bradley G. Mayes, Director,
Compensation and Pension Service, Veterans Benefits Administration,
U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Subcommittee, thank you for
inviting me to speak today on the timely and important issues related
to providing compensation for quality of life (QOL) loss to our
Nation's disabled Veterans.
I. Quality of Life Loss Issues
Background
Department of Veterans Affairs (VA) compensation for service-
connected disability is based on average lost earnings due to an injury
or disease incurred in or aggravated by military service. Benefits are
paid according to a rating assigned to a Veteran's disability based on
the VA Schedule for Rating Disabilities. The statute at 38 U.S.C.
Sec. 1155 states that ``ratings shall be based, as far as practicable,
upon the average impairments of earning capacity.'' As a result, the VA
rating schedule compensates Veterans for the average loss in income
resulting from their service-connected disabilities. In recent years,
this approach to compensation has been challenged as inadequate because
it focuses only on earnings loss and not on the larger issue of QOL
loss. VA has received input on the QOL loss issue from numerous sources
and has sought to identify the implications of adopting a policy of
compensating Veterans for QOL loss in conjunction with the current
earnings loss compensation system. Those sources providing information
and recommendations to VA have included: the President's Commission on
Care for America's Returning Wounded Warriors (Dole-Shalala
Commission); the Veterans' Disability Benefits Commission (Benefits
Commission); the Center for Naval Analyses (CNA); the National Academy
of Sciences' Institute of Medicine (IOM); and, most recently, Economic
Systems, Incorporated (EconSys).
Definitions of QOL loss vary and may focus on aspects of an
individual's physical and mental health or may address the individual's
overall satisfaction associated with life in general. The IOM traces
the concept back to the Greek philosopher Aristotle's description of
``happiness'' but the IOM's definition encompasses the cultural,
psychological, physical, interpersonal, spiritual, financial,
political, temporal, and philosophical dimensions of a person's life. A
more succinct definition utilized by EconSys refers to an individual's
overall sense of well-being based on physical and psychological health,
social relationships, and economic factors.
Dole-Shalala Commission
QOL loss was addressed in the 2007 Report of the President's
Commission on Care for America's Returning Wounded Warriors, also
referred to as the Dole-Shalala Commission. Although the report
primarily focused on ways to assist severely wounded servicemembers
returning from Iraq and Afghanistan, it recommended that Congress
should restructure VA disability payments to include compensation for
non-work-related effects of permanent physical and mental combat-
related injuries. According to the report, this would compensate a
disabled Veteran for the inability to participate in favorite
activities, social problems related to disfigurement or cognitive
difficulties, and the need to spend a great deal of time performing
activities of daily living. As a result of the report, VA contracted
for a study on QOL loss with EconSys, which was completed in 2008.
In terms of existing compensation, the EconSys study agrees with
prior studies that earnings loss is on average at least fully
compensated under the current system and in some cases overcompensated.
However, studies agree that certain conditions such as mental health
are undercompensated. Prior studies found that QOL loss does exist for
service-disabled Veterans and recommended that VA examine possibilities
for QOL compensation, acknowledging that implementation would be
lengthy and have significant cost implications.
Veterans' Disability Benefits Commission
The Benefits Commission was created by the National Defense
Authorization Act of 2004 and produced a final report in 2007 that
provided recommendations on a wide range of issues related to the
claims process and the benefits award system. Among the issues
addressed was QOL loss. The Benefits Commission incorporated
information from the CNA and IOM studies into its final report,
agreeing with these organizations that QOL loss exists among disabled
Veterans. The Benefits Commission also supported the idea that VA
should undertake studies to research and develop QOL measurement tools
or scales and ways to determine the degree of loss of QOL on average
resulting from disabling conditions listed in the rating schedule.
However, it acknowledged that QOL loss assessment is relatively new and
still at a formative stage, which indicates that implementation would
be a long-term, experimental, and costly activity. In addition, it
recognized special monthly compensation benefits and ancillary benefits
as existing vehicles to assist with QOL loss among disabled Veterans.
Center for Naval Analyses
A study on QOL loss among Veterans was conducted by CNA at the
request of the Benefits Commission. It focused on whether the current
VA benefits program compensates for QOL loss. A survey was conducted to
determine whether QOL loss existed among disabled Veterans and whether
parity existed between the amounts of VA compensation received by
disabled Veterans and the average earned income of non-disabled
Veterans. CNA determined that QOL loss does exist among disabled
Veterans. CNA also found that VA generally compensated adequately for
lost earnings and in some cases overcompensated, as with Veterans who
enter the system at retirement age, which CNA stated implies a built-in
QOL loss payment for these Veterans. However, CNA found that
undercompensation occurred for younger Veterans with more severe
disabilities and for Veterans with all categories of mental
disabilities compared to physical disabilities. CNA also pointed out
that those Veterans with mental disabilities showed the greatest QOL
loss.
Institute of Medicine
The Benefits Commission considered QOL loss findings documented in
A 21st Century System for Evaluating Veterans for Disability Benefits,
produced by IOM at the commission's request. This lengthy IOM review of
the VA disability benefits process addressed QOL loss. A distinction
was made by IOM between current VA compensation for a Veteran's work
impairment and a compensation system based on ``functional
limitations'' on usual life activities. IOM concluded that the
Veterans' disability compensation program should compensate for: work
disability, loss of ability to engage in usual life activities other
than work, and QOL loss. IOM also recommended that VA develop a tool
for measuring QOL loss validly and reliably in the Veteran population
and develop a procedure for evaluating and rating the QOL loss among
disabled Veterans.
Economic Systems, Incorporated
The most recent study of QOL loss was produced by EconSys, titled
Study of Compensation Payments for Service-Connected Disabilities,
Volume III, Earnings and Quality of Life Loss Analysis, released in
September 2008. VA tasked EconSys with analyzing potential methods for
incorporating a QOL loss component into the current rating schedule and
with estimating the costs for implementing these methods. The EconSys
study proposed three options that could be utilized by VA.
The first and simplest method would be to establish statutory QOL
loss payment rates based on the combined degrees of disability. This
method would ``piggy-back'' the QOL loss payment on top of the assigned
disability evaluation under the current rating schedule. The amount of
the payment would be determined by assigning a QOL score, ranging from
-2 to 4, with 4 representing death and negative values representing an
increase in the QOL of the Veteran. Although this method would be the
easiest to administer because significant changes to the VA medical
examination and rating process would not be necessary, it raises issues
of fairness. EconSys found that the severity of QOL loss does not
mirror the severity of earnings loss captured in the ratings schedule.
Moreover, EconSys found that QOL loss varies greatly both by condition
and by individual, meaning that different Veterans with the same
disability rating or the same condition could vary widely in their QOL.
Under this proposed method, a Veteran with minimal actual QOL loss
could receive the same extra QOL loss payment as a Veteran with the
same disability who has a severe actual QOL loss. EconSys has estimated
that additional annual program costs for implementing this method range
from $10 billion to $30.7 billion.
A second optional method proposed by EconSys would key QOL loss
payment amounts to the medical diagnostic code of the primary
disability, as well as to the combined percentage rate of disability.
This option anticipates that Congress would create a separate pay scale
based on the Veteran's combined degree of disability and primary
disability. This method would arguably produce more accurate QOL loss
payments because two variables rather than one would be involved and
previous studies have shown that some disabilities, such as mental
disorders, are associated with greater actual QOL loss than others.
However, implementing this would involve conducting large sample-size
surveys to assess the average QOL loss for each of over 800 diagnostic
codes and then factoring in the additional loss for each of the 10
percent increments of the rating schedule up to 100 percent. No surveys
like this have been conducted in the past as a means to assign a dollar
value to QOL loss. Inherent in such surveys is the potential for
inconsistency and inaccuracy because the data would involve Veterans'
self-reported answers to subjective questions. Given the number of
``diagnostic code-evaluation percentage'' combinations involved, a QOL
loss scale developed under this method would be extremely complex and
require extensive program and system modifications. In the event this
method were implemented, it would likely be subject to the same issues
of fairness as the first method. A Veteran with a low combined
disability percentage rating may receive more total compensation than a
Veteran with a high combined disability percentage rating because of a
difference in the QOL loss value assigned to different diagnostic
codes. Moreover, the disability identified as primary for existing
compensation may not be the primary cause of a Veteran's QOL loss.
EconSys has estimated that this method would result in annual program
costs of $9 billion to $22.2 billion.
A third option proposed by EconSys would involve an individual
assessment of each Veteran for QOL loss by both a medical examiner and
a claims adjudicator. It would also involve establishing separate
rating tables for earnings loss and QOL loss and using these in
combination with subjective information received from the Veteran about
his or her QOL loss. This method would arguably allow for the most
accurate assessment of QOL loss because of its individualized nature.
However, it would require extensive training of VA personnel to
administer and interpret QOL loss assessment tools and then apply them
in the rating process. Once again, issues of subjectivity and fairness
would likely be involved. EconSys has estimated that this method would
result in annual administrative costs of approximately $71.5 million,
in addition to program costs of $10.5 billion to $25.7 billion.
II. Implementing Quality of Life Loss Compensation
VA Challenges
Implementing a disability rating system that compensates for QOL
loss would involve at least two major challenges for VA. The first
would be to accurately and reliably determine whether, and to what
extent, a disabled Veteran suffers from QOL loss. The second would be
to establish equitable compensation payments for varying degrees of QOL
loss. The first challenge has been addressed by other organizations and
has led to the development of QOL loss assessment tools. The most well-
known of these is the RAND Corp.'s Short Form 36 Health Survey Version
2 (SF-36) and Short Form 12 Health Survey (SF-12). These are survey
questionnaires that measure physical functioning, role limitations due
to physical health, bodily pain, general health perceptions, vitality,
social functioning, role limitations due to emotional problems, and
mental health. The questionnaires yield a score that is interpreted to
measure QOL loss in relation to the non-disabled population.
The CNA study conducted for the Benefits Commission utilized a
survey instrument derived from the SF-36 and SF-12. The results showed
that service-connected disabled Veterans were more likely to report QOL
loss than non-disabled Veterans. However, CNA made it clear that the
results were based on subjective self-reporting by Veterans and that,
although survey instrument scoring showed a difference between disabled
and non-disabled Veterans, the instruments were not able to show how
much difference in QOL loss existed between the two groups. This is
problematic for VA because the second challenge of assigning a dollar
value for compensation purposes depends on distinguishing different
degrees of QOL loss among disabled Veterans.
As EconSys stated in its study, users of existing QOL loss
assessment instruments seek to make comparisons of QOL loss between
different groups or to measure improvements in QOL loss as a result of
treatment interventions. However, they are not trying to attach a
dollar value to differences in loss of QOL. Therefore, although the CNA
study indicates a greater QOL loss among disabled Veterans compared to
non-disabled Veterans, it does not provide VA with a means to measure
the extent of differences and provide equitable compensation
accordingly.
The EconSys study, described above, provides options for
implementing a compensation procedure for QOL loss among Veterans, but
is not specific about how new assessment instruments would be
developed. For example, in the second option offered by EconSys, part
of the QOL loss payment would be tied to the medical diagnostic code
that represents the disability which is service-connected. This is
based on the assumption that certain medical disabilities generally
produce greater QOL loss than others. To implement this, VA would be
required to develop new survey instruments that target specific
diagnostic codes. Surveys now in use, such as the SF-36 and SF-12, are
generic and would be of little help. When developing any new survey
instrument, the issue of minimizing subjectivity would always be
present. Additionally, the EconSys study does not address a viable
means to assign a dollar value to the different degrees of QOL loss
that may be experienced by individual Veterans. This burden would
remain with VA and Congress.
VA would face many additional problems in the attempt to implement
QOL loss compensation. Since a major goal of VA is successful treatment
and rehabilitation for disabilities, it is likely that the mental and
physical health of some Veterans would improve over time. On the other
hand, a Veteran's circumstances may lead to an increase in QOL loss.
Therefore, the issue of how to adjust compensation payments for changes
in a Veteran's QOL loss over time would need to be dealt with.
An additional concern presented by two of the EconSys options is
the potential for appeals of Veterans' ratings. In options two and
three, it is highly likely that Veterans with similar conditions of
similar severity would receive different ratings and awards. This
inconsistency introduces an equity issue that could lead to additional
appeals and therefore a more frustrating process for Veterans.
Current VA Compensation
Most of the organizations that have provided input to VA on QOL
have stated that VA has a number of special benefits that implicitly,
if not expressly, compensate for QOL loss, such as ancillary benefits,
special monthly compensation, and total disability based on individual
unemployability. Special monthly compensation and ancillary benefits
are provided to Veterans in addition to compensation paid on the basis
of the schedular rating assigned to service-connected disabilities.
The ancillary benefits to which these organizations refer are
intended to provide assistance to Veterans with special needs resulting
from exceptional handicaps due to certain service-connected
disabilities. Assistance with the purchase of an automobile or other
conveyance, with obtaining the adaptive equipment necessary to ensure
that the Veteran can safely operate the vehicle, is authorized by 38
U.S.C. Sec. 3902. Eligible Veterans include those with service-
connected loss, or permanent loss of use, of one or both feet or one or
both hands, and those with permanent significant visual impairment.
Another ancillary benefit that provides assistance to Veterans and
servicemembers with certain service-connected disabilities is
assistance in acquiring housing with special features, which is
authorized by 38 U.S.C. Sec. 2101(a). Eligible Veterans and
servicemembers include those with permanent and total service-connected
loss, or loss of use, of both lower extremities that precludes
locomotion without the aid of a mechanical device; blindness in both
eyes plus loss, or loss of use, of one lower extremity; loss, or loss
of use, of one lower extremity plus residuals of organic disease or
injury that precludes locomotion without the aid of a mechanical
device; loss, or loss of use, of one lower and one upper extremity that
precludes locomotion without the aid of a mechanical device; loss, or
loss of use, of both upper extremities that precludes use of the arms
at or above the elbows; or disability due to a severe burn injury. In
addition, VA is authorized by 38 U.S.C. Sec. 2101(b) to provide
assistance in adapting a residence or acquiring an already adapted
residence to Veterans who are not eligible for assistance under
Sec. 2101(a) and are entitled to compensation for a permanent and total
service-connected disability due to blindness in both eyes; including
anatomical loss, or loss of use, of both hands; or due to a severe burn
injury.
Additionally, a yearly clothing allowance is authorized by 38
U.S.C. Sec. 1162 for a Veteran who, because of a service-connected
disability, wears or uses a prosthetic or orthopedic appliance,
including a wheelchair, which tends to wear out or tear the Veteran's
clothing. A clothing allowance is also authorized when a physician
prescribes medication for a service-connected skin condition that
causes irreparable damage to a Veteran's outer garments.
In addition to these ancillary benefits, VA is authorized by 38
U.S.C. Sec. 1114 to provide special monthly compensation in addition to
schedular disability compensation to Veterans with service-connected
disabilities who are housebound, are in need of aid and attendance to
accomplish daily living activities, have severe hearing loss or visual
impairment, or have loss, or loss of use, of extremities or
reproductive organs. In addition, VA is authorized to pay special
monthly compensation to female Veterans for breast tissue loss.
VA regulations authorize a rating of total disability based on
individual unemployability if a Veteran is unable to obtain, or
maintain, substantially gainful employment because of service-connected
disabilities. This is an extra-schedular rating resulting in
compensation paid at the 100-percent schedular rate for Veterans who
have been awarded a single 60-percent or a combined 70-percent
disability rating and are unable to work as a result of their service-
connected disability. The benefit is also available based on a VA
administrative review, if the schedular requirements are not met.
III. Conclusion
This testimony attempts to outline some of the issues and
challenges that VA would face if authorized to provide QOL loss
compensation. If VA is to provide QOL loss compensation consistent with
the proposed options in the EconSys study, statutory changes would be
required. Additional administrative costs for training VA personnel and
reconfiguring VA computer systems, as well as the costs for providing
additional benefits to Veterans, would be considerable. The
implications for adopting such a policy are significant for VA. This
testimony also illustrates how, in addition to compensation provided
under the rating schedule, VA provides special monthly compensation,
ancillary benefits, and extra-schedular ratings to Veterans with
certain service-connected disabilities, which multiple studies have
recognized as existing tools to promote the QOL of Veterans.
As always, VA maintains its dedication to fairly and adequately
serving the disabled Veterans who have sacrificed for our country.
Statement of Sarah Wade, Chapel Hill, NC
Chairman Hall, Ranking Member Lamborn, Members of the Subcommittee,
thank you for allowing me the opportunity to provide testimony
regarding quality of life and ancillary benefit issues. My name is
Sarah Wade, wife of Army Sergeant (Retired) Ted Wade.
My husband served first in Afghanistan, later Iraq, and on
Valentine's Day 2004, his Humvee was hit by an Improvised Explosive
Device (IED) on a mission in Mahmudiyah. Ted sustained a severe
Traumatic Brain Injury (TBI), his arm was completely severed above the
elbow, suffered a fractured leg, broken foot, shrapnel injuries, as
well as other complications, and later would be diagnosed with Post-
traumatic stress disorder (PTSD). He remained in a coma for over 2\1/2\
months, and withdrawal of life support was considered, but miraculously
he pulled through.
After the battle for his life was won, the war for the necessary
mix of benefits and services began, and continues today. Due to the
severity of his brain injury, Ted is sometimes unable to fight for
himself, so his struggle has become my own. I am consumed 24 hours a
day assisting my husband with managing his special diet, preparing
meals, providing transportation, enforcing medication management and
other necessary routines, overseeing his medical care, checking his
blood glucose level, administering injections of insulin because of
blood sugar issues, or for hormone replacement therapy due to residual
pituitary damage secondary to the brain trauma, and much more.
These responsibilities have left no time for me to return to
school, full-time employment, or have a life of my own, because this is
more than one person can keep up with. Five-and-a-half years later, my
schedule continues to be hectic and we still struggle to maintain a
reasonable standard of living. Updating section 1114, Title 38, United
States Code, to include impairment specific to Traumatic Brain Injury
(TBI) would create a less restrictive option for providing more
appropriate and individualized long-term supports, allowing the veteran
reasonable access to the community, maximizing quality of life, and
rehabilitation outcomes.
The new schedule for rating Traumatic Brain Injury, which was
updated last fall, is an enormous improvement for the mild to moderate
range of TBI. It will allow veterans within this range of disability,
deserving of a 100 percent rating, to be granted that decision. But,
there were no changes made to special monthly compensation (sec. 1114),
as VA felt ``the SMC regulations potentially apply in all cases and
therefore need not be repeated,'' or as Mr. Tom Pamperin, Deputy
Director of VA Compensation and Pension Service was quoted as saying in
USA Today, ``Veterans who have suffered the most severe brain injuries
will not receive much, if any, extra money because existing regulations
provided adequate compensation in serious cases.'' However, the SMC
regulations have not been updated to include impairment specific to
TBI, and therefore, fail to address a group within the moderate to
severe range, that are functioning individuals with serious
disabilities and significant needs.
My husband is not seeking monetary compensation for his loss, but
the wherewithal for veterans with severe TBI to live in their own homes
and communities as independently as possible. They have paid a high
price, and if these veterans are not able to be fully independent, they
should be self-managed as much as possible, and have choices. It is our
belief these veterans who were severely injured while serving their
country should be given the tools to live as normal a life as possible
and integrate into their communities to the fullest extent that they
are capable. And unfortunately, this does require additional financial
resources.
One of our concerns with special monthly compensation is the
criteria for ``regular'' aid and attendance (A&A) at the ``L'' rate.
The new schedule ``added a note defining `instrumental activities of
daily living' as referring to activities other than self care that are
needed for independent living, such as meal preparation, doing
homework, and other chores, shopping, traveling, doing laundry, being
responsible for one's own medication, and using the telephone.'' This
is certainly an improvement and 3.352(a), the basic criteria for
regular A&A, should be updated to include instrumental activities of
daily living as a qualifying disability, as these activities require
the regular assistance of another person.
Some instrumental activities of daily living could potentially
apply under the basic criteria for regular A&A, where it states, ``The
following will be accorded consideration in determining the need for
regular aid and attendance . . . incapacity, physical or mental which
requires care or assistance on a regular basis to protect the claimant
from hazards or dangers incident to his or her daily environment.''
However, meal preparation, homework, chores, shopping, traveling, or
laundry, for example, may not be interpreted this way. A&A should be
updated to include instrumental activities of daily living so these
veterans may be eligible for compensation under section 1114(l), Title
38, United States Code.
The other major issue we have is that needing ``assistance on a
regular basis to protect the claimant from hazards or dangers incident
to his or her daily environment,'' does not qualify a veteran for the
higher level aid and attendance allowance at the ``R1'' or ``R2'' rate.
The regular ``L'' rate works out to only be an additional $21.50 a day.
These are not adequate resources for someone who needs the assistance
of another person most or all of the time. This may only be enough to
provide 16 hours of support to the veteran each week, not including the
cost of transportation or other expenses. Depending on schedule and
fuel cost, a family in our situation could spend $1500.00 a year on
gasoline to get to and from appointments. This does not include
recreation, shopping, socialization or community reintegration that is
so important to rehabilitation after a severe TBI. And Ted and I live
in an urban area where he is able to walk to the grocery store, gym,
and other activities, with the appropriate supervision. That is not the
case for many veterans.
The support services currently offered by VHA are not appropriate
either and are too restrictive for someone who is active, self aware,
and whose needs are largely non-medical. Someone like my husband needs
supports and services that will allow him to continue to live and be
cared for in his own home and community. My current respite options are
to leave Ted in a VA extended care facility up to 30 days a year. He
can go to an adult day care program or TBI group, though he feels this
is belittling and will not go voluntarily. VA has offered to provide a
home health aide that is unable to take him outside of the home, even
though he does not need regular skilled care, and his needs are often
outside of the home. The fee basis program, when pursued, will pay for
an assisted living facility at a per diem higher than the additional
money he receives monthly at the ``L'' rate. However, he would prefer
to live at home, not in an institutional setting. Forcing Ted to be
homebound or forcing him out of his community, in my opinion, is a
serious quality of life concern. And it is also important to note that
none of these options would help him achieve a higher level of
functioning, independence, and will set back his recovery.
Veterans with severe TBI need the option of supported living in
their own homes and out in their own communities. The VHA options I
have mentioned will allow Ted to merely exist, not truly live, or be
included in society. These veterans need to be involved in decisions
about their own lives, allowed to choose what, when and where they eat,
where they live and shop, what they do with their time, what their
needs are, how they are provided, who provides this support, and who is
involved in their life. A higher level of aid and attendance would give
them the same autonomy, dignity, flexibility, and quality of life
afforded to veterans with physical disabilities. This would allow them
to be spontaneous and obtain more appropriate, individualized, timely
assistance, with less bureaucracy. It would also enable these veterans
to achieve their maximum potential, becoming more capable, and as a
result, may not require this level of benefit for life.
Some veterans diagnosed with severe Traumatic Brain Injury only
meet one of three criteria for the higher level aid and attendance
rate. To qualify, one, the Veteran must be entitled to compensation
under section 1114(o) of Title 38, United States Code, which is based
on anatomical loss, or loss of use of extremities, some organs (not
including the brain), hearing, or sight. Anatomical loss of part of the
brain, loss of use of cognitive capability, such as loss of use of
working memory, for example, does not apply. Two, they must be entitled
to the regular aid and attendance allowance, or ``L'' rate described in
3.352(a), which I mentioned above. Three, they must have a higher level
of need for personal health care services provided on a daily basis in
the home, described in 3.352(b), paragraph 2, and in the absence, would
require hospitalization, nursing home care, or other residential
institutional care.
Though veterans with severe TBI may require 24-hour care,
supervision for safety, or assistance with most, or all, higher level
activities, they are not always provided a comparable level of
compensation to a veteran with severe physical residuals. Though a
veteran with a severe TBI may be able to perform some instrumental
activities of daily living, they may require queuing or it may take
much longer to complete these tasks than it would have pre-injury.
These veterans not only need assistance with tasks they can no longer
perform, but also someone to facilitate, or to accomplish ones they
cannot keep up with. Without the aid of a family member with additional
resources, although having no major physical disabilities, these
veterans are not able to reside in their own homes, and therefore, will
require residential care.
A veteran who requires a greater amount of assistance, in the home
or out in the community, medical or non-medical, should be considered
for compensation under sections 1114(r)(1) and (r)(2), Title 38, United
States Code. We believe all veterans should be given access to the
community whenever medically possible, not homebound, and the criteria
for the higher level special monthly compensation rates should be
updated to allow that.
Ted and I feel H.R. 3407, the Severely Injured Veterans Benefits
Improvement Act of 2009, is a step in the right direction toward
eliminating the disparity in benefits. We applaud Congressman Buyer,
the Ranking Member of the House Committee on Veterans Affairs, along
with Chairman Michaud and Ranking Member Brown of the Subcommittee on
Health, for introducing this bill.
It appears that the intent of H.R. 3407 is to move veterans with
Traumatic Brain Injury up to the 1114(o) rate, which will then
potentially qualify them for the ``R1'' or ``R2'' rate, if they meet
the aid and attendance requirements. However, we are concerned that
this may be too broad, if anyone who qualifies for SMC, and has a TBI,
will automatically qualify for the ``O'' rate. For example, an above
elbow amputee with a mild TBI, who is able to live independently, would
be granted the same compensation as my husband, an above elbow amputee
with a severe TBI, who requires the assistance of another person around
the clock. An able-bodied veteran with a mild TBI would not be granted
any SMC at all. We feel the language of the bill should be modified to
compensate TBI by itself, according to the severity of consequences.
In contrast, H.R. 3407 may be too narrow if the criteria for the
higher level of aid and attendance is interpreted to only include
veterans with a TBI that has caused physical limitations. We feel the
bill should also include an amendment to 3.352(b), paragraph 2, to
address cognitive or other neurological impairment, and assistance to
protect the safety of the veteran from his or her environment. Without
this higher level of support or supervision, the veteran with severe
impairment (other than physical limitations), will also ``require
hospitalization, nursing home care, or other residential institutional
care.'' Preventing the veteran from being placed in institutional care
appears to be the intent of the A&A benefit. Ted and I would like to
see special monthly compensation updated to prevent this for all
service-connected disabilities.
My husband will continue to face significant challenges for the
rest of his life, as a severe TBI is never static, but a progression of
peaks and valleys. Veterans like Ted need support that will be around
as long as the injuries they sustained in service to their country.
Passing legislation to update section 1114, Title 38, United States
Code, to address impairment specific to Traumatic Brain Injury, will
restore a lot of freedoms he has lost since being wounded. Mr.
Chairman, thank you again for the opportunity to share my story with
you and please feel free to contact me if there are any questions you
may have.
MATERIAL SUBMITTED FOR THE RECORD
Economic Systems Inc
Falls Church, VA
July 27, 2009
Hon. John J. Hall
Chairman
Subcommittee on Disability Assistance
and Memorial Affairs
Committee on Veterans' Affairs
335 Cannon House Office Building
Washington, DC 20515
Dear Mr. Chairman:
As requested, I would like to extend my remarks to your question
regarding including Vietnam Era veterans in a future analysis of
earning loss. My oral answer should be extended as indicated in the
enclosed statement.
Thank you for the opportunity to appear before your Subcommittee.
If you have any further questions, please feel free to contact me.
Sincerely,
George Kettner, Ph.D.
President
Enclosure
__________
EXTENSION OF REMARKS
GEORGE KETTNER, Ph.D.
PRESIDENT, ECONOMIC SYSTEMS INC.
BEFORE THE HOUSE COMMITTEE ON VETERANS' AFFAIRS
SUBCOMMITTEE ON DISABILITY ASSISTANCE & MEMORIAL AFFAIRS
JULY 23, 2009
Chairman Hall recognized that the 2008 EconSys study focused on
veterans who were discharged from the military after 1980 which omitted
a large segment of the veteran population, especially Vietnam Era
veterans. He asked how the analysis could be done differently if data
were readily available to include the baby boom generation that is
placing the greatest demand on VA.
Demographic and human capital data available from the Defense
Management Data Center (DMDC) is not considered accurate on veterans
discharged prior to 1980. Therefore, it is not possible to identify a
sample of non service-connected veterans from DMDC data closely matched
on human capital characteristics to serve as a comparison group in an
analysis of the impact of disability on earnings. However, it could be
possible to randomly select a sample of non service-connected veterans
from either the DMDC data or from the VA Beneficiary Identification and
Records Locator Subsystem (BIRLS) matched on a more limited set of
known characteristics such as age, military rank, and date of
discharge. This sample would lack key characteristics such as education
level, military occupational series, and Armed Forces Qualification
Test scores as are available on the post 1980 group and may not be as
well matched to the service-connected veteran population. This
limitation would need to be recognized.
In addition, if more time were available for the analysis, more
detailed analysis of the earnings data for veterans discharged prior to
1980 and since 1980 could be completed, especially analysis of lifetime
earnings. Social Security Administration retains annual earnings for
individuals from 1951. These annual earnings were captured last year
but there was not sufficient time to analyze that data.
We note that of the estimated seven million living Vietnam Era
veterans, 28.4 percent are age 65 or older; 44.6 percent are age 60 to
64 and thus are nearing the normal retirement age. Thus, the earnings
of Vietnam Era veterans are likely to be already diminishing or very
limited already.
For those veterans already service-connected, it is unlikely that
benefits would be reduced in any way. We suggest that the focus of
policy or statutory adjustments should be on future earnings and that
the emphasis of future analysis should be on veterans discharged since
1980, even if veterans discharged prior to 1980 are also analyzed.
DEPARTMENT OF VETERANS AFFAIRS
Veterans Benefits Administration
Washington, D.C. 20420
July 22, 2009
Director (00/21)
All VA Regional Offices and Centers
In Reply Refer To: 211B
Fast Letter 09-33
SUBJ: Special Monthly Compensation at the Statutory Housebound Rate
This letter provides guidance for adjudicating claims involving
entitlement to special monthly compensation (SMC) at the housebound
rate based on a decision by the U.S. Court of Appeals for Veterans
Claims (CAVC or Court) in Bradley v. Peake.
Background
38 U.S.C. Sec. 1114(s) provides that SMC at the (s) rate will be
granted if a veteran has a service-connected disability rated as total,
and (1) has additional service-connected disability or disabilities
independently ratable at 60 percent or more, or (2) is permanently
housebound by reason of a service-connected disability or disabilities.
VA's implementing regulation at 38 CFR Sec. 3.350(i) essentially
mirrors the statutory language.
Prior to the CAVC's decision in Bradley v. Peake, VA excluded a
rating of total disability based on individual unemployability (TDIU)
as a basis for a grant of SMC at the (s) rate. VA relied upon language
in citing VAOPGCPREC 6-99, dated June 7, 1999, in which the General
Counsel stated that a TDIU rating takes into account all of a veteran's
service-connected disabilities and that considering a TDIU rating and a
schedular rating in determining eligibility for SMC would conflict with
the requirement for ``additional'' disability of 60 percent or more by
counting the same disability twice.
On November 26, 2008, the Court, in Bradley v. Peake, disagreed
with VA's interpretation and held that the provisions of section
1114(s) do not limit a ``service-connected disability rated as total''
to only a schedular 100 percent rating. The Court found the opinion too
expansive because it was possible that there would be no duplicate
counting of disabilities if a veteran was awarded TDIU based on a
single disability and thereafter received disability ratings for other
conditions.
The Court's holding allows a TDIU rating to serve as the ``total''
service-connected disability, if the TDIU entitlement was solely
predicated upon a single disability for the purpose of considering
entitlement to SMC at the (s) rate.
The Court held that the requirement for a single ``service-
connected disability rated as total'' cannot be satisfied by a
combination of disabilities. Multiple service-connected disabilities
that combine to 70 percent or more and establish entitlement to TDIU
under 38 CFR Sec. 4.16(a) cannot be treated as a single ``service-
connected disability rated as total'' for purposes of entitlement to
SMC at the (s) rate.
New Evidentiary Standard
Based on the Court's decision in Bradley, entitlement to SMC at the
(s) rate will now be granted for TDIU recipients if the TDIU evaluation
was, or can be, predicated upon a single disability and (1) there
exists additional disability or disabilities independently ratable at
60 percent or more, or (2) the veteran is permanently housebound by
reason of a service-connected disability or disabilities.
For example, a veteran in receipt of TDIU based on a 70 percent
evaluation for Post-traumatic stress disorder (PTSD) and other service-
connected disabilities consisting of a below-the-knee amputation, rated
40 percent disabling; tinnitus, rated 10 percent disabling; and
diabetes mellitus, rated 20 percent disabling, would be entitled to SMC
at the (s) rate if it is determined that PTSD is the sole cause of the
unemployability, as the other disabilities have a combined evaluation
of 60 percent.
It is important that, for purposes of section 1114(s)(1), no
disability is considered twice to ensure that the prohibition against
pyramiding contained in 38 CFR Sec. 4.14 is not violated when
determining which disability results in TDIU entitlement and in
determining which disability or disabilities satisfy the independent 60
percent evaluation to award SMC at the (s) rate.
However, for purposes of section 1114(s)(2), a disability may be
considered in determining TDIU entitlement as well as in determining
whether a veteran is permanently housebound as a result of service-
connected disability or disabilities because that provision does not
specify ``additional service-connected disability or disabilities'' as
in section 1114(s)(1).
Accordingly, a determination for entitlement to SMC at the (s) rate
must be made in all TDIU cases where potential entitlement to SMC (s)
is reasonably raised by the evidence.
Current Status
Regulations and M21-1MR, IV.ii.2.H.46.a will be revised to comply
with the Court's decision. In the interim, the Court's holding will be
applied to all pending and future claims.
In applying the Court's holding, if the medical evidence is
insufficient to render an adjudicative determination as to whether the
veteran's TDIU entitlement solely originates from a single service-
connected disability, and there is potential entitlement to SMC at the
(s) rate, the veteran should be scheduled for a VA examination to
include an opinion as to the cause of unemployability.
Questions
Questions concerning this fast letter and other issues related to
this issue should be submitted to the VAVBAWAS/CO/21FL mailbox.
Bradley G. Mayes
Director
Compensation & Pension Service