July 2008

By Sydney J. Freedberg Jr. National Journal July 18, 2008 
The influx of wounded troops from Afghanistan and Iraq has burst the seams of the military health care system.

The much-publicized scandal in 2007 at Walter Reed Army Medical Center, which kick-started reforms, has proved to be only the tip of a large and ugly iceberg.

The problem is not just about organizations and processes, but about mind-sets.

Although most people in the Defense Department go above and beyond to take care of their wounded, others can still lapse into an attitude of "shut up, shape up, and soldier on"--especially toward those troops who suffer subtle but deeply disabling mental problems rather than obvious physical wounds. Yet it is precisely the hard-to-diagnosis cases of post-traumatic stress disorder and "mild" traumatic brain injury that have become the distinctive injuries of this war.

This fall, however, the departments of Defense and Veterans Affairs will decide whether to expand a pilot program that has the potential to dramatically change the treatment of those disabled in the line of duty. Started in November and currently limited to the Washington metropolitan area, the program takes aim at a bureaucratic redundancy that has long bedeviled injured troops leaving the armed forces. This is the double take in which--before discharge--the Army, Navy, or Air Force first conducts an exit exam of a departing service member to assess any conditions that might trigger military disability benefits, and then--after discharge--the VA conducts its own entry exam of the same individual for the same conditions to determine eligibility for VA benefits.

Rarely do the two departments agree on just how disabled a departing service member is. Even when they do, they pay compensation at different rates set by different statutes. What's more, under federal laws banning "concurrent receipt" of both benefits by the same person, a disabled veteran will often discover his monthly check from the Defense Department is reduced by an amount equal to some or all of the value of his VA benefit. Because the VA is usually more generous, this offset can cut the payment from Defense to nothing. The whole system is a source of endless confusion and complaint.

"The biggest criticism was the redundancy, the complexity," said Samuel Retherford, a retired Army colonel who oversees the pilot program as the Pentagon's deputy director for personnel management policy. "They had to re-explain their case, fill out forms over and over, and [re]state the same thing."

So, in the pilot program, the Defense Department is essentially subcontracting much of its disability assessment system to the Veterans Affairs Department. VA doctors will conduct one set of physical exams, and VA specialists will determine one set of disability ratings, which both departments will then use. This reform should go a long way toward eliminating the disparity in which the military has historically rated the exact condition in the exact same patients as less disabling, and therefore worthy of fewer benefits, than has the VA.

"There's this presumption of guilt that has pervaded the [military] system for years," said a veteran who works on Capitol Hill. "Good soldiers got screwed. The system never worked. It was dysfunctional in peacetime--but now it's an absolute disaster."

Last August, a government-ordered study by CNA, a nonprofit research group, compared 31,473 individuals who had been assessed by both systems for the same condition. According to the study, the VA ratings were, on average, 8.6 percentage points (out of 100) higher than the Defense Department's. On mental disorders, the military rated disabilities much lower than did the VA: 11.9 percentage points lower for traumatic brain injury, 24.5 points lower for severe depression, and 32.8 points lower for PTSD.

Mental problems have been a major focus for the VA since Vietnam. In the military, they are still widely stigmatized or ignored--and given lowball ratings from official disability assessment boards. Take Wendell McLeod, an Army specialist mentally impaired after a 2005 accident in Kuwait. "He has to be reminded to do the simple things in life," said his wife, Annette, who has testified before Congress. "He hasn't started driving yet." Even as a passenger, she said, "he grabs the steering wheel now at the least little thing. He doesn't comprehend that just because there's a bag in the road, that doesn't mean it's an IED [improvised explosive device]."

Spc. McLeod is being treated by the VA, which assessed him as 100 percent disabled. But military raters initially declared his problems a case of mental retardation that was unrelated to and pre-existed his military service; they pointed to his receiving Title I remedial education in elementary school and denied him benefits. Annette McLeod had that ruling overturned through appeals, but she is still struggling to get a military board to reconsider an interim rating of 50 percent. "Hopefully, this will be the last battle with the Army," she told National Journal. Because of their case's high profile, she said, "for us it's a little bit easier this time around. But some people I've talked to, they're still bogged down in the system."

Dubious ratings like those given to Spc. McLeod have become distressingly common since the invasion of Iraq. "About a year and a half ago, we were getting anecdotal evidence that the Army's system was severely underrating cases," said Kerry Baker, a staffer who works on veterans appeals for the 1.4 million-member Disabled American Veterans. "What we found was just atrocious." In one case, Baker went on, "we found a kid with several penetrating skull injuries, a couple of different craniotomies, major seizure disorder, major migraines on a daily basis, and a cognitive disorder so severe his mother was appointed as his guardian." The VA rated the young soldier as 100 percent disabled; the military, 10 percent.

The cause of such discrepancies goes back to the birth of the Republic. Since the American Revolution, the military has had a medical corps to keep troops healthy before battle and to patch them up after--focusing on the collective fighting power of the force and discharging any individual no longer fit to fight. By contrast, federal veterans facilities--authorized by law in 1811--have always focused on care for people who were no longer serving a military purpose, but whose injuries, poverty, or both affected the conscience of a grateful nation.

Over time, however, the two systems have come to overlap in one area: the population eligible for benefits from both--military retirees. Most of these beneficiaries are commissioned officers and senior noncoms who served a full 20 years, but they include those who were so disabled in accidents or combat while in uniform that they were medically retired from military service and therefore eligible to use military hospitals as well as VA facilities for their care.

From 2003 through '07, the Pentagon medically retired more than 22,000 such disabled troops, who will receive military-subsidized medical care and monthly pension checks for life. Another 57,000 troops have been "medically separated," discharged as unfit to serve but with lesser degrees of disability, which entitles them to only a onetime severance payment. All 79,000, both the medically retired and the medically separated, also count as disabled veterans who may qualify for VA health care and disability checks. Because the law often entitles the same person to two benefits, one from the Defense Department and one from the VA, each department must determine a disability rating.

Ostensibly, the two departments have used the same standard schedule, written by the VA, to rate each disabling condition, from 10 percent for a bullet through the foot to 100 percent for blindness in both eyes. But for years, the military "supplemented" the schedule with layers of regulations that effectively altered it beyond recognition--until Congress banned the practice last year. The 2007 "wounded warrior" reforms forced all military disability raters to use the VA schedule, without alterations, and ordered the pilot program combining the military and VA assessment systems.

Under the pilot program, the military uses not only the VA-written schedule of ratings but also VA doctors and VA ratings specialists to assess each service member. Military personnel still make the critical decision on whether a given individual is unfit to serve or can return to duty. The Defense Department and the VA provide different kinds of benefits, determined by different laws and regulations, for the same individuals. But the often-bizarre discrepancies in how the two departments rated the same condition in the same individual will no longer exist.

By the end of June, 461 service members had entered the pilot process, of whom just 61 had been discharged from the military (13 medically separated, 48 medically retired). The Washington area benefits from an unusually rich cluster of military and veterans medical facilities, which makes coordination easier here than elsewhere. In late August, the Pentagon and the VA will begin considering a second location, probably an underserved and relatively rural area where implementing the pilot program will be distinctly harder.

Even if the expanded pilot program succeeds, wholesale adoption of the reforms is at least a year away. As the casualties keep coming in, the pressure on the disability system will continue to mount.