Veterans Benefits Research Articles

The financial legacy of Afghanistan and Iraq: How wartime spending decisions will constrain future U.S. national security budgets

The Afghan and Iraqi conflicts, taken together, will be the most expensive wars in United States history, totaling somewhere between US$4 to US$6 trillion. This includes long-term medical care and disability compensation for service members, veterans and families, military replenishment, and social and economic costs. The largest portion of that bill is yet to be paid. Since 2001, the U.S. has expanded the quality, quantity, availability, and eligibility of benefits for military personnel and veterans. This has led to unprecedented growth in the Department of Veterans Affairs and the Department of Defense budgets. These benefits will increase further over the next 40 years. Additional funds are committed to replacing large quantities of basic equipment used in the wars and to support ongoing diplomatic presence and military assistance in Afghanistan and Iraq. The large sums borrowed to finance war-related operations will also impose substantial long-term debt servicing costs. As a consequence of these wartime spending choices, the United States will face constraints in funding investments in personnel and diplomacy, research and development, and new military initiatives. The legacy of decisions taken during the Afghan and Iraqi wars will dominate federal budgets for decades to come.

Feasibility of creating a National ALS Registry using administrative data in the United States

Uncertainty about the incidence and prevalence of amyotrophic lateral sclerosis (ALS), as well as the role of the environment in the etiology of ALS, supports the need for a surveillance system/registry for this disease. Our aim was to evaluate the feasibility of using existing administrative data to identify cases of ALS. The Agency for Toxic Substances and Disease Registry (ATSDR) funded four pilot projects at tertiary care facilities for ALS, HMOs, and state based organizations. Data from Medicare, Medicaid, the Veterans Health Administration, and Veterans Benefits Administration were matched to data available from site-specific administrative and clinical databases for a five-year time-period (1 January 2001–31 December 2005). Review of information in the medical records by a neurologist was considered the gold standard for determining an ALS case. We developed an algorithm using variables from the administrative data that identified true cases of ALS (verified by a neurologist). Individuals could be categorized into ALS, possible ALS, and not ALS. The best algorithm had sensitivity of 87% and specificity of 85%. We concluded that administrative data can be used to develop a surveillance system/registry for ALS. These methods can be explored for creating surveillance systems for other neurodegenerative diseases.

A Qualitative Study of Chronic Pain in Operation Enduring Freedom/Operation Iraqi Freedom Veterans: “A Burden on My Soul”

Over half of the veterans returning from the conflicts in Iraq and Afghanistan are burdened with chronic pain. Although these young veterans may have to live with pain for the rest of their lives, little is known about the struggles this new group of veterans faces, or their perceptions of support from family, friends, and others. The purpose of this study is to understand Operation Enduring Freedom/Operation Iraqi Freedom veterans' experiences with chronic pain and social support. In-depth qualitative interviews were conducted with veterans who participated in an intervention for chronic pain. Grounded theory guided data analysis. Veterans described a range of emotions associated with chronic pain, including hopelessness, anger, and fear that their pain would worsen. For some, talking about their pain was helpful, but others avoided talking about their pain, often because people did not understand or overreacted. Although support from friends and family is often effective, veterans and others with chronic pain are uniquely positioned to offer support to others with pain. Clinically, an approach to pain management in which veteran peers are integrated into chronic pain treatment approaches, similar to the Veterans Affairs' mental health model of care, might offer additional benefits for veterans with chronic pain.

Veterans Law, Jon Stewart, and a Challenge for the Legal Academy

This is a collection of 20 posts made as a guest blogger on the Faculty Lounge in June 2013. These posts were written to generally introduce veterans law to legal academics unfamiliar with the area and to point out important issues in the field in need of further study. The theme of the posts is that veterans law is far less than the sum of its parts. Despite countless “veteran friendly” rules and procedures, the process suffers from severe system effects that produce unsatisfactory results. Accordingly, it is a system that is in desperate need of experts in the underlying areas to examine how the system handles evidence, causation, pleading, discovery, separation of powers, and many other issues. As Jon Stewart nicely expressed: The veterans benefits system is crucial to anyone who supports a substantial role for the administrative state, because if you cannot make this system work with all the political support and funding it has, then how can you expect anyone to believe that government can solve actual controversial problems?

Statement before the House Committee on Veterans’ Affairs, Subcommittee on Disability Assistance and Memorial Affairs, on 'Why Are Veterans Waiting Years on Appeal?: A Review of the Post-Decision Process for Appealed Veterans’ Disability Benefits Claims'

The fundamental challenge for the veterans benefits system today, including the appellate process, is system effects. That is the term academics use to describe the problem that occurs in large systems when the number of rules grows so large that the system stops producing the desired result, even though each individual rule can be defended as making a positive contribution to the goal. We have long passed the point of critical mass where the sum total is too complex for adjudicators at every level to keep straight, much less for untrained veterans to understand. A better appellate system – and a better adjudication system in general – needs to move away from trying to deal with millions of veterans with millions of rules, and instead focus on finding the smallest number of rules that will fulfill the goal of creating a truly veteran-friendly system that is capable of delivering timely and accurate results. An improved appellate process needs to contribute to this paradigm shift. In a system suffering from system effects, there are no magic bullets. The problem of complexity can be solved only by dramatic change. Because the large number of rules is the central challenge, a great number of individual parts must be critically examined and streamlined. These are just a few suggestions that I have proposed in the past, and are just the beginning of a larger project that must include all the stakeholders. Most importantly, changes must be rigorously tested with real veterans to make sure that they understand and benefit from the system that is supposed to be friendly and paternalistic toward them. Everyone wants the system to provide better results, but at this point more rules increase delay, not quality. Less process and more effectiveness are the true answers.

The Financial Legacy of Iraq and Afghanistan: How Wartime Spending Decisions Will Constrain Future National Security Budgets

The Iraq and Afghanistan conflicts, taken together, will be the most expensive wars in US history – totaling somewhere between $4 to $6 trillion. This includes long-term medical care and disability compensation for service members, veterans and families, military replenishment and social and economic costs. The largest portion of that bill is yet to be paid. Since 2001, the US has expanded the quality, quantity, availability and eligibility of benefits for military personnel and veterans. This has led to unprecedented growth in the Department of Veterans Affairs and the Department of Defense budgets. These benefits will increase further over the next 40 years. Additional funds are committed to replacing large quantities of basic equipment used in the wars and to support ongoing diplomatic presence and military assistance in the Iraq and Afghanistan region. The large sums borrowed to finance operations in Iraq and Afghanistan will also impose substantial long-term debt servicing costs. As a consequence of these wartime spending choices, the United States will face constraints in funding investments in personnel and diplomacy, research and development and new military initiatives. The legacy of decisions taken during the Iraq and Afghanistan wars will dominate future federal budgets for decades to come.

What Process is Due? Reversal of Diagnosis in Veterans Benefits Claims and Procedural Due Process

An increasing number of service members who have been deployed now suffer from invisible wounds of war including Post-Traumatic Stress Disorder (PTSD). Some of those veterans' diagnoses were reversed through nothing but a review by a team of psychologists who never personally met or examined the veterans. This paper examines the general attitude towards PTSD at a particular Army medical center, the PTSD diagnostic criteria, and the reasons for diagnosis reversals. And due process and VA administrative procedures are analysed and applied to diagnosis reversals. Lastly, an additional layer of due process for veterans with PTSD is suggested.

BJOG Editor's Choice

BJOG Editor's Choice

Overcoming barriers to care for returning Veterans: Expanding services to college campuses

INTRODUCTION The need to expand mental health and social work care available to Veterans in the community and for increased Department of Veterans Affairs (VA) and community partnership has become increasingly recognized [1]. Over 2.4 million men and women have served in Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and/or Operation New Dawn (OND) since 2001 [2]. Following their deployments to combat zones and separation from the military, many Veterans are faced with the choice of obtaining employment, enrolling in college, or both. The Post-9/11 GI Bill, passed by Congress in 2008, greatly expanded educational benefits for Veterans who served in the Armed Forces on or after September 11, 2001 [3], and increasing numbers of former servicemembers are using this benefit. According to the Veterans Benefits Administration (VBA) Office of Educational Services, the number of Veteran students and beneficiaries (i.e., dependents or spouses) accessing VBA educational benefits across the United States has increased from 397,598 Veteran beneficiaries in 2000 to 564,487 in 2009 and to 1,014,227 in 2012, totaling over $10.5 billion in utilized benefits (in 2011 alone) [4]. However, while the number of Veterans enrolled in college has dramatically increased, student Veterans have generally had lower graduation rates than their civilian counterparts [5]. Although the majority of student Veterans will complete their postsecondary programs, it has been estimated that about 30 to 40 percent will not [6], placing them at risk for adverse outcomes such as increased unemployment. This indicates a critical need to better understand and respond to the factors contributing to psychosocial difficulties among student Veterans that lead to poor academic outcomes. In this article, we will illustrate a replicable model that provides multifaceted Veterans Health Administration (VHA) healthcare, social work, and mental health services on the college campus and discuss ways in which clinicians and campus partners can promote wellness and academic success for student Veterans. Veteran students arrive on campus with a military background that includes unique experiences, knowledge, skills, and codes of behavior. Factors that can influence adjustment from military service to student life include the amount of time between discharge and entry into college, differences between military and civilian culture, balance between academic and other life responsibilities, and psychological consequences of combat or other trauma exposure. Military culture, which emphasizes service, respect, camaraderie, structure, discipline, and order, can differ from that of civilian or traditional college student life [7]. While military life can bring its own challenges and stressors, there are also significant benefits, such as having stable housing and income, healthcare, and support from superiors and/or peers, as well as generally more consolidated, centrally located or familiar resources. Loss of one's social network and need to obtain one's own housing, healthcare, and source of income can compound an often challenging cultural transition from the military to the college campus. Less than 10 percent of U.S. citizens serve in the military [8], and many civilian students may lack an understanding of the servicemember's experience. This disconnect is compounded by the often nontraditional status of student Veterans, who are typically older and often need to balance family (including parenting responsibilities), work, and academic demands. Indeed, nearly half (49.4%) of servicemembers and Veterans who have deployed to Iraq and Afghanistan are married [9]. In addition to general cultural or experiential differences, Veterans who have deployed to Iraq and Afghanistan are at higher risk for a number of adverse medical, psychiatric, and social outcomes. Milliken et al. reported exposure to deployment-related stressors in Reserve and Active Duty soldiers at rates of 69. …

Brief alcohol counseling improves mental health functioning in Veterans with alcohol misuse: Results from a randomized trial

BackgroundAlcohol misuse occurs at high rates among U.S. Military Veterans presenting to primary care and is linked to numerous negative social and health consequences. The Veterans Health Administration has recently implemented brief alcohol interventions (BAI) in VA primary care settings. An emerging literature suggests that BAIs that target alcohol consumption may also have secondary health benefits such as reducing symptoms of depression and anxiety in civilian samples. The present study sought to examine whether secondary health benefits of BAIs observed in civilians generalize to a sample of alcohol misusing Veterans presenting to primary care. MethodsVeterans (N=167) screening positive for alcohol misuse during a routine primary care visit were randomized to receive treatment-as-usual (TAU) or TAU plus a web-delivered BAI. Assessment of overall mental health functioning, posttraumatic stress disorder, and depression occurred at baseline, three- and six-month post-treatment. ResultsVeterans receiving both BAI protocols demonstrated significant improvements in mental health functioning, depressive symptoms, and use of approach coping from baseline to six-month follow-up. No differential treatment effects on these outcomes were observed. LimitationsFindings are limited by the lack of a no-treatment control group, and the potential impact of regression to the mean and assessment effects on outcomes. ConclusionsOur findings replicate prior studies suggesting that a single-dose BAI may have some secondary mental health benefits for Veterans presenting to primary care with alcohol misuse.

Utility of Capture-Recapture Methodology to Assess Completeness of Amyotrophic Lateral Sclerosis Case Ascertainment

Background: With the establishment of a national amyotrophic lateral sclerosis (ALS) registry in the United States, methods are needed to ascertain the completeness of case ascertainment, especially in view of the proposal to rely largely on existing data sources. Methods: Data about ALS patients residing in the 5-county metropolitan Atlanta area (within the State of Georgia) from 2001 to 2005 were categorized according to their source – ALS Association, clinical (Emory Healthcare, community neurologist, Veterans Health Administration, Veterans Benefits Administration), Medicare and death certificates. ALS diagnoses were verified using chart review. Capture-recapture analyses were carried out using log-linear modeling, stratified by age and race. Results: The final model (based on 798 cases), which included the 4 main sources and 3 two-way interaction terms, yielded an estimated total population of 880 (95% CI 816–965), indicating that the combination of case-finding methods identified about 90.7% of cases. The estimated 5-year period prevalence is 38.5/100,000 (95% CI 35.66–42.19). Conclusion: This study highlights gaps in data based on existing data sources and illustrates a method for combining data from multiple sources to help facilitate the successful establishment of a US national ALS registry.

Disability among US Army Veterans vaccinated against anthrax

ContextTo protect troops against the use of anthrax as a biological weapon, the US Department of Defense began an anthrax vaccination program in 1998. 14 years after the inception of the vaccination program, there is no evidence suggesting vaccination against anthrax carries long-term health risks for Active Duty Soldiers. ObjectiveTo investigate the association between Anthrax Vaccine Adsorbed (AVA) received while on Active Duty and subsequent disability determined by the Veterans Benefits Administration. Design, setting and participantsCase–control study nested in the cohort of all Active Duty personnel known to have separated from the US Army between December 1, 1997 and December 31, 2005. Cases were ≥10% disabled, determined either by the Army prior to separation (N=5846) or by the Veterans Benefits Administration (VBA) after separation (N=148,934). Controls (N=937,705) separated from the Army without disability, and were not receiving pensions from the VBA as of April 2007. Data were from the Total Army Injury and Health Outcomes Database and the VBA Compensation and Pension and Benefits database. Main outcomesDisability status (yes/no); for primary disability, percent disabled (≥10%, 20%, >20%) and type of disability. ResultsVaccination against anthrax was four times more likely among disabled Veterans with hostile fire pay records (HFP, a surrogate for deployment). Vaccinated Soldiers with HFP had lower odds of disability separation from the Army 0.89 (0.80, 0.98); there was no association between vaccine and receiving Army disability benefits among those without HFP (OR=1.05, CI: 0.96, 1.14). Vaccination was negatively associated with receiving VA disability benefits for those with HFP (OR=0.66, CI: 0.65, 0.67), but there was little or no association between vaccine and receipt of VA disability benefits for those without HFP (OR=0.95, CI: 0.93, 0.97). ConclusionsRisk of disability separation from the Army and receipt of disability compensation from the VA were not increased in association with prior exposure to AVA. This study provides evidence that vaccination against anthrax is not associated with long term disability.

VOW to hire veterans offers new incentives for employers and expanded benefits for veterans

VOW to hire veterans offers new incentives for employers and expanded benefits for veterans

The Colorado Violent Death Reporting System (COVDRS): Validity and Utility of the Veteran Status Variable

Using the Veterans Affairs Beneficiary Identification Record Locator Subsystem (BIRLS) as the criterion database, we evaluated the sensitivity and specificity of the death certificate information in the Colorado Violent Death Reporting System (COVDRS) to determine Veteran status for those who died by suicide. The study sample consisted of 3,820 individuals aged 18 years and older who died by suicide in Colorado from January 1, 2004, through December 31, 2008. To determine agreement on Veteran status, COVDRS data were submitted to the Veterans Benefits Administration for linkage to the BIRLS using Social Security numbers. Sensitivity and specificity of the Veteran status information on the death certificate were 93.1% (95% confidence interval [CI] 90.7, 95.2) and 91.7% (95% CI 90.5, 92.8), respectively. The overall agreement between the death certificate and the BIRLS on Veteran status was very good (kappa = 0.76; 95% CI 0.74, 0.79). This study of 3,820 suicide deaths in Colorado demonstrated a high level of agreement between the COVDRS Veteran status variable and the BIRLS. Such findings offer support for using the COVDRS in studying factors associated with suicide in the Veteran population.

Erratum to: Mind Reading and the Art of Drafting Medical Opinions in Veterans Benefits Claims

The Department of Veterans Affairs' disability com- pensation program is distinctly different from other benefits systems and legal claims of disability. A medical professional seeking to provide evidence to be used in deciding such a claim must understand how that evidence fits into the process so that he or she may present a complete and useful opinion. This article assists those providing expert opinions in veterans bene- fits claims by describing: (a) the kinds of adjudicators who will evaluate the opinions, (b) the legal requirements defining the types and amount of detail required, and (c) the basic substance of veterans law with which a medical examiner should be familiar so as to produce a complete and relevant opinion.

Computer-based hearing loss prevention education program for Veterans and military personnel

INTRODUCTION According to the Veterans Benefits Administration, more than 672,000 Veterans were service-connected for hearing loss and more than 744,000 Veterans were service-connected for tinnitus as of fiscal year 2010 [1]. Hearing loss and tinnitus are the most prevalent disabilities experienced by Veterans who served during peacetime, Operation Iraqi Freedom/Operation Enduring Freedom, World War II, and the Korean war. In fiscal year 2010, the Department of Veterans Affairs (VA) provided 561,212 hearing aids at an estimated cost of $196.7 million and audiological services to Veterans at a cost of $227.4 million. * Therefore, hearing loss and tinnitus prevention should be a priority for the VA. At least one type of hearing loss--noise-induced hearing loss (NIHL)--can be prevented if appropriate protective strategies are implemented. Citing the high prevalences of hearing loss and tinnitus among Veterans, Fausti et al. concluded that programs aimed at preventing hearing loss should include education concerning the effects of both occupational and recreational noise exposures, as well as counseling on the hearing protection methods available to individuals at risk for NIHL [2]. Subsequently, authors Saunders and Griest worked with a video production company (Craftmaster Productions; Portland, Oregon) to implement this recommendation by developing a computer-based hearing loss prevention program (HLPP) for Veterans that could be accessed by patients in VA medical clinics [3]. HEARING LOSS PREVENTION PROGRAM The HLPP uses the constructs described in the Health Belief Model (HBM) developed by Rosenstock [4] to explain individual differences in decisions to practice particular health behaviors. To varying degrees, the HBM predicts health-related behaviors, such as prenatal care visits [5], breast cancer self-examination [6], continued enrollment in diabetes-related pharmaceutical services [7], and hepatitis B vaccination [8]. The principles outlined in the HBM were described by Folmer et al. [9, p. 12] as follows: 1. Susceptibility: The feeling of being vulnerable to a condition and the extent to which the individual believes he/she is at risk of acquiring the condition. 2. Perceived Severity: Belief in the seriousness of the consequences incurred if [a person is] affected by the condition both medically (e.g. death, disability, pain) and socially (e.g. effects on family life, personal relations). 3. Perceived Benefits: The belief that intervention will result in positive benefits. 4. Perceived Barriers: The barriers an individual believes he/she needs to overcome in order to effectively conduct some form of intervention. This includes costs, negative side effects, social stigma, and time needed for implementation. 5. Perceived Efficacy: Belief the individual has that he/she can successfully use the intervention. 6. Cue to Action: A cue that prompts an individual to take action. This could be internal, such as symptoms of a health problem, or external, such as media communications, interpersonal communications, or information from healthcare providers. One goal of the HLPP is to increase participants' knowledge about auditory system damage that can be caused by loud sounds and methods of hearing protection, which in turn would change participants' understanding and attitudes about noise exposure and hearing protection. The ultimate goal of this, and all HLPPs, is to motivate participants to change their behaviors in noisy situations so they implement appropriate hearing protection strategies. Most Veterans were exposed to loud sounds during their military service. Additional unprotected noise exposure will contribute to hearing loss in this population. Indeed, evidence exists that ears with prior noise damage age differently than those without significant noise exposure. Specifically, hearing loss progresses more quickly in noise-exposed ears than in ears not exposed to noise and loud sounds cause greater damage to already-exposed ears [10]. …

Medicalisation, morality, and addiction : why we should be wary of problem gamblers in primary care

In the 35 years since Ivan Illich led a vanguard of searing medical-scepticism with his Limits to Medicine: Medical Nemesis, the Expropriation of Health ,1 critiques of medicalisation may have become less fashionable, but no less necessary. The continuing need for a critical perspective on medicalisation is apparent at a time when the UK media displays a violent backlash against people with drink and drug problems; when the British Prime Minister defines the optimal method to ‘get drug addicts clean’;2 and when the Chair of the RCGP endorses an addiction model for addressing ‘problem gambling’ in primary care.3 Medicalisation is the ‘process by which non-medical problems become defined and treated as medical problems’.4 A recent BMJ article on the subject perceived ‘medicine’s imperial project’: the medical profession determinedly defining new diseases and broadening the diagnostic criteria of old ones (so much so that ‘virtually the entire older adult population is now classified as having at least one chronic disease’).5 However, medicalisation is frequently a more complex phenomenon than the united professional advance implied by analogies with imperialism. The processes of medicalisation may be as varied as the problems medicalised (pregnancy,6 masturbation,7 and repetitive strain injury8 for example, have fascinatingly unique, and mercifully unrelated, medical histories). Furthermore, sociologist Ellie Lee has described uses of medicalisation that even the most anti-imperialist, anti-establishment agitators among us might find it difficult to disapprove of: ‘battered woman syndrome’ has been valuably employed in the legal defence of women who have killed their abuser; post-traumatic stress disorder (PTSD) gained benefits for unacknowledged US Vietnam war veterans in the 1980s; and a PTSD diagnosis still occasionally halts the Home Office from returning an asylum seeker to a country where they have been tortured.9 Arguably though, the immediate gains …

Factors Influencing Military Police Officers in Their Decision in Selecting Higher Educational Institutions

The active duty personnel in the United States Armed Forces exceed 1,411,932. When combined with reserve units and auxiliary units, the number of personnel surpasses 2 million. Due to the nature of worldwide urban conflict, a great number of military personnel are subjected to, assigned to, or affiliated with some type of criminal‐justice‐related duty. These urban situations and associated policing‐type experiences have captured the interest of many active duty personnel. Countless military members are currently planning honorable discharge and re‐entry into civilian life and seeking educational degrees as a resource for access into a criminal justice career. Educational benefits for veterans offer an enormous advantage to the military personnel. On 1 August 2009, these benefits, which include tuition, books, and housing, were expanded to veterans with at least 90 days of aggregate service on or after the September 11th terrorist attacks. Little is known about this vast group of potential students and what factors play a role in their selecting a college or university. Based on a survey of over 300 active duty military personnel currently assigned to criminal justice duty, the authors were able to extract some important findings on this subject. The factors obtained include, among others, preferred type of course delivery and the importance of official statements of military support. Based on the evidence collected and analyzed, this research exposed and examined several important findings.

Mind Reading and the Art of Drafting Medical Opinions in Veterans Benefits Claims

The Department of Veterans Affairs’ disability compensation program is distinctly different from other benefits systems and legal claims of disability. A medical professional seeking to provide evidence to be used in deciding such a claim must understand how that evidence fits into the process so that he or she may present a complete and useful opinion. This article assists those providing expert opinions in veterans benefits claims by describing: (a) the kinds of adjudicators who will evaluate the opinions, (b) the legal requirements defining the types and amount of detail required, and (c) the basic substance of veterans law with which a medical examiner should be familiar so as to produce a complete and relevant opinion.

The military advantage: the Military.com guide to military and veterans benefits

The military advantage: the Military.com guide to military and veterans benefits