STATEMENT of
the MILITARY OFFICERS ASSOCIATION OF AMERICA

on the
Status of VA and DOD Collaboration in the
Care and Treatment of OIF / OEF Veterans

before the

SENATE COMMITTEE ON VETERANS' AFFAIRS

October 17, 2007

Presented by

Colonel Steve Strobridge, USAF (Ret.)
Director, Government Relations

MISTER CHAIRMAN AND DISTINGUISHED MEMBERS OF THE COMMITTEE, I am honored to appear before you today on behalf of the Military Officers Association of America (MOAA), to present our views on various Commission recommendations on the wounded warrior care, transition support, the disability evaluation process and related matters.

MOAA does not receive any grants or contracts from the federal government.

EXECUTIVE SUMMARY

Urgency of Joint Congressional Action and Oversight.  Military and VA systems have been caught unprepared for the large wave of wounded and traumatized veterans returning from Iraq and Afghanistan, and these veterans' needs will only grow in the future.  Sustained bipartisan, bicameral congressional leadership focus and cooperation will be vital to successfully address continuing problems, especially with a change of leadership coming soon in the Executive Branch, and attendant introduction of new DoD and VA leaders who will be far less sensitized to the urgency of leadership-driven changes currently underway or contemplated.

VA-DoD Disability Evaluation Reform.  MOAA strongly endorses the recommendation of the Veterans' Disability Benefits Commission (VDBC) that DoD and VA should realign the disability evaluation process so that the Services determine fitness for duty, and service members who are found unfit are referred to VA for the disability rating. 

All conditions that are identified as part of a single, comprehensive medical exam should be rated and compensated.  In revamping the DES, the Services must include all unfitting conditions as rated by the VA in assessing whether the servicemember is to be medically retired or separated.  (See Items 6, 12 and 46 in the attached matrix)

MOAA does not support elimination of the military disability retired pay system, as some would interpret the Dole/Shalala recommendations as implying.  Rather, we support DoD's acceptance of VA-determined disability percentages in calculating military disability retired pay.

Traumatic Brain Injury / PTSD Care, Treatment and Service Connection.   MOAA strongly supports the recommendations of the Dole-Shalala Commission and other panels on TBI / PTSD care, coordination and rehabilitation.  (See Items 3, 4, 15, 22, 23, 33, 37 and 38 in the matrix).
Establish Joint Seamless Transition Agency / Office.   MOAA strongly supports establishment of a separate, joint DoD-VA Seamless Transition Agency staffed with full-time DoD and VA professionals to oversee the development, fielding, completion and assessment of seamless transition imperatives.  (See Item 50 in the matrix).
Overlap in Active Duty and VA Health Coverage.   MOAA strongly recommends authorization of at least three years of eligibility for active duty TRICARE benefits for wounded warriors after leaving service.  This will protect them from loss of urgently needed services - such as cognitive therapy and caregiver per diem - that now terminate when they leave active duty.  (See Item 34 in the matrix).

Caregiver Support and Case Management.  MOAA strongly endorses the recommendations of the commissions and task forces on caregiver support / assistance and case management for wounded warriors.  (See Items 2, 10, 13, 21, 29, and 34 in the matrix).

Reaffirmation of the "24-7" Principle in Assessing Service-Connection of Disabilities.  MOAA strongly recommends the Committee reaffirm its longstanding commitment to the principle that all service men and women who are disabled in the line of duty - the "24/7" rule - are entitled to service-connected compensation, or if eligible, military retirement, if the disability did not result from misconduct.

Collaboration and Oversight of Congressional Committees.  MOAA notes that parochial departmental concerns in the past have extended beyond the Executive Branch, and strongly recommends that leaders of the Committees on Veterans Affairs and Armed Services make a concerted effort with their House counterparts to develop a more collaborative framework to assess, oversee, prioritize, and fund cross-jurisdictional issues affecting wounded warriors and their families who are having such unacceptable difficulties getting fair and effective outcomes from DoD and VA bureaucracies. 

Introduction

Last February, a series of articles in the Washington Post titled "The Other Walter Reed" profiled shocking cases of wounded servicemembers who became lost in military health care and administrative systems upon being transferred to outpatient rehabilitative care.

Subsequently, the national media were flooded with stories of seriously wounded troops warehoused in substandard quarters, waiting weeks and months for medical appointments and evaluation board results, confused by a maze of benefit and disability rules, and lowballed into disability separations rather than being awarded the higher benefits of military disability retirement.

There were interviews with family members - spouses, children, and parents - who quit their jobs and virtually lived at military hospitals to become caregivers to seriously wounded troops.  Left with diminishing resources and unfamiliar with military benefit and disability rules, they were severely disadvantaged in trying to represent the interests of their wounded spouses and children who couldn't stand up for themselves.

These issues drew the attention of the President and Congress, leading to the appointment of special commissions and task forces charged with investigating the problems and identifying needed solutions. The details of sorting out the multiple overlapping proposals to fix the bureaucratic snafus among multiple federal departments can be mind-numbing, whether you're a legislator, a lobbyist, a federal administrator, or an average citizen. 

The key to success will be to stay focused on the top priorities, and recognize that the government must bear responsibility for these long-term costs of war. 

MOAA is very grateful for the work of the Dole-Shalala Commission, the Veterans Disability Benefits Commission, the Marsh-West Independent Review Group, VA Interagency Task Force on Returning Veterans, and the Mental Health Task Force.  Attached to this satement is a summary of the major recommendations of these panels and MOAA's positions and recommendations on them.  We are very pleased to say that with relatively few exceptions, as noted, MOAA endorses the vast majority of these groups' recommendations. 

Urgency of Joint Congressional Action and Oversight

Military and VA systems have been caught unprepared for the large wave of wounded and traumatized veterans returning from Iraq and Afghanistan, and these veterans' needs will only grow in the future. 

Sustained bipartisan, bicameral congressional leadership focus and cooperation will be vital to successfully address continuing intra- and inter-agency problems.  With a change of leadership coming soon in the Executive Branch, and attendant introduction of new DoD and VA leaders who have not been a party to developing urgent leadership-driven changes currently underway or contemplated, the importance of congressional oversight cannot be overstated.

Disability Evaluation System (DES) Reform

Current gross disability rating disparities between the services and between DoD and the VA must be resolved.  The Independent Review Group appointed by the Secretary of Defense found huge disparities between the disability retirement (vs. separation) statistics between the services for returning veterans.  The percentage of returning veterans who received military disability ratings of 30 percent or higher (and thus qualified for lifetime retirement benefits) was far lower among the Army and Marine Corps, who had the greatest exposure to combat injuries.  The disability retirement rate for the Navy was nearly three times higher than the Army's, feeding perceptions that seriously combat-wounded soldiers were being "low-balled" to save the government money, as shown on the following chart.

Disability Retirement Disparity
Percent of disabled members awarded disability retirement( 30+% DoD disability rating)

Army 13%
Navy 36%
USMC 18%
USAF 27%

MOAA believes strongly that members with significant, lifelong, service-caused disabilities should be retired rather than separated with no military benefits. There must be a common rating standard that accounts for all service-connected disabilities and provides fair compensation and benefit packages commensurate with the level of disability.  Wounded members should be retained on active duty until the disabling condition is stabilized, rather than expediting separation and shifting care responsibility to the VA.

Further, the process of assigning fair and consistent disability ratings is too important to be left to five independent agencies (four services and the VA).  While the services need to be the arbiters of what conditions render a soldier, sailor, airman or Marine unfit for continued service, the percentage disability rating should be determined by the VA, and the VA system must be made as uniform as possible across the country.  (In this regard, MOAA is concerned at studies that have shown large disparities in disability ratings by VA offices in different states / regions.)

MOAA strongly endorses the recommendation of the Veterans' Disability Benefits Commission (VDBC) that DoD and VA should realign the disability evaluation process so that the Services determine fitness for duty, and service members who are found unfit are referred to VA for the disability rating. 

All conditions that are identified as part of a single, comprehensive medical exam should be rated and compensated.  MOAA strongly recommends that in revamping the DES, the Services must include all unfitting conditions as rated by the VA in assessing whether the servicemember is to be medically retired or separated.  (See Items 6, 12 and 46 in the attached matrix)

MOAA does not support elimination of the military disability retired pay system, as some would interpret the Dole/Shalala recommendations as implying.  Rather, we support DoD's acceptance of VA-determined disability percentages in calculating military disability retired pay.

Wounded Warrior Care and Treatment: Focus on Traumatic Brain Injury (TBI) and Post-Traumatic Stress Disorder (PTSD)

TBI and PTSD affect 25 percent to 50 percent of returning veterans, according to a number of government and other studies. And the percentage rises with prolonged and repeated exposure through multiple and extended deployments.  But reluctance to disclose mental health conditions deters many members and families from testing and treatment. 

Traditional military "can-do" and "tough-it-out" attitudes that are the pride of the warrior ethos actually work against the future well-being of the warrior who doesn't understand the potential long-term consequences of failing to at least find someone to talk to.  Officers and senior NCOs who fear that acknowledgement of such conditions may affect their security clearances or future leadership opportunities are particularly vulnerable through such reluctance. 

Even less visible and likely to go unidentified are the secondary effects on family members who also suffer the long-term effects of living with victims of war-related stress. 

We must get a better handle on cause and effect, starting with crash efforts to destigmatize mental health conditions and publicize opportunities for confidential discussions. 

We also must dramatically improve diagnosis and treatment capacity and methodology. One key is to dramatically improve testing for the effects of traumatic brain injury, including routine baseline pre- and post-deployment neurocognitive assessments, and testing as soon as possible after any exposure to high-risk blast or concussive events.

MOAA strongly endorses the recommendations of the commissions / task forces on Traumatic Brain Injury and PTSD care and rehabilitation.  (See Items 3, 4, 15, 22, 23, 33, 37 and 38 in the matrix).

Joint Seamless Transition Agency Needed

Widely reported breakdowns in the management of care at Walter Reed Army Medical Center reflect the fact that policies and administrative procedures for the care, rehabilitation, outprocessing and transitioning of our wounded warriors are not working "seamlessly" for them and their families.  

DoD and VA have critical, complementary roles in the transition process.  The pace of the two departments' collaborative and cooperative efforts continues to be hampered by bureaucratic and parochial barriers.

The key, we believe, is a coordinated top-down strategy which engages both departments' leadership from a single point of attack.  Recent leadership initiatives generated at the secretarial level have had galvanizing effects on the two agencies' staffs, and there has been unprecedented cooperation and progress in recent months.

However, MOAA is very concerned for the viability of these newly energized efforts beyond the next 15 months, given the inevitable leadership turnover that will attend any new administration.

 The JEC does not appear to have the authority to direct change in both departments, only to forge broad agreements and report to Congress.  We are into the fifth year of the war on terror, and the hand-off between the departments for those who are in the greatest need is far from seamless, despite recent, more strenuous leadership efforts.
This effort is too important to be someone else's part-time job.  MOAA believes strongly that there is an overriding  need to establish a permanent joint office, with permanently assigned staff from both departments, whose full-time mission is to devise, implement, oversee and sustain the joint mission of serving our warriors rather than serving their respective departments' bureaucratic prerogatives.
Acting Secretary of Veterans Affairs Gordon Mansfield, a distinguished disabled Vietnam veteran, endorsed a joint transition agency in testimony before the House Veterans' Affairs Committee on 28 September 2006.
Some elements of seamless transition oversight and implementation that should come under this office include:
-         Bi-Directional Electronic Medical Records
-         A Single Separation Physical and Electronic Separation Document (DD-214)
-         Coordination of Policy / Procedures for Special Needs Health Care, including implementation of a case management system and patient-centered recovery plan program
 -         Coordination of multiple agency inititiatives on Traumatic Brain Injury (TBI) and PTSD diagnosis, treatment and Rehabilitation
-         Expansion of Joint DoD - VA Research
-  Improvement and Expansion of the Benefits Delivery at Discharge program
Joint Bi-Directional Electronic Health Record.
MOAA and our colleagues in The Military Coalition recently were briefed on efforts underway to improve the transfer of medical records between DoD and the VA.  There are significant signs of progress, in our view, on this complex issue.  However, we are concerned that full electronic record "jointness" won't be completed until 2012 at best.  That is just too long to wait.  MOAA strongly endorses accelerated completion of this critical seamless transition function.
Joint DoD/VA Physical
A "one stop" separation physical supported by an electronic separation document (DD214) is a cost-saving initiative that is an essential component of the seamless transition model. Although prototypes exist in some facilities, one has yet to be accepted as a standard throughout the two departments.  It must become the "gold standard" of effective and efficient transitions.
Polytrauma Centers and Traumatic Brain Injury
TBI is the signature injury of OIF/OEF -- its impact on combat veterans ranges from mild to severe.  Developing best practices for identification and treatment is essential, including research on the long-term consequences of mild TBI. The goal of achieving optimal function of each individual TBI patient requires improved interagency coordination between VA and DoD.
MOAA is pleased to note that the VA is establishing a fifth Level One polytrauma center.  The new center and the four existing VA Polytrauma Rehabilitation Centers require special attention in order to ensure the needed resources are available, to include specialized staff, technical equipment and adequate bed space in order to ensure top-quality care for severely injured service members and veterans.
MOAA strongly supports establishment of a separate, joint DoD-VA Seamless Transition Agency to oversee the development, fielding, completion and assessment of seamless transition imperatives.  (See Item 50 in the matrix).

Assistance for Family Caregivers. 

The unprecedented quality and rapid delivery of battlefield health care, along with widespread use of body armor and other protective equipment, means that unprecedented numbers of warriors who would have died of their wounds in previous wars are surviving to return to their families.  Unfortunately, many of these heroes face long and arduous recovery periods, and many require significant levels of care for months or years, and some for the rest of their lives.

In this tragic situation, many spouses, parents, siblings, and other family members find themselves having to take on roles as full-time caregivers and representatives of severely injured/disabled personnel who are unable to navigate military and VA personnel and compensation bureaucracies on their own.  Many give up their jobs and careers to care for a loved one, in come cases having to rely on the goodwill of charities and communities to meet various necessities of their loved ones' new lives. 

MOAA believes strongly that the government has an obligation to change this situation and develop new programs to meet the extreme needs of these special cases.  There must be institutionalized outreach programs to provide information and navigation assistance on administrative proceedings, appeal options, and benefit programs.  In the more severe cases, compensation is appropriate and essential to recognize family members' sacrifice of their own incomes and careers to care for service-disabled members.

For the longer term, the VA needs to establish fair compensation for caregivers forced into hardship situations.  For the short term, MOAA strongly recommends authorization of at least three years of eligibility for active duty TRICARE benefits for wounded warriors after leaving service.  This will protect them from loss of urgently needed services - such as cognitive therapy and caregiver per diem - that now terminate when they leave active duty.  (See Item 34 in the matrix).

MOAA strongly endorses the recommendations of the commissions and task forces on caregiver support / assistance and case management for wounded warriors.  (See Items 2, 10,  13, 21, 29, and 34 in the matrix).

Retroactive Case Review

In addition to making more sensitive decisions in the future, equity demands a review of discharge and retirement cases already completed for warriors wounded or otherwise disabled in Iraq or Afghanistan, while their case histories are still fresh.  Multiple examples of severely disabled soldiers whose separation with zero disability ratings created the pressure for change, but that change can't just be prospective.  It must include retroactive review and re-adjudication for those whose examples brought the inequities to public attention.

In the same vein, an even more sensitive situation is coming to light.  There are numerous cases of exemplary soldiers and marines who, after multiple tours in Iraq or Afghanistan, became "changed men" - disciplinary cases who experienced demotion, incarceration, and adverse separation characterizations that now bar them from eligibility for VA treatment, compensation and rehabilitation for conditions many would not have incurred if not for their wartime service.

 Lengthy claims processing delays are intolerable and must be fixed

The workload and complexity of VA disability claims continues to increase.  As of mid-February 2007, there was a backlog of 626,429 claims.  VA projects that by the close of this year there will be at least 800,000 claims in the system.  Moreover, disability claims processing time rose to nearly six months (177 days) on pending claims in 2006 against an original performance goal of 100 days.  It's our understanding that VA has moved the goalposts and its new performance goal for completing initial claims is 125 days.

MOAA endorses the VDBC's recommendation on improving the VA claims processing system.  (See Item 48).  MOAA recommends that the Committee work with its Armed Services Committee counterparts to ensure this review is completed as soon as possible.  (See Item 8 in the matrix). 

MOAA Concerns

MOAA applauds the work of the commssions and task forces that have examined wounded warrior care, treatment, transition, and services.  As indicated elsewhere in this Statement, MOAA endorses most of the major recommendations of these panels.  We do, however, have some concerns about certain recommendations, while recognizing that in some cases a commission's recommendation was limited by its charter and time.

Military service is a "24/7" enterprise, and is substantively different from civilian employment.

Under current law, the term "service-connected" means generally, "with respect to disability or death, that such disability was incurred or aggravated, or that the death resulted from a disability incurred or aggravated, in the line of duty in the active military, naval, or air service." (38 U.S.C. § 101(16))  An injury or disease incurred "during" military service "will be deemed to have been incurred in the line of duty" unless the disability was caused by the veteran's own misconduct or abuse of alcohol or drugs, or was incurred while absent without permission or while confined by military or civilian authorities for serious crimes." (38 U.S.C. § 105)

This statutory framework has withstood the test of time and thorough past reviews. MOAA is confident that the statutes reflect the will of Congress and the American people regarding the unique nature and the inherent sacrifices involved in military service. 

Disability and survivor benefits should continue to reflect the unique nature of that service in defense of the nation.

MOAA understands that the Dole - Shalala Commission was empowered to examine only wounded warrior issues.  However, we cannot support establishment of separate disability evaluation processes and benefit differentials for combat or operations-related disabilities vs.  other service-connected disabilities. (See Items 6, 30 and 46 in the matrix). 

MOAA strongly recommends that the Committee reaffirm its longstanding commitment to the principle that all service men and women who are disabled in the line of duty - the "24/7" rule - are entitled to service connected compensation, or if eligible, military retirement, unless the disability was a result of misconduct.

Collaborative Congressional Leadership Needed

MOAA was pleased to note that a rare joint hearing was held earlier this year between the Senate Veterans Affairs and the Armed Services Committees to receive the views and preliminary recommendations of the Veterans Disability Benefits Commission.  In the House, there have been joint hearings on educational benefits under the Montgomery GI Bill. 

But it's no secret that on some issues, jurisdictional firewalls in the Legislative Branch as well as the Executive Branch inhibit effective collaboration on some of the core issues affecting VA and DoD interaction.  In this regard, we have been dismayed on many occasions at the continuing skepticism of Veterans Affairs and Armed Services Committee staffs in both chambers about the extent of joint cooperation between the committees that's likely or feasible on various topics of common interest.

We recognize the enormous challenges involved in crafting and revising public laws that cross jurisdictional lines.  We also can appreciate the budgetary and political histories that have arisen from difficult interactions over multiple past congresses.

But MOAA believes strongly that there is bipartisan, bicameral agreement among all of the committees on the need for far greater communication and collaboration between DoD and VA to achieve positive outcomes for wounded veterans in such great need.

We've been extremely encouraged by the personal efforts of the Secretaries of Veterans Affairs and Defense, demonstrating that determined leadership initiative can, in fact, cut through longstanding parochial red tape and generate a genuine cooperative effort among staffs whose main experience has been colored by "stove-piped" perspectives. 

But those efforts can be undermined in the longer term if there is not decisive, determined, top-down congressional leadership direction to develop joint congressional staff consensus on priorities, policy direction, and funding responsibilities on these vital matters.

MOAA strongly recommends that leaders of the Senate Committees on Veterans Affairs and Armed Services make a concerted effort with their House counterparts to develop a more collaborative framework to assess, oversee, prioritize, and fund cross-jurisdictional issues affecting wounded warriors and their families who are having such unacceptable difficulties getting fair and effective outcomes from DoD and VA bureaucracies.