“Yes, although being more proactive will increase costs and require congressional action,” says Drew A. Helmer, M.D., the deputy director of the Center for Innovations in Quality, Effectiveness and Safety.
Americans have an implicit social contract to “care for him who shall have borne the battle.” The United States Department of Veteran Affairs (VA) fulfills that obligation. However, to receive benefits, veterans must prove “service-connection” through a complex claims process. Service-connection (SC) requires a “nexus” between military service and an injury or diagnosis that began or worsened during military service. Benefits include graduated monthly payments based on the percentage of total SC disability and no-cost VA health care for individual, service-connected conditions or for comprehensive care if the total SC rating is 50% or higher. The SC process fulfills the social contract and helps veterans recover from war-related injuries.
The experience of Vietnam War veterans illustrates a breakdown in that contract. All U.S. troops sent to the Vietnam theater (1962-1975) are presumed to have been exposed to Agent Orange and its toxic contaminant, dioxin. This presumption connects dioxin-related health conditions to military service. Over time, diagnoses have been added to the list of “presumed service-connected conditions” for Vietnam War veterans, lowering the barrier for SC. Diabetes mellitus (DM) was added to the list in 2001, and ischemic heart disease (IHD) was added in 2010. However, even if veterans are receiving care for a presumed service-connected condition from the VA, they still must file a claim for benefits.
By examining VA records from 2013, the researchers found that among 196,650 Vietnam War veterans who received VA services in 2011-2013, 125,399 (43%) had DM and 71,251 (25%) had IHD. Among those with DM, 13,715 (10.9%) were not service-connected (i.e., had a DM gap). Among those with IHD, 28,353 (39.7%) had an IHD gap. Factors associated with the DM and IHD gaps included diagnosis of post-traumatic stress disorder (PTSD) and having a maximum disability rating. Having a high burden of chronic conditions was associated with the IHD gap, but not the DM gap.
Thus, in 2013, more than 40,000 Vietnam War veterans did not receive SC benefits for DM and IHD, according to their VA care records. A conservative estimate (based on an increase in SC from 10% to 20%) suggests these veterans missed out on more than $70 million per year in compensation. The higher gap for IHD compared to DM suggests it may take years for veterans to file a claim when new conditions are recognized. PTSD and a high burden of chronic disease may also create barriers. Having a maximum disability rating is also associated with the SC gap; veterans gain little from additional claims once eligible for comprehensive VA health care and after receiving the maximum disability benefit (about $3,100 per month in 2020 for a single veteran).
We want our warriors to function optimally in society. VA health care and disability compensation are critical to that goal, but expensive. In 2019, the net cost of VA health care was $89 billion, and for benefits, it was $115 billion. Until a more seamless process is created, Congress should amend the law to allow the VA to proactively connect eligible veterans in its health care system to their presumed SC benefits, says Helmer and his colleagues. This would cost more, but it would better honor the social contract for all veterans, not just those who are able to file SC claims.
In This Issue
The paper “Factors Associated with Uptake of U.S. Department of Veterans Affairs Disability Benefits among U.S. Vietnam War Veterans who were VA System Users in 2013,” co-authored by Drew A. Helmer, M.D., was published in the Journal of Military and Veterans’ Health in April 2019. Helmer is the deputy director of the Center for Innovations in Quality, Effectiveness and Safety.
About Health Policy Research
Health Policy Research presents a summary of findings on current health policy issues. It is provided by Vivian Ho, Ph.D., the James A. Baker III Institute Chair in Health Economics at Rice University’s Baker Institute for Public Policy, in collaboration with Laura Petersen, M.D., MPH, chief of the Section of Health Services Research in the Department of Medicine at Baylor College of Medicine.
This publication aims to make research results accessible to regional and national health policymakers. The views expressed herein are those of the study authors and do not necessarily represent those of the Baker Institute or of Baylor College of Medicine.
The Baker Institute and Baylor College of Medicine’s Section of Health Services Research work with scholars from across Rice University and Baylor College of Medicine to address issues of health care — access, financing, organization, delivery and outcomes. Special emphasis is given to issues of health care quality and cost.