Big Money: The Compensation AngleOctober 31, 2006
The Raw Story
Veterans' advocates fought long and hard to have Congress pass measures in 1997 that require the Department of Defense (DOD) to document the pre- and post-war health of American troops.
Which is precisely why those same veterans' advocates are hopping mad today.
DOD implements those mandatory measures haphazardly at best. "Compulsory" pre-and post-deployment face-to-face medical examinations are not happening regularly. Only 22% of all returning troops who come forward with symptoms of potential post-traumatic stress disorder (PTSD) are being referred for further mental health evaluation. And by the Veterans Administration's (VA) own account, record numbers of veterans from the wars in Iraq and Afghanistan are resurfacing at their facilities, where a third are being diagnosed with possible mental health disorders. (View full VA PowerPoint presentation.)
There is no record of how many of those veterans are the very same soldiers who did not get diagnosed at demobilization time in a face-to-face medical examination that did not happen. Or of how many of them initially tried to come forward with PTSD symptoms, but were not referred for further mental health evaluation.
But one thing is for sure: A solider who at the time of his demobilization has no documentation of his condition on the post-deployment health assessment form (the 2796) that he may or may not have filled out is going to have a hell of a time later when he tries to get free treatment from the VA or collect compensation for a service-connected disability.
"There's no way you'll read that not coming forward at 2796 time will be held against you later, but it's true," says Shad Meshad of the National Veterans Foundation. "It's all about money and percentages, because there's a major difference in a monthly reimbursement on 30% as opposed to 70% and 70% as opposed to 100. The folks at the Department of Veterans' Benefits who review all the paperwork try to measure how much PTSD is in your brain pretty much the same way that they calculate how much of an arm or leg is missing. We're talking about money: it's all about big, big, big money."
Nearly 10 years after veterans' advocates successfully lobbied for Congress to mandate pre-and post-deployment face-to-face medical examinations for troops, (see public law 105-85, sections 762-767 in the attached National Defense Authorization Act for Fiscal Year 1998), they are still facing many of the same access-to-care and liability issues they once thought they had resolved.
Paul Sullivan and his Veterans for America (VFA) colleague, Steve Robinson, both fought for passage of the 1997 Congressional order. As Gulf War veterans they knew from bitter first-hand experience what a huge difference a mandatory, documented face-to-face medical examination with a health care professional could make for service members on their way to and from duty.
The men and women who fought in the Gulf War had neither. And thousands of them came home in the early 90s reporting symptoms that included joint pain, headaches, memory loss, rashes, balance problems, and loss of motor skills -- all part of what has commonly come to be known as "Gulf War syndrome."
But veterans' attempts to access diagnosis, treatment, and compensation through the DOD and/or the VA were mostly denied as unsubstantiated. It was easy to dismiss their claims, but nearly impossible for veterans to prove that their symptoms were not pre-existing conditions, because the DOD had never established a pre-deployment baseline for service members' health, nor measured their exposure to contaminants in the field. (Vietnam veterans two decades earlier had successfully sued the makers of Agent Orange for their ailments, but not the military itself.)
The DOD's failure to collect this data also meant that it avoided even the possibility of paying millions, if not billions, of dollars in compensation to disabled veterans.
Robinson, Sullivan, and their colleagues never wanted to see another veteran go through this wringer again. They thought they had won a great victory when Congress mandated pre-and post-deployment health screenings in 1997. Instead, what they have found themselves up against for nearly a decade now is a DOD that inches towards compliance with Congress' orders at a snail's pace -- and then usually in response to congressional hearings, investigative reports, and pressure from veterans' advocacy groups.
Testifying before the House Subcommittee on National Security, Emerging Threats, and International Relations on the very same day in March of 2003, Dr. William Winkenwerder, Jr., the Assistant Secretary of Defense for Health Affairs, and veterans' advocates like Robinson appeared to be talking about two entirely different DODs.
Robinson testified, as Thomas H. Corey of Vietnam Veterans of America had three days prior, that DOD has failed utterly to comply with the 1997 law. According to the Pentagon's own statements, as well as the testimony of service members, DOD is conducting no medical examinations before deployment, or any mental and physical evaluations afterwards. At best, the advocates say, DOD is handing soldiers a questionnaire (pre-deployment assessment form 2795 or post-deployment assessment form 2796) to fill out -- when it's even doing that.
By contrast, Winkenwerder describes a military where all deploying and redeploying troops "receive individual health assessments," though he provides no documentation to prove his case. Nor does he address the fact that just three weeks prior, DOD's top medical guy, Dr. Michael Kilpatrick, the Pentagon's deputy director for force deployment health, had acknowledged to the Kansas City Star that DOD interpreted the law as simply requiring "better documentation."
Any questions about which of these competing accounts is correct were resolved less than half a year later with the appearance of a September 2003 GAO report. Specifically, it finds that "the percentage of Army and Air Force servicemembers missing one or both of the pre- and post deployment health assessments ranged from 38 to 98 percent of our samples." Meaning that the GAO could not find evidence that DOD was complying with Congress' 1997 directive, even by the standards of documentation alone.
Three years have passed since that GAO report, and since four PTSD screening questions were added to the post-deployment health assessment in April of 2003. But little progress appears to have been made towards full DOD compliance, with either the 1997 law or the PTSD screening protocol. Of the half a dozen veterans I interviewed for this piece, not one had a face-to-face post-deployment health screening -- or knew anyone else who had.
Still, Kilpatrick claimed that DOD was in full compliance with Congress' directive when I questioned him. Specifically, I asked whether there was any reason to believe that some troops had not filled out the 2796 or had not had face-to-face medical examinations. Could he tell me whether the number of post-deployment health assessment forms in the DOD database matched the number of troops that had been demobilized from October of 2001 through September of 2004?
Kilpatrick responded that "the Post-Deployment Health Assessment is a process, not a form" -- one that "includes a face-to-face interview with a qualified health professional." And while he acknowledged that there might have been some missteps during the start-up process, he assured me that "compliance now stands at over 90%" -- but offered no documentation.
Sullivan doesn't believe a word of it. "DOD should turn over the data. According to the 1997 law, there should be evidence of a face-to-face pre-deployment screening for each of the 1.5 million servicemembers who have been deployed since the beginning of OEF/OIF. And when the wars are over, there should be 1.5 million post-deployment forms. The burden is on DOD to prove that every soldier received a face-to-face mental health care exam from a mental health care professional, because we have the evidence that veterans are coming home with significant mental health care problems, and we know that a lot of veterans have gone through the discharge process and were not screened."
"Every time you and I get on an airplane, we are confident that the pilot and the co-pilot have done a walkaround of the plane and a systems check to make sure that all of the instruments on the plane work," Sullivan continued. "We believe that soldiers are our nation's most important national defense assets. Therefore, the greatest emphasis should be placed on making sure that we send the best soldiers into combat, and that means screening; and when the soldiers come home from combat after one year of 24/7 non-stop bullets and roadside bombs and dangerous convoys and mortaring and snipers, and everything else that's going on in Iraq -- that solider has earned the right to have a full, face-to-face professional mental health care screening. To do less is a disservice to those of us who are protecting our country. If we do it for an airplane, we should do it for the veterans."
"Congress intended that there be a face-to-face mental health care encounter," says Robinson. "And DOD is saying, 'They get face-to-face: they fill out a piece of paper, they turn it in to somebody who may or may not be a medical professional, and that's a face-to-face.' No, Mr. Winkenwerder: that is not what Congress intended. It's a game of words now, and the reasons why DOD is not providing troops with the face-to-face mental health care encounter are all about cost, capacity, and demand."
The military bristles at any suggestion that its mental health referral system might be letting soldiers fall through the cracks.
Classically, DOD responds to such inferences by insisting that it is simply practicing good sense by not jumping to conclusions regarding troops' mental health. It warns against the dangers of diagnosing too early symptoms that might be routine reactions to stress, touts its own philosophy of "watchful waiting" -- shorthand for telling the soldier to come back and seek care if her symptoms do not improve, or worsen -- and insists that it is doing all that it can to follow up with troops, who can, after all, access care at any time.
In fact, these were precisely the arguments DOD used when it responded to the May 2006 Government Accountability Office (GAO) report that evaluated the DOD's PTSD screening system.
In this response, first Winkenwerder, despite explicitly concurring with GAO's conclusions and recommendations in DOD's written comments on an earlier draft of the report (see pages 33-37), tries to get GAO to change its findings. Specifically, DOD asks GAO to remove the report's key statement -- that DOD could not provide "reasonable assurance" that all servicemembers who needed referrals were getting them. (GAO declined.)
The rest of the DOD comments that follow Winkenwerder's letter are devoted to countering an argument for immediate medicalization that the GAO report never makes and touting the benefits of "watchful waiting." It closes by reminding the reader that the post-deployment health assessment is not the only avenue to care and insisting that the DOD is already in the midst of conducting a thorough program evaluation of the pre- and-post deployment processes. (The validation study projected for completion in October 2006 -- last month -- has not yet appeared.)
Later, an unhappy DOD actively tried to discredit GAO's report altogether.
The military has built much of its philosophy of treatment on the concept of "watchful waiting," with the justification that it makes no sense to evaluate, let alone diagnose or treat, troops who are still so close to their time in the theater of combat. (As discussed in Part III of Mind Games, all forms and procedures associated with demobilization, including the post-deployment health assessment and the 2796 form, are completed during a soldiers' last five days or so of duty.) The DOD argues that a few nights of rest and restoration, followed by sending troops' home with information about potential problems that might arise, makes more sense and is less stigmatizing than suggesting that something more serious might be wrong in the early stages of post-deployment.
Obviously the concept of "watchful waiting" is quite useful in certain medical contexts, such as when one is monitoring a small tumor to see if it grows larger. But it is a bit more problematic when applied to a possible mental health disorder -- especially given the DOD's own protocols regarding documentation and the potential for harm to oneself and others.
First there is Meshad's point, which Robinson reiterates in his Congressional testimony and Rieckhoff repeats in "Chasing Ghosts," his memoir of his time in Iraq: that waiting until after one is discharged to document symptoms means an uphill battle for diagnosis, treatment, and compensation.
Then there is the question of who is watching whom: Is a traumatized veteran really her own best judge or guardian? And finally, there is the steep downside of letting this particular ailment develop further: When it comes to PTSD, the signs that one's illness is worsening include acting out in ways that can be dangerous, violent, and illegal.
"All kinds of bad stuff can happen while you're waiting around with PTSD," says Meshad. "There are other people involved here: spouses, children, friends, employers."
"While people are waiting for the face-to-face mental health care encounter they should have gotten during their post-deployment health assessment, they turn to other coping mechanisms," says Robinson. "They turn to drugs and alcohol, they become discipline problems, they're arrested or dishonorably discharged from the military, and they lose their veterans' benefits forever."
Given the extent of the military's reliance on "watchful waiting," I was eager to hear what kind of follow-up DOD did with solders who followed their recommended method, and how they tracked the soldiers' progress. Kilpatrick's response to my inquiry indicates that DOD does not do any personal outreach or tracking aside from sending them their latest form. The 2900, another self-reported questionnaire, will be mailed to service members who have been home for three to six months. Otherwise, the full extent of the DOD's follow up is to leave it up to veterans to follow the directions they have been given: Pay special attention to your symptoms and seek care once at home if they do not get better, or worsen.
"All DOD does is keeping throwing paper at these guys," sighs Meshad. "It's like their gift isn't working, but their attitude is 'Well, we're offering it, so that's all we can do.'"
"There are a lot of barriers to care, but the biggest problem I see is that the system is not pro-active," says Paul Reickhoff, Executive Director of Iraq and Afghanistan Veterans of America (IAVA) and a former Infantry Platoon Leader in the Adamiyah section of central Baghdad. "For a year I made sure these guys tied their shoes and wiped their asses. And they get home, and no one's calling them to see what they're doing. No one's calling them to say, 'Hey, Sergeant Smith, did you go see anyone? Hey, Sergeant Smith, are you alive?'"
"This isn't any kind of procedure," says Robinson. "Watchful waiting is DOD hoping that if they wave people off the first time around, they won't come back. It's a methodology to reduce the number of people the DOD has to see, because they're not in the business of long-term care. Nor do they have the capacity to meet the demand of the returning veterans that are having mental health problems even if they wanted to."
Robinson's doubts about capacity have been echoed multiple times in these last two months, particularly in hearings before the Pentagon's Task Force on Mental Health, in a report by Democrats from the House Committee on Veterans' Affairs Subcommittee on Health, and in a September 2006 GAO report that explored the VA's allocation of some $300 million dollar it had planned for underwriting mental health services in 2005 and 2006. (It found that 12M of the money had not been allocated in fiscal year 2005 and that 35M may have been allocated too late to be of use in 2006.)
In testimony before the Pentagon's Task Force on Mental Health, Commander Mark Russell, a Navy psychologist, sounded a very different note from Dr. Michael J. Kussman, the acting undersecretary for health and top doctor at the VA. A week prior to Russell's testimony, Kussman had responded to the release of the VA's own report on a ten-fold increase in demand for mental health services over 18 months by insisting that the number of troops reporting symptoms of stress probably represented a "gross overestimation" of those actually suffering from mental health disorders.
By contrast, Russell described the combination of rising need on the part of troops and veterans and shrinking resources for quality mental health care as a "perfect storm."
He cited as major problems in the mental health care system the failure of the DOD to diagnose and treat service members earlier -- chronic conditions and disability payments are very expensive -- a shortage of mental health caregivers and their relative inexperience, and a high rate of burnout among experienced hospital staff. While only 80 of 135 key mental health slots in the Navy are filled, five new retirement requests are filed per month. His informal survey of 133 mental health providers revealed that 90% had not been trained to treat PTSD and could not do so.
The same week that Russell testified, Democrats from the House Committee on Veterans' Affairs Subcommittee on Health released a report showing that high demand from returning Iraq and Afghanistan war veterans at many Department of Veterans Affairs (VA) Readjustment Counseling Service Centers (Vet Centers) had forced the Centers to create waiting lists and limit individual counseling sessions.
PTSD skeptics like Dr. Sally Satel, from the arch-conservative American Enterprise Institute, claim that "generous Veterans Affairs entitlements for chronic PTSD may have created financial incentives for veterans to claim psychological disorders and reduced the motivation to recover." And Republican chairman Larry Craig of the Senate Veterans' Affairs Committees has called the jump in disability payments "stunning increases that are going to require a reality check from Congress."
But Vets Centers, which are community-based direct service centers that provide readjustment counseling services to veterans making the transition from military duty to civilian life, do not provide medical treatment, nor are they an avenue for filing for compensation of any kind. And demand for their services doubled in the nine-month period from October of 2005 to July of 2006.
The debate about mental health disorders among US troops, and about the proper implementation of the 1997 Congressional order, will continue for years to come, even if the wars overseas end tomorrow. It's inevitable, with so many people affected and so much at stake for this administration, which appears to be as unprepared for the wars' aftermath as it is for the wars themselves.