This report compares selected recommendations of the President's Commission on Care for America's Returning Wounded Warriors (PCCWW), often called the Dole-Shalala Commission in reference to its co-chairs, and the Veterans' Disability Benefits Commission (VDBC). The VDBC was established in 2004 to study veterans' benefits in a broad context. The PCCWW was established in 2007 following reports of problems among injured servicemembers returning from Iraq and Afghanistan with medical rehabilitation and access to benefits. The PCCWW was charged to focus specifically on the needs of these individuals.
The recommendations presented in this report are those that relate to the transition of injured servicemembers from military service to civilian life and/or veteran status. This report does not examine certain other recommendations, such as those in the VDBC report regarding benefits for survivors of deceased servicemembers, or regarding evaluation of presumptive disability, i.e., establishing service connection for certain long-term health effects of hazardous exposures. As this report is limited to a comparison of the final recommendations of the PCCWW and the VDBC, it will not be updated.
This report compares selected recommendations of the President's Commission on Care for America's Returning Wounded Warriors (PCCWW),1 often called the Dole-Shalala Commission in reference to its co-chairs, and the Veterans' Disability Benefits Commission (VDBC).2 The recommendations presented are those that relate to the transition of injured servicemembers from military service to civilian life and/or veteran status. This report does not examine certain other recommendations, such as those in the VDBC report regarding benefits for survivors of deceased servicemembers, or regarding evaluation of presumptive disability, i.e., establishing service connection for certain long-term health effects of hazardous exposures.3
Congress, the two commissions, and others have determined that certain programs and systems that involve both the Department of Defense (DOD) and the Department of Veterans Affairs (VA) are particularly problematic in providing continuity and quality of care and services to injured servicemembers. In January 2008, Congress passed the National Defense Authorization Act for Fiscal Year 2008 (P.L. 110-181). Titles XVI and XVII of the act address matters related to the care and treatment of servicemembers and former servicemembers (i.e., veterans) who were wounded, or who contracted an illness, while serving on active duty. Among the problems addressed in the act are the efficient maintenance and transfer of servicemembers' health and benefits records between the departments, and the separate evaluations of disability by each department. Efforts to address these and other transition problems were already under way in both departments, partly in response to the recommendations of the PCCWW, the VDBC, and several other commissions or task forces. These legislative and administrative actions constitute the first wave of responses to the recommendations of these bodies. Further congressional and administrative actions are anticipated. As this report is limited to a comparison of the final recommendations of the PCCWW and the VDBC, it will not be updated.
The commissions were given different charges. The PCCWW was established by Executive Order 13426 in March 2007,4 and was to focus on the needs of a specific population, namely, seriously injured servicemembers returning from combat theaters in support of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). The commission was asked to look broadly at services and benefits provided by all relevant Cabinet departments—principally the Departments of Defense (DOD) and Veterans Affairs (VA)—as well as the private sector, and at a broad slate of services and benefits, including health care, disability, traumatic injury, education, employment, and other benefits. The PCCWW was to study individuals' experiences as servicemembers and, for those who were retired or separated from military service, their transition from military to civilian and/or veteran status, problems in providing services and benefits across that transition, and subsequent experiences in civilian life. Though the PCCWW's recommendations were to apply narrowly to seriously injured OEF/OIF servicemembers, it could prove difficult, politically and administratively, to implement the recommendations in this fashion. Doing so could run counter to existing policies, such as compensating service-connected disabilities equally whether or not they are combat related, and prioritizing groups of veterans to receive VA health care.
The VDBC was established in Title XV of the National Defense Authorization Act of 2004 (P.L. 108-136) to study benefits provided to veterans and their survivors to compensate for service-connected disabilities and deaths. The VDBC was to consider these benefits regardless of the time or manner in which a disability or death occurred, and whether it occurred during a conflict or during peace time. While the VDBC examined certain transition issues for injured OEF/OIF servicemembers who were retired or separated from military service, this was not its principal focus. The VDBC examined services and benefits for veterans across their life spans, making a more comprehensive assessment of the full complement of veterans' benefits than did the PCCWW, but a less comprehensive assessment of DOD services, benefits, authorities and policies.
The PCCWW made six broad recommendations, each with several specific action steps directed to the Congress, DOD and/or VA, and published a matrix of the 23 action steps in its main report.5 The six broad recommendations are as follows:
1. Implement comprehensive recovery plans for returning injured servicemembers.
2. Restructure the military and veterans disability and compensation systems.
3. Improve care for people with post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI).
4. Strengthen support for families.
5. Transfer patient information across the DOD and VA systems.
6. Support Walter Reed Army Medical Center (WRAMC) until its closure.
The VDBC made 113 recommendations, also directed to the Congress, DOD and/or VA, designating 13 of them as priority recommendations.6 Recommendations were made in the following broad categories:
The attached Table 1 compares selected action steps from the PCCWW and recommendations from the VDBC that relate to the transition of injured servicemembers from military service to civilian life and/or veteran status. Since the PCCWW focused on these individuals, all of its action steps are discussed, and the table is organized according to the PCCWW's six broad recommendations. The table does not include all of the VDBC recommendations, but only those that relate to the transition of injured servicemembers or that are otherwise comparable to recommendations of the PCCWW. Each table entry notes the entity (Congress, DOD and/or VA) to whom the recommendation is directed. Bracketed notations show the relevant numbered recommendation(s) from the PCCWW and VDBC respectively.
Because the commissions had distinct charges and areas of emphasis, head-to-head comparison of their recommendations must be made with care. For example, the commissions largely agreed on the proposed end point for a revised disability compensation system, namely, that DOD would evaluate the fitness of injured servicemembers for continued duty, while VA would evaluate for disability compensation. But the commissions differed in their priorities for implementing this revised system, reflecting their focus on different populations. When comparing PCCWW and VDBC recommendations, it must be borne in mind that unless otherwise stated, PCCWW recommendations would apply, at least initially, only to injured OEF/OIF servicemembers and veterans, while VDBC recommendations would apply to all servicemembers or veterans, including those from previous conflicts, who are otherwise eligible for the service or benefit being discussed.
The following CRS Reports discuss the variety of DOD and VA programs and benefits that are addressed by the commissions and referred to in this report:
Table 1. Comparison of Selected Recommendations of the PCCWW and VDBC
|
Provision |
PCCWW Recommendations |
VDBC Recommendations |
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CASE MANAGEMENT/INDIVIDUAL RECOVERY PLANS |
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Overview |
DOD and VA: Develop integrated care teams of healthcare, social work and vocational rehabilitation staff, to coordinate health care and access to benefits for servicemembers. Create individual Recovery Plans for each seriously injured servicemember, including plans developed retroactively for any servicemembers injured since the beginning of OEF or OIF who may still benefit from them. Develop a corps of trained Interagency Recovery Coordinators to implement the Recovery Plans. [1] |
DOD and VA: Create an intensive case management program for severely disabled veterans, with a lead agency. [10.3] |
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Case manager/Recovery Coordinator |
DOD and VA: Interagency Recovery Coordinators should be officers in the Commissioned Corps of the U.S. Public Health Service, in the Department of Health and Human Services, cross-trained by DOD and VA. [1] |
The commission does not comment specifically on the affiliation or credentials of the proposed lead agency. |
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DISABILITY: RATING AND RATING PROCESS |
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|
Proposed end state |
Congress, DOD, and VA: Completely restructure the disability and compensation systems, so that DOD, through its service branches, maintains authority to determine fitness for continued military service, and VA determines disability ratings and all resulting compensation and benefits. If DOD finds the servicemember unfit, DOD provides annuity payments based solely on rank and years of service. VA's disability system compensates for transition costs and lost quality of life in addition to lost earnings potential. [2] (Recommended actions to achieve this end state follow. See, in particular, "Restructure VA disability payments.") |
Congress, DOD, and VA: Realign the disability evaluation process so that the service branches determine fitness for duty, and servicemembers who are found unfit are referred to VA for disability rating. All conditions that are identified as part of a single, comprehensive medical examination should be rated and compensated. [Priority Recommendation 7.12] (Recommended actions to achieve this end state follow. See, in particular, "Restructure VA disability payments.") |
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Congress: Clarify the objectives of the DOD and VA disability programs. [2] |
VA: The VDBC makes 21 additional recommendations regarding administration of the proposed disability compensation system. [4.3 - 4.23] |
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Cause of disability |
Congress, DOD, and VA: PCCWW recommends enhancements of disability compensation selectively for combat-injured OEF/OIF servicemembers. [2] |
Congress, DOD, and VA: Benefits should be awarded solely according to the severity of the disability, regardless of whether the injury was incurred or the disease was contracted during combat or training, or in wartime or peacetime. [5.3] |
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Single medical examination |
DOD and VA: Develop a single comprehensive, standardized medical examination, to be administered by DOD, that would serve both DOD's fitness evaluation, and VA's initial determination of disability. [2] |
DOD and VA: Servicemembers being considered unfit by DOD should be given a single, comprehensive examination, and all identified conditions should be rated and compensated. [Priority Recommendation 7.12] Conduct a comprehensive multidisciplinary medical, psychological, and vocational evaluation of each veteran applying for disability compensation at the time of service separation. [4.10] DOD: Mandate that separation examinations be performed on all servicemembers. [10.6] |
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Re-evaluation of disability |
VA: Re-evaluate veterans' disability status every 3 years. [2] |
VA: Re-evaluate individuals with PTSD every 2—3 years to gauge treatment effectiveness and encourage wellness. [Priority Recommendation 5.30] |
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Veterans Administration Schedule for Rating Disabilities (VASRD) |
VA: Update and keep current the VASRD to reflect injuries seen in OIF/OEF injured servicemembers, and modern concepts of the impact of disability on quality of life. Post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) are mentioned specifically. The commission does not stipulate a specific timetable for revisions. Update the VASRD to reflect modern understanding of PTSD and TBI. [2] |
VA: Update the VASRD, beginning with mental health and neurological body systems, to prioritize the revision of schedules for PTSD, other mental disorders, and TBI. After establishing priorities for revision of the remaining systems, revise the remainder of the schedule, completing the revision for all body systems within five years. [Priority Recommendation 4.23] Develop specific VASRD rating criteria for PTSD. [Priority Recommendation 5.28] |
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Reassessment of DOD disability ratings of 0-30% |
No comparable recommendation. |
DOD: Reassess any such ratings of servicemembers to determine if they are equitable. [7.11] |
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Individual Unemployability (IU) |
No comparable recommendation. |
VA: Eligibility for IU benefits should have a consistent basis. Revise the VASRD to accommodate individual inability to work in basic rating, without need for IU rating. Reduce IU benefits gradually rather than terminating abruptly. [4.12 and Priority Recommendations 7.4 and 7.5] |
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DISABILITY: COMPENSATION |
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Restructure VA disability payments |
Congress: Restructure VA disability payments to include transition payments, earnings-loss payments, and quality of life payments. (See additional information for each below.) Transition payments would cover living expenses for disabled veterans and their families. Earnings-loss payments would begin when transition payments end, and cease when Social Security benefits for retirement begin. Earnings loss payments are intended to make up for any lower earning capacity remaining after training. Quality of life payments would compensate for non-work-related effects of permanent physical and mental service-connected disabilities. [2] |
Congress: Disability compensation should compensate for: (1) work disability; (2) loss of ability to engage in non-work life activities; and (3) loss of quality of life. [4.1, 4.2, 4.3] |
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Transition payments |
VA: Provide transition payments to disabled veterans and their families, either three months of base pay for those returning to their communities without receiving continued rehabilitation, or, for those receiving longer-term rehabilitation or education and training programs, longer-term payments to cover family living expenses. Commission a study to determine appropriate longer-term payment levels. [2] |
Congress: Create a severely disabled stabilization allowance that would allow for up to a 50% increase in basic monthly VA compensation for up to 5 years to address the real out-of-pocket costs above the compensation rate at a time of need, to supplement, to the extent appropriate, any coverage under Traumatic Servicemembers' Group Life Insurance. [7.7] |
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Special Monthly Compensation |
No comparable recommendation. |
Congress: Consider increasing Special Monthly Compensation benefits, where appropriate, to address the more profound impact on quality of life of the disabilities subject to special monthly compensation. [6.1 and Priority Recommendation 7.8] |
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Quality of life payments |
VA: Move swiftly to update and keep current the disability rating schedule (see the prior reference to the VASRD) to reflect current injuries and modern concepts of the impact of disability on quality of life. [2] |
Congress: Review ancillary benefits to determine where additional benefits could improve disabled veterans' quality of life. [6.1 and Priority Recommendation 7.8] While the program is revised to accomplish this, consider an immediate increase (up to 25%) in disability compensation. [7.6] |
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DISABILITY: OTHER BENEFITS |
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Vocational rehabilitation |
VA: Develop flexibility within the program by allowing veterans to suspend training or attend part-time, with the approval of the Recovery Coordinator and vocational counselor. Provide bonuses for completion of stages of vocational training. [2] |
Congress and VA: Require vocational assessment in the determination of eligibility for Individual Unemployability (IU) benefits. [4.14] VA: Review the 12-year limitation for vocational rehabilitation for service-connected veterans and, when appropriate, revise the limitation on the basis of current employment data, functional requirements, and individual vocational rehabilitation and medical needs. [4.12] Develop and test incentive models to promote vocational rehabilitation and a return to gainful employment among veterans for whom this is a realistic goal. [4.13] |
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Tricare |
Congress: Establish lifetime Tricare benefits eligibility for all combat-injured servicemembers found unfit for continued service, and their dependents. [2] (Currently, this benefit is available only to those found unfit with disability ratings of 30% or greater.) |
DOD: Remove Tricare requirements for copays and deductibles for severely injured servicemembers and their families. [10.17] |
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Concurrent receipt of DOD and VA disability benefits |
The commission's proposed end state would eliminate DOD disability payments, having DOD provide an annuity payment, similar to military retired pay, based on rank and years of service, with only the VA providing a disability payment. [2] |
Congress: Eliminate the ban on concurrent receipt. VDBC recommends that servicemembers who are separated before 20 years of service for being medically unfit receive DOD retirement and VA disability benefits concurrently (i.e., without offset), regardless of their disability rating, and that priority be given to veterans separated or retired with fewer than 20 years of service and either a service-connected disability rating greater than 50%, or a combat-related disability. [Priority Recommendation 6.14] Eliminate the Survivor Benefit Plan/Dependency and Indemnity Compensation offset for survivors of retirees and in-service deaths. [Priority Recommendation 8.2] |
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Social Security benefits |
Congress: In restructuring VA disability compensation, earnings loss compensation would end upon retirement and receipt of Social Security retirement benefits. Compensation for lost quality of life would continue in retirement. [2] |
Congress: For severely injured veterans, consider eliminating the Social Security Disability Insurance (SSDI) eligibility requirement of having worked a minimum number of quarters. [10.16] DOD and VA: Include the Department of Labor and the Social Security Administration in the Joint Executive Council to improve the transition process. [10.2] Make transitioning servicemembers aware of SSDI. [10.15] |
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POST-TRAUMATIC STRESS DISORDER (PTSD) AND TRAUMATIC BRAIN INJURY (TBI) |
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|
PTSD |
Congress: Enable all Iraq and Afghanistan veterans who need PTSD care to receive it from the VA, without waiting for enrollment or disability evaluation, and regardless of their priority status. [3] |
VA: Develop a "holistic approach" to PTSD, involving treatment, compensation, and vocational assessment, and including closer coordination of the Veterans Health Administration (VHA) and Veterans Benefits Administration (VBA), with re-examinations conducted every two to three years. [Priority Recommendation 5.30] The commission also makes recommendations regarding benefits, training and certification of raters, and data collection and research, including research on the relationship between military sexual assault and PTSD. [5.29 - 5.33] |
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Workforce and training |
DOD and VA: Establish and expand networks of experts in PTSD and TBI, to expand training, and to develop or disseminate clinical practice guidelines. Both departments must work to reduce the stigma associated with PTSD. [3] DOD: Address shortages of mental health professionals. [3] |
VA: Establish a standardized training program for clinicians who conduct psychiatric evaluations for compensation and pension physical exams [5.32], and a certification program for raters who handle PTSD claims. [5.33] |
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VASRD |
VA: Update the VASRD to reflect modern understanding of PTSD and TBI. [2] |
VA: Develop specific VASRD rating criteria for PTSD, and prioritize the revision of criteria for other mental disorders and TBI. [Priority Recommendations 4.23 and 5.28] |
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SUPPORT FOR FAMILIES OF INJURED SERVICEMEMBERS |
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In general |
No comparable recommendation. |
Congress: Authorize and fund VA to establish and provide support services for the families of severely injured veterans similar to those provided by DOD, such as counseling, travel and per diem benefits, and assistance with employment and health care when relocating to assist an injured servicemember. [10.12] |
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Health care and attendant care costs |
Congress: Provide lifetime Tricare comprehensive health care and pharmacy benefits to servicemembers found unfit because of combat-related injuries, and their dependents. [2] Make combat-injured servicemembers eligible for respite care and aide and attendant care in DOD's Tricare Extended Care Health Option program. [4] |
Congress: Extend eligibility for VA's aide and attendant benefit to severely injured active-duty servicemembers who are in medical hold or Temporary Disability Retired List (TDRL) status pending discharge. [6.3] Adjust the amount of payment for aid and attendance to fully pay for the extent of assistance required. [6.2] Extend eligibility for the VA's Civilian Health and Medical Program to caregivers, and create a caregiver allowance for caregivers of severely disabled veterans. [8.1] DOD: Eliminate Tricare co-pays and deductibles for severely injured servicemembers and their families. [10.17] |
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Training and counseling |
DOD and VA: Provide families of servicemembers who require long-term personal care with appropriate training and counseling for their caregiving roles. [4] |
See recommendation 10.12 (in general) above. |
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Family and Medical Leave Act (FMLA) |
Congress: Lengthen the FMLA period for job-protected unpaid leave from the current 12 work weeks to 6 months (26 weeks) for otherwise eligible spouses and parents caring for injured servicemembers. [4] |
No comparable recommendation. |
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HEALTH INFORMATION MANAGEMENT AND SHARING |
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In general |
DOD and VA: Within 12 months, make patient data more accessible (initially, in viewable form). All essential health, administrative, and benefits data must be immediately viewable by any clinician, allied health professional, or program administrator who needs it. Continue the work under way to create a fully interoperable information system that will meet the long-term administrative and clinical needs of all military personnel over time. Develop a plan for a user-friendly, tailored web portal with services and benefits information for service-members, veterans, and family members. [5] |
DOD and VA: Expedite development and implementation of compatible information systems including a detailed project management plan that includes specific milestones and lead agency assignment. [Priority Recommendation 10.11] Improve electronic information record transfers and address issues of lost, missing, and unassociated paper records. [10.10] DOD: To expedite claims processing, provide an authenticated electronic DD 214 form to VA. [10.9] |
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Long-term health effects from hazard exposures |
No comparable recommendations. |
DOD and VA: Improve the data linkage between the electronic health record data systems used by DoD and VA, including capabilities for handling individual soldier exposure information in individual health records. [5.23] Develop a data interface that allows VA to access the electronic exposure data systems used by DoD. [5.25] Additional recommendations regarding processes to define service-connected illnesses that may arise many years following exposure. [5.8-5.27] |
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SUPPORT WALTER REED ARMY MEDICAL CENTER (WRAMC) UNTIL ITS CLOSURE |
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In general |
DOD: Assure that WRAMC has the resources it needs to maintain a standard of excellence in both inpatient and outpatient care. Implement tailored incentive packages to encourage civilian health care and administrative professionals to continue working there and to enable recruitment of new professionals, as needed. [6] |
No comparable recommendations. |
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DISCHARGE OF SERVICEMEMBERS FROM THE MILITARY |
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Conduct-related discharge |
No comparable recommendation. |
Congress: Change the character-of-discharge standard to require that when an individual is discharged from his or her last period of active service with a bad conduct or dishonorable discharge, it bars all benefits. [5.1] |
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Outreach regarding benefits |
No strictly comparable recommendation. For injured servicemembers, the requirement for case management (see discussion of case management / recovery plans above) would enhance servicemembers' knowledge of and access to benefits for which they were eligible. [1] |
Congress: Adequately fund and mandate the Transition Assistance Program throughout the military to ensure that all servicemembers are knowledgeable about benefits before leaving the service. [10.4] DOD: Require a mandatory benefits briefing to all separating military personnel, including Reserve and National Guard components, prior to discharge from service. [5.7] DOD and VA: Benefits Delivery at Discharge should be available to all disabled separating servicemembers, to include National Guard, Reserve, and medical hold patients. [10.5] Make transitioning servicemembers aware of Social Security Disability Insurance. [10.15] |
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| 1. |
President's Commission on Care for America's Returning Wounded Warriors (PCCWW), Serve, Support, Simplify, main report, and subcommittee reports and survey findings, July 2007, at http://www.pccww.gov/. |
| 2. |
Veterans' Disability Benefits Commission (VDBC), Honoring the Call to Duty: Veterans' Disability Benefits in the 21st Century, October 2007, at http://www.vetscommission.org/. |
| 3. |
The PCCWW report does not contain recommendations regarding survivor benefits or presumptive disability. These matters are addressed in VDBC recommendations 8.2 through 8.3, and 5.8 through 5.27, respectively. |
| 4. |
White House, "Executive Order: Establishing a Commission on Care for America's Returning Wounded Warriors and a Task Force on Returning Global War on Terror Heroes," March 6, 2007, at http://www.whitehouse.gov/news/releases/2007/03/20070306-3.html. |
| 5. |
PCCWW main report, p. 28, table. |
| 6. |
VDBC full report, pp. 378-395, and executive summary, pp. 12-15. One commissioner's separate views on four of the commission's recommendations are published as Appendix L in the full report. |