[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]

EXAMINING VA'S PROCESSING OF GULF WAR ILLNESS CLAIMS

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JOINT HEARING

before the

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

joint with

SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

of the

COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES

ONE HUNDRED FIFTEENTH CONGRESS

FIRST SESSION

__________

THURSDAY, JULY 13, 2017

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Serial No. 115-23

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Printed for the use of the Committee on Veterans' Affairs

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Available via the World Wide Web: http://www.fdsys.gov

_________

U.S. GOVERNMENT PUBLISHING OFFICE

30-369 WASHINGTON : 2018

COMMITTEE ON VETERANS' AFFAIRS

DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BRAD R. WENSTRUP, Ohio JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida KILILI SABLAN, Northern Mariana
JODEY ARRINGTON, Texas Islands
JOHN RUTHERFORD, Florida ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

JACK BERGMAN, Michigan, Chairman

MIKE BOST, Illinois ANN MCLANE KUSTER, New Hampshire,
BRUCE POLIQUIN, Maine Ranking Member
NEAL DUNN, Florida KATHLEEN RICE, New York
JODEY ARRINGTON, Texas SCOTT PETERS, California
JENNIFER GONZALEZ-COLON, Puerto KILILI SABLAN, Northern Mariana
Rico Islands

SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

MIKE BOST, Illinois, Chairman

MIKE COFFMAN, Colorado ELIZABETH ESTY, Connecticut,
AMATA RADEWAGEN, America Samoa Ranking Member
JACK BERGMAN, Michigan JULIA BROWNLEY, California
JIM BANKS, Indiana KILILI SABLAN, Northern Mariana
Islands

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.

C O N T E N T S

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Thursday, July 13, 2017

Page

Examining VA's Processing Of Gulf War Illness Claims............. 1

OPENING STATEMENTS

Honorable Mike Bost, Chairman.................................... 1
Honorable Ann Kuster, Ranking Member............................. 2

WITNESSES

Mr. Bradley Flohr, Senior Advisor, Compensation Service, Veterans
Benefits Administration, U.S. Department of Veterans Affairs... 4
Prepared Statement........................................... 29

Accompanied by:

Patrick Joyce, MD, MPH, Chief, Occupational Health Clinics,
Washington VA Medical Center, Veterans Health
Administration, U.S. Department of Veterans Affairs

Ms. Melissa Emrey-Arras, Director, Education, Workforce and
Income Security, U.S. Government Accountability Office......... 5
Prepared Statement........................................... 30

Mr. Zachary Hearn, Deputy Director for Claims, Veteran Affairs
and Rehabilitation Division, The American Legion............... 7
Prepared Statement........................................... 35

Mr. Michael S. Figlioli, Deputy Director, National Veterans
Service, Veterans of Foreign Wars.............................. 8
Prepared Statement........................................... 38

Mr. Anthony Hardie, National Board Chair & Director, Veterans for
Common Sense................................................... 10
Prepared Statement........................................... 40

FOR THE RECORD

Ronald E. Brown, President, National Gulf Warsource Center
(NGWRC) & Gulf War Veteran..................................... 55
Mr. Paul Sullivan, Gulf War Veteran, Director of Veteran
Outreach, Bergmann & Moore, LLC................................ 66
Mr. Kirt Love, former member of the Veteran Affairs Advisory
Committee on Gulf War Veterans................................. 71
Denise Nichols, MAJ, RET, USAF, RN RET, BSN, MSN, National
Vietnam and Gulf War Veterans Coalition........................ 73

QUESTIONS FOR THE RECORD

HVAC to VA....................................................... 78

EXAMINING VA'S PROCESSING OF GULF WAR ILLNESS CLAIMS

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Thursday, July 13, 2017

U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight
and Investigations,
Washington, D.C.
The Subcommittees met, pursuant to notice, at 10:30 a.m.,
in Room 334, Cannon House Office Building, Hon. Mike Bost
[Chairman of the Subcommittee on Disability Assistance and
Memorial Affairs] presiding.
Present from the Subcommittee on Disability Assistance and
Memorial Affairs: Representatives Bost, Bergman, Coffman,
Radewagen, Banks, Esty, Brownley, and Sablan.
Present from the Subcommittee on Oversight and
Investigations: Representatives Bergman, Bost, Dunn, Kuster,
and Sablan.
Also Present: Representative Roe.

OPENING STATEMENT OF HONORABLE MIKE BOST, CHAIRMAN

Mr. Bost. Good morning, and welcome everyone. This joint
hearing of the Subcommittees on Disability Assistance and
Memorial Affairs and Oversight and Investigations will now come
to order.
I first want to thank my colleagues, Chairman Bergman,
Ranking Member Esty, who should be along shortly, and Ranking
Member Kuster for holding the hearing here with me today on the
important issue that we are facing. And that is helping Gulf
War veterans get the benefits that they have earned.
It should go without saying that we have a duty to take
care of the men and women who have been wounded while serving
in our military. Unfortunately, too many injured Gulf War
veterans are not being taken care of. VA estimates that 44
percent of Gulf War veterans develop Gulf War Illness. Yet, 26
percent of these veterans are receiving benefits. Something
does not add up.
On March 15, 2016 during a similar joint hearing on GWI
claims, VA testified that it was taking steps to improve
service for Gulf War veterans. Yet one year later GAO found VA
is still only approving 17 percent of the claims of Gulf War
Illness, which is about a third of the approved rate for other
claims. For example, a GAO report says that only 13 percent of
the claims of veterans that were diagnosed with the illness are
approved. I cannot understand that at all. VA regulations state
that if veterans have certain symptoms, such as headache,
fatigue, or joint pain, VA is supposed to presume that these
symptoms are related to the veteran's service in the Gulf area.
Yet 87 percent of these claims are denied.
GAO found that one of the problems is that the VA
physicians are applying the wrong standards during the exams.
Another issue is that the VA employees are not ordering the
exams when necessary. I appreciate that recently the VA
retrained all of its employees on GWI claims and I am looking
forward to hearing whether retraining these employees made a
difference.
I am also frustrated because GAO pointed out that the VA's
decision letters are not clear. This issue keeps coming up. As
you know, my Appeals Reform Bill, H.R. 2288, would require VA
to make its decision letters more clear and useful for the
veterans. But it should not take legislation to force the VA to
act. I would like to see the VA change its decision letters now
so that the veterans understand why VA made the decisions it
did.
So GAO also found several other problems that may be
keeping the approval rate for GWI claims low, such as the lack
of a single case definition for GWI. I am looking forward to an
honest discussion about the VA's need to do so and how to
ensure that they do. None of us want to come back here next
year to find the same problems. After this hearing I intend to
work with my colleagues to keep on VA to make sure these
changes are made and made this time where we will not have to
do it again.
I ask unanimous consent that written statements provided
for the record be placed into the hearing record. Without
objection, so ordered.
I also want to thank the witnesses for being here today.
With that, I want to call on the Oversight and Investigations
distinguished Ranking Member Ms. Kuster for her opening
statement.

OPENING STATEMENT OF ANN KUSTER, RANKING MEMBER

Ms. Kuster. Thank you, Chairman Bost. And to General
Bergman, and Ms. Esty when she arrives, and to the witnesses
for being here today.
It has been 26 years since the beginning of the Persian
Gulf War and since that time 44 percent of veterans who served
in that conflict have suffered from Gulf War Illness. Sadly,
these veterans struggle to receive accurate diagnoses for their
symptoms, access to needed health care, and compensation for
their service-connected conditions, even with the presumptions
that should result in more veterans receiving benefits and not
denied claims.
Last year our Subcommittee held a hearing, as the Chairman
said, on access to treatment for Gulf War Illness and how more
research is needed to develop treatments and get our veterans
the health care they need. Now we are back here again. And by
the way, this is entirely bipartisan across our Committee, to
determine why 83 percent of Gulf War Illness claims are denied
by the VA and what we can do to ensure that our Gulf War
veterans receive the benefits that they have earned. Gulf War
Illness is a chronic, painful, often debilitating disease and
veterans suffering from Gulf War Illness deserve disability
compensation and to have their condition recognized and treated
by VA providers.
Now just this past Monday, the State Veterans Advisory
Committee in my home state of New Hampshire, whom I meet with
on a quarterly basis, were criticizing the VA's process for
adjudicating Gulf War Illness claims. In fact one of the
members of our State Advisory Committee had his own claim for
Gulf War Illness denied. And for the veterans in my state and
across the country, the VA's process is poorly run and fails to
adequately train personnel.
This latest GAO report confirms what our constituents
suffering from Gulf War Illness continue to tell us on a
regular basis. Their claims continue to be denied because
medical examiners do not know how to diagnose Gulf War Illness
or the VA fails to apply the presumption that Congress intends
to grant this service-connection disability. When these claims
are denied, VA does not communicate to veterans, as the
Chairman said, the reasons for the denial, leading to veterans
becoming frustrated, losing faith in the VA, and filing
appeals.
The GAO report found that 90 percent of medical examiners
that the VA relies upon to assess veterans' disabilities have
not completed the elective training on Gulf War Illness so they
can better assess veterans' disability levels. I would like to
know why this training is not a mandatory requirement and when
it will become mandatory. I would also like to know if this web
based training is sufficient to train medical examiners and if
claims processors need better training requirements as well.
I also wish to hear from the VA on its plan to improve the
way in which it communicates decisions made on claims. When
veterans are not provided the reason that the claim was denied,
they become frustrated and angry and they end up in our appeals
process, which is already swamped. If they do not know why the
claims were denied, they can often spend years attempting to
obtain their benefits through a lengthy appeals process.
Finally we know that the VA continues to conduct and
support research on Gulf War Illness. However, the VA lacks a
single case definition, and as I understand it has no plan to
develop one. A uniform case definition for Gulf War Illness was
recommended in 2014 by the VA's Research Advisory Committee and
the National Academy of Medicine. A single case definition is
needed to improve research, diagnosis, and treatment of Gulf
War Illness and I would like to see a plan put in place to
develop a single Gulf War Illness definition. The number of
Gulf War Illness claims doubled from 2010 to 2015 and we can
expect that more veterans will file claims and will
subsequently appeal denied claims. It is imperative that the VA
implement the GAO's recommendations now so that Gulf War
veterans receive the treatment and disability benefits that
they deserve without having to fight the VA every step of the
way.
Thank you, Chairman Bost. I yield back.
Mr. Bost. Thank you, Ms. Kuster. And I am going to ask that
all Members waive their opening remarks, as per the Committee's
custom. I understand that Chairman Bergman and Ranking Member
Esty will give their statements at the end of the hearing.
Now I would like to welcome our witnesses again and thank
you for taking the time to be here today. Our first witness is
Bradley Flohr, Senior Advisor for Compensation Services. He is
accompanied this morning by Dr. Patrick Joyce, the Chief,
Occupational Health Clinics of the Washington VA Medical
Center. We are also joined by Melissa Emrey-Arras--is that
correct? Well, now see with a name like Bost, where people say
Bost, I want to make sure that we get everybody's right. Who is
Director of the Education, Workforce and Income of the GAO.
Zachary Hearn, the Deputy Director for Claims for the Veterans
Affairs and Rehabilitation Division of the American Legion; and
Michael Figlioli, correct? The Department Director of National
Veterans Services of the VFW; and finally Anthony Hardie, the
National Board Chair and Director of Veterans for Common Sense.
I want to remind the witnesses that your complete written
statement will be entered into the hearing record. And with
that, Mr. Flohr, you are recognized for five minutes.

STATEMENT OF BRADLEY FLOHR

Mr. Flohr. Thank you, Chairman Bost, Chairman Bergman,
Ranking Members Esty and Kuster, and Members of the Committee.
Thank you for the opportunity to discuss how VA processes Gulf
War veterans' compensation claims for undiagnosed illnesses or
medical unexplained chronic multi-symptom illnesses. For
purposes of my testimony, I will refer to these categories of
illness as Gulf War Illness. Today I will provide an overview
of VA's processing of Gulf War Illness claims and some of our
training and quality assurance efforts.
Service connection may be awarded for Gulf War Illness when
a veteran has service in the Southwest Asia Theater of
operations after August 2, 1990 and has a qualifying disability
in accordance with 38 C.F.R. 3.317. VA recently revised this
regulation to extend the date for which service-connection may
be awarded for Gulf War Illness from December 31, 2016 from
December 31, 2021.
In fiscal year 2016, 18,681 veterans received a decision
for a claim specifically for Gulf War Illness. From this
number, 4,594 veterans were awarded service-connection for one
or more undiagnosed illness or chronic multi-symptom illness.
Thirteen percent of these awards were for an undiagnosed
illness and 31 percent for a medical unexplained multi-symptom
illness.
VBA continues to strengthen its training program for Gulf
War Illness claims. We have developed 13 related courses for
claims processors and over the last year VBA headquarters
mandated ten hours of training for rating veteran's service
representatives. In addition, we are currently developing a new
training module which will focus on the proper development of
Southwest Asia Gulf War claims. This module is scheduled to
launch to fiscal year 2018.
VA has implemented a number of other initiatives to improve
Gulf War claims processing, to include improvement of the
notification process, specifically to include a more thorough
explanation when a claimed issue is denied. In recent years VA
has developed special tracking to specifically account for Gulf
War claims. VA has also amended its Gulf War general medical
examination template to include important information for
examiners when address undiagnosed and chronic multi-symptom
illnesses, as well as information on various environmental
exposures in the Gulf War.
VA is constantly looking for ways to improve benefits and
services it provides to veterans who served in the Gulf. VBA
works closely with the Veterans Health Administration in
reviewing the research done by its Offices of Public Health and
Research and Development, as well as the National Academy of
Medicine's biennial updates on Gulf War issues. VBA also works
with VHA and the Department of Defense in joint work groups
that research environmental exposures coincident with military
service. VBA collaborates with VHA to update training for its
medical examiners, as well as VBA's contract medical examiners.
And finally, VBA's national quality review staffs, as well as
local quality reviewers in our regional offices, continue to
ensure employees correctly process and decide claims for Gulf
War Illness.
As agreed upon with the National Gulf War Resource Center,
VBA conducted two distinct special focus reviews of decisions
on claims for Gulf War related illnesses in December, 2015 and
September, 2016. The review in 2015 focused on fiscal year 2015
Gulf War Illness cases and showed a 94 percent accuracy rate.
The 2016 review expanded the review to cases that involve
claims from medical unexplained chronic multi-symptom illnesses
over a four-year period, starting from fiscal year 2011. This
review showed an 89 percent accuracy rate.
VA continues to improve the efficient, timely, and accurate
processing of claims involving service in the Gulf War.
Although the science and medical aspects of undiagnosed
illnesses and chronic multi-symptom illnesses are complex, VA
continues to review scientific and medical literature to gain a
better understanding of the impact of these illnesses on our
Gulf War veterans.
This concludes my opening statement. I am pleased to
address any questions you or Members of the Committee may have.

[The prepared statement of Bradley Flohr appears in the
Appendix]

Mr. Bost. Thank you, Mr. Flohr. Ms. Emrey-Arras, you are
recognized for five minutes to give testimony for the GAO.

STATEMENT OF MELISSA EMREY-ARRAS

Ms. Emrey-Arras. Thank you, Chairman Bost, Chairman
Bergman, Ranking Member Kuster, and Members of the
Subcommittees. I am pleased to be here today to discuss our
recent report on VA's evaluation of Gulf War Illness disability
claims.
The exact causes of Gulf War Illness are not always known
and veterans' symptoms vary widely. Veterans with Gulf War
Illness may experience symptoms such as fatigue, headaches,
joint pain, indigestion, insomnia, respiratory disorders, skin
problems, and memory impairment. They may also have infectious
diseases, like malaria or West Nile Virus. VA refers to claims
for Gulf War Illness as undiagnosed illness, medically
unexplained chronic multi-symptom illness, and infectious
disease claims. We refer to these three types of claims as Gulf
War Illness claims.
My testimony today will focus on our findings related to
three key areas. One, recent trends in Gulf War Illness
disability claims. Two, challenges VA faces. And three, VA's
Gulf War Illness research.
In terms of claims trends, we found that the number of Gulf
War Illness claims processed has increased in recent years. In
fiscal year 2015, VBA completed processing about 11,400 claims,
which was more than double the 4,800 claims it processed in
fiscal year 2010. Many of these claims included multiple
medical issues or symptoms related to Gulf War Illness. On
average, we found that Gulf War Illness claims took four months
longer to process than other claims. We also found that Gulf
War Illness claims were approved at lower rates than other
types of disability claims. We found that approval rates for
Gulf War Illness medical issues were about three times lower
than for all other claimed disabilities. Specifically we found
that 17 percent of Gulf War Illness medical issues were
approved compared to 57 percent for all other types of medical
issues.
According to VA, several factors may contribute to the
lower approval rates, including that these claims are not
always understood by VA staff. Additionally, veterans sometimes
file for Gulf War Illness benefits but according to some VA
staff we spoke with do not provide sufficient evidence that
their symptoms have existed for at least six months as
generally required by VA regulations.
In terms of challenges VA faces, we found that there is
inadequate training for VHA medical examiners. VBA claims
rating staff often rely on these medical examiners to assess a
veteran's disability before they make a decision on a claim.
Medical examiners we interviewed said that conducting Gulf War
medical exams is challenging because of the range of symptoms
that could qualify as Gulf War Illness. The VHA has offered an
optional 90-minute web based Gulf War Illness training for its
medical examiners since 2015, but according to VHA, training
data only showed ten percent of the examiners had taken this
training as of this past February. We recommended that VA
require its medical examiners to complete training on Gulf War
Illness and VA agreed with this recommendation.
We also found that decision letters VA sends to veterans
denying benefits for Gulf War Illness claims do not always
clearly explain to the veteran how their claim was decided,
which can leave a veteran uncertain about how the claim was
evaluated and potentially lead to unnecessary appeals. We
recommended that VA require decision letters to clearly explain
how the claim was evaluated and VA agreed with our
recommendation.
In terms of Gulf War Illness research, we found that VA
does not have a plan to develop a single case definition of
Gulf War Illness. VA advisory groups have emphasized that
establishing a single definition could further improve the
research, diagnosis, and treatment of veterans. VA's advisory
groups recommended that in the near term VA analyze data from
its existing datasets and in the long term conduct research
projects to contribute to the establishment of the single case
definition. VA included in its 2015 Gulf War Research Strategic
Plan an objective to establish a single definition, but the
agency has no action plan in place to achieve it. Without a
plan VA risks engaging in research that is not targeted towards
its goal. We recommended that VA prepare a plan to develop a
single definition and VA agreed with this recommendation.
Thank you. This concludes my remarks.

[The prepared statement of Melissa Emrey-Arras appears in
the Appendix]

Mr. Bost. Thank you. Mr. Hearn, you are recognized to begin
the testimony for the American Legion, please.

STATEMENT OF ZACHARY HEARN

Mr. Hearn. Thank you. It is like deja vu, all over again.
Ranking Member Kuster, you made this assertion in your opening
remarks during the March, 2016 hearing regarding Gulf War
Illness. 486 days, one damning GAO report, and thousands of
injured veterans and impacted dependents later, we are here
again to discuss the adjudication of Gulf War Illness claims by
VA. And yes, Ranking Member Kuster, it definitely feels like
deja vu all over again.
Chairman Chairmen Bergman and Bost, Ranking Member Kuster,
and distinguished Members of the Subcommittees on Oversight and
Investigations and Disability Assistance and Memorial Affairs.
On behalf of National Commander Charles E. Schmidt and the over
two million members of the Nation's largest veteran's service
organization, the American Legion appreciates the opportunity
to testify regarding the adjudication of Gulf War Illness
claims.
Gulf War Illness claims are inherently complicated.
Veterans must tread murky waters to gain service-connection for
many Gulf War related undiagnosed illnesses. An undiagnosed
illness is just as it sounds, a cluster of symptoms that are
unexplained and undefined. Veterans seeking treatment for these
symptoms are often treated for years and often have multiple
diagnoses before VA will acknowledge that the symptoms are
related to an undiagnosed illness. It is terribly frustrating
for veterans and as seen by a recent GAO report, overwhelmingly
denied by VA when service-connection is sought.
VA has previously acknowledged its frustrations with Gulf
War Illness. With that in mind, one would think that there
would be mandatory training to improve its workforce's
understanding of the conditions. However, the GAO report
indicated only about ten percent of VA's medical examiners
successfully completed an optional course related to Gulf War
Illness. This is pathetic. Only one of ten medical examiners
have taken the optional course, but yet the other nine of ten
are equally qualified to conduct Gulf War related examinations?
Let us also not forget that many examinations are now being
conducted by private sector contractors. If VA is not providing
mandatory training regarding Gulf War Illness to its own
employees, what requirements are being made of those examiners?
The American Legion has over 3,000 accredited
representatives located throughout the Nation. These dedicated
individuals are the lifeblood for staff in Washington. They are
the souls that provide the necessary feedback regarding issues
our veterans face regularly. One service officer reported that
a VA regional office employee stated that veteran's service
organizations receive more frequent and higher quality training
than RO employees. Training received as a web based training
that often results in various interpretations, ultimately
resulting in inconsistent decisions.
Each service officer spoken to prior to this hearing stated
that they have had to accept that claims sought for undiagnosed
illnesses will have to go to the Board of Veterans Appeals if
they expect the claim to be granted, costing the veteran not
months, but numerous years to possibly result in a positive
decision. Veterans will provide lay statements detailing
symptoms and impacts of symptoms from family members and
friends. These statements will have little, if any, impact on
RO decisions. However, the service officers report BVA
decisions are much more favorable for veterans and take into
account those lay statements.
The GAO report combined with American Legion findings paint
a bleak picture of the development in adjudication of Gulf War
related claims. Medical providers have optional training, of
which only ten percent participate, and VBA personnel complain
of a lack of adequate training on the subject. Three
generations of veterans have potentially been impacted by Gulf
War Illness and these concerns have been swirling for over a
quarter of a century. Think about this. A 20-year-old deployed
troop right now in Iraq was not even born when these symptoms
arose and may one day suffer, and we have yet to discover, A,
the cause and proper treatment for it, and B, how to properly
adjudicate the claims that are associated with it.
It is evident that there is need for improvement and the
American Legion is willing to work towards achieving these
goals. In the last year VSOs worked with VA in designing an
appeals modernization plan that we collectively achieved. We
have proven for substantial change to occur it takes VSO and VA
collaboration. The American Legion is eager to work with VA and
VSOs to accomplish this feat. This is a problem that will not
be resolved strictly by finger pointing. It is a problem that
will be resolved by agreeing on identified problems and
arriving at sensible solutions.
Again, on behalf of National Commander Charles E. Schmidt
and the members of the American Legion, we truly appreciate the
opportunity to speak with you this morning. I will be happy to
answer any questions. Thank you.

[The prepared statement of Zachary Hearn appears in the
Appendix]

Mr. Bost. Thank you, Mr. Hearn. Mr. Figlioli, you are
recognized to present the position for the VFW.

STATEMENT OF MICHAEL S. FIGLIOLI

Mr. Figlioli. Thank you, Chairmen Bost and Bergman, Ranking
Members Esty and Kuster, Members of the Subcommittees. On
behalf of the VFW, I would like to thank you for the
opportunity to testify on VA's disability claims process with
respect to Gulf War Illness.
As professionally trained accredited advocates, VFW service
officers have work extraordinarily hard to ensure our veterans
and their families receive the maximum benefit allowable by law
from VA. All too often, however, this does not happen for a
myriad of reasons. For today's hearing I will focus on the
signature condition of the Persian Gulf War referred to largely
across the veterans community as Gulf War Illness, or more
commonly in VA as medically unexplained chronic multi-symptom
illness.
Unlike nearly all other claimed conditions, Gulf War
Illness is intrinsically difficult to diagnose and treat. Gulf
War Illness has no clear and concise set of rules. In other
words, no one distinctive set of symptoms that allow for a
single, unmistakable diagnosis. Gulf War Illness presents
itself as a conglomeration of possible symptoms to which
countless members of the general public with no military
experience can also be subject. As such, Persian Gulf veterans
have a steeper hill to climb in relating the symptoms to
service, the most critical link in establishing service-
connection.
None of this is remotely possible without the benefit of a
VA exam. As VA continues to evolve on a number of fronts, such
as electronic business management, VA developed disability
benefits questionnaires, or DBQ, with an eye towards efficiency
and timeliness. Last year the VFW strongly advocated for the
elimination of the parsing out of symptoms and placing greater
concentration on the clustering of these indicators of
potentially one illness affecting multiple body symptoms as
opposed to specific conditions related to each symptom. Put
more simply, the VFW feels Gulf War Illness claimants would be
better served by VA eliminating the assignment of multiple DBQs
and posit from the outset that the evidence meets the criteria
for Gulf War Illness. It remains our contentions that the
current system of assigning separate DBQs for each symptom
claimed in association with Gulf War Illness promotes
incorrectly assigning a diagnosis to a condition linked to Gulf
War Illness, which ultimately results in the veteran's claim
being denied.
More than a year ago these Committees met to discuss this
topic and pressed VA to develop a single DBQ for GWI that would
assist in establishing service-connection. Regrettably, VA has
not reported any progress in developing this DBQ and veterans
continue to have their claims denied. VA continues to rely on a
Gulf War Illness general medical DBQ that is not singular in
nature for claims for Gulf War Illness but instead rely on a
subjective non-medically trained construal of a claims
assistant to interpret a veteran's claimed conditions and
schedule the appropriate VA exam. When asked about the
possibility of a more favorable DBQ the response of record was
that VA would look into the issue, and first we had to confirm
that the lack of a single DBQ is a real problem. Mr. Chairman,
let us stop mincing words. We know this is a problem and GAO
agrees.
This continued problem also has the downstream effect of
the appellate process. VFW advocates at the Board of Veterans
Appeals continue to find numerous inconsistencies when
decisions are remanded to the VA regional office. In assessing
pending appeals for Gulf War Illness, the VFW notes that VA
appears to clearly favor finding a diagnosis for each reported
symptom and thereby rule out Gulf War Illness rather than
further developing and accurately applying the rating schedule
with a diagnosis that is even a minimally supported one. The
VFW urges VA to consider both possibilities as existential.
Since the preponderance of evidence shows the possibility that
Gulf War Illness may exist, the balance of evidence as to Gulf
War Illness' non-existence is equal or in equipoise. Therefore,
VA's own regulations show that VA should develop the claim for
the potential grant of Gulf War Illness disability.
The VFW suggested in prior testimony that inconsistencies
in the application of the rating schedule is universal across
the VA regional office spectrum with regard to claims for Gulf
War Illness disabilities. While we are not in any way
suggesting that this is deliberate, we continue to put forward
that a grant for Gulf War Illness in Michigan should be exactly
the same in New Hampshire, or any other VA regional office,
based on the same evidence and fact pattern. VA's Office of
Performance Analysis and Integrity has demonstrated their
capability to track data nearly to the keystroke. This presents
the perfect opportunity to identify and develop best practices
across VA in properly adjudicating claims for Gulf War Illness
and eliminate the disparities. At the very least with VA's
national work queue, VA could easily distribute these
specialized claims to the regional offices that have a proven
track record in proper adjudication of Gulf War Illness claims.
As one of the large Nation's VSOs responsible for providing
direct assistance to veterans seeking their earned benefits,
the VA thanks the Subcommittee for conducting oversight
regarding Gulf War Illness claims. We ask that you join us in
urging VA to adopt a single DBQ for all Gulf War Illness
claims.
Mr. Chairman, this concludes my testimony. I will be happy
to answer any questions you or the Subcommittee Members may
have.

[The prepared statement of Michael S. Figlioli appears in
the Appendix]

Mr. Bost. Thank you, Mr. Figlioli. Mr. Hardie, you are
recognized for five minutes.

STATEMENT OF ANTHONY HARDIE

Mr. Hardie. Good morning, and thank you, Chairmen Bergman
and Bost, Ranking Members Kuster and Esty, and distinguished
Members and staff for this hearing and the opportunity to speak
with you today. Thank you, Gulf War veterans, we know you are
watching live from all over the country and what happens here
today matters to you most of all.
I am Anthony Hardie, National Chairman and Director of
Veterans for Common Sense, and a U.S. Army veteran of the Gulf
War and Somalia. We appreciate last year's Gulf War hearings
and today's follow-on hearing to try and fix these many
unresolved issues. Included in our written statement are many
identified issues and recommendations and pages of heartfelt,
painful stories from Gulf War veterans from all over the
country, written in their own words, just a few of the tens of
thousands whose denied VA claims left them hurting, bewildered,
distraught, and angry.
A Maryland veteran describes what it is like to actually
live with the chronic fatigue of Gulf War Illness, saying, ``I
slept fourteen and a half hours, woke up for three, slept for
another eight and a half. This is right off my Fitbit. Yet I
have been denied each time. How am I supposed to work when I
literally cannot get out of bed? This is not how I saw my life
at 47 years old.''
They write about losing their health, their jobs, their
finances, and even their homes. All write about VA improperly
denying their presumptive Gulf War claims, exactly what GAO
writes about in their report. One from Louisiana even writes
about having to instruct a VA supervisor who had it wrong, and
calling the White House seeking resolution. A Kentucky veteran
wrote, ``I filed for a constellation of neurologic symptoms and
was denied for each symptom of my undiagnosed illness.'' Others
say the same thing or their symptoms being attributed to
diagnosed conditions and then denied. That is the crux of the
problem.
It is now 23 years since Congress enacted the well-
intentioned 1994 law that created a presumption for undiagnosed
illness symptoms. A written statement details later fine-tuning
by Congress and VA. Today we have heard about GAO confirming
VCS' earlier findings, that VA denies Gulf War Illness at a
rate of greater than 80 percent. We see in their report that is
three times the denial claim of any other claim, that the
denial rates for undiagnosed illnesses are the worst of all,
and that these trends are worsening over time and are now
actually 87 percent overall, and get this, 90 percent for
undiagnosed illness.
We see from their report that these claims also take 50
percent longer than other claims, meaning veterans who are the
worst off suffer the longest, and that VA underreported Gulf
War Illness claims by 57,000 issues, masking the true scope of
this already egregious problem. The fact that VA developed
evidence that led to these denials leaves the door open for
potential litigation.
Given GAO's findings that VA has not heeded external or
even internal recommendations, a finding that mirrors our
exasperated experiences, we are glad VA leaders seem to be
stepping up to the plate to fix GAO's three basic
recommendations. However, in reviewing VA's disability benefits
questionnaires using claims processing, many if not most for
diagnosed health conditions begin with this first basic
question, does the veteran have this diagnosis? But that basic
question obviously does not work for undiagnosed illness
claims. And when GAO reports that some claims examiners will
never find in favor of an undiagnosed illness, and will always
attribute a veteran's symptoms to a diagnosable illness, that
is most damning, showing that it is inevitable these claims
will continue to be denied at near total rates no matter how
much training is conducted.
Collectively this decades-long body of evidence makes it
clear. Undiagnosed illness as a judicable VA claim simply does
not and cannot work. It is now beyond clear what we need to do.
A statutory fix along the lines of what we propose in our
written testimony is needed or we are going to keep having
these investigations and hearings that all say essentially the
same thing, decade after decade. We ask that Congress work in a
bipartisan manner with President Trump to enact legislation to
once and for all fix Gulf War Illness claims and the many other
Gulf War issues we raise in this and previous testimony. And if
VA is serious about resolving these issues, and the ones that
the veteran raises in the last paragraph I am about to read,
then VA leaders should leap at the chance to work with
stakeholders and Congress to craft this legislation together if
for no other reason than the human impact of VA's denial of
nearly all Gulf War Illness claims is all too real.
Listen carefully to these words written by a fellow
Wisconsin veteran. ``I was told there is a two-year wait before
my appeal will even be opened, and that it's now up to four
years. Over the last ten years I have lost two jobs and have
lost my home and land due to bankruptcy. We have had to move
twice and change schools, which is really tough for my kids. I
feel like I am on the verge of losing another job and I am
afraid I cannot rebuild things again. My VA psychologist told
me Wednesday that it was an awful long time to hold onto life
by my fingernails and I agreed. I have put a belt around my
neck twice and told my doctor Wednesday that I would blow my
brains out if I am denied again. Twenty-two per day do not kill
themselves because of PTSD. It is for being continually denied
and called a liar by the administration that is supposed to be
helping us. Veterans, and particularly those of war like me,
look at life very differently than most. If I have no hope, I
will not continue to be a burden on myself, my family, or my
country. I will, however, do my best to let them know I was
destroyed by the VA.''

[The prepared statement of Anthony Hardie appears in the
Appendix]

Mr. Bost. As soon as I turn my microphone on I will start.
I do want to thank you all for being here and for your
testimony. But I do want to start with a question. Mr. Hearn,
do you think the VBA's adjudication manual provides useful
guidance for VBA employees related to the Gulf War Illness?
Mr. Hearn. When preparing for the testimony I was reviewing
the manual and I think it is fairly clunky in the way that it
is written. And I question as to whether to not aspects of
Joyner or more recent cases is applied properly in there and
alerts the staff.
I understand why the raters, and more importantly the VSRs,
are having difficulty understanding what to do. And I think
when you look at the VSO, the VSO does not use the manual when
advocating for a case. And you know else does not? The Board of
Veterans Appeals. So it is funny that the one aspect that seems
to be different is this manual and a VBA rater. So that
certainly is a concern with the way that VA goes about dealing
with these types of cases.
Mr. Bost. Mr. Flohr, how do you respond to his statement
about where we are at with this right now?
Mr. Flohr. Thank you, sir. First of all, I would like to
say that a week before last I had my 42nd anniversary working
at the Department of Veterans Affairs, all of them here in
Washington, D.C. All kinds of jobs, from a basic adjudicator to
where I am now. And we used to have a very, you know, the
manual, or adjudication procedures manual was all in paper, it
took forever to make changes to get them to our adjudicators
out in the field and our field stations. Now it is a live
manual. We call it a live manual because it is live. It is
online. We make changes easily, whenever we find a change that
needs to be made, we can do it. We have a large staff that can
do that. It is very much superior to what we used to have.
Is it perfect? Now. Nothing is going to be really always
perfect, because there are always changes. There is either a
court decision, or new legislation that is going to require us
to make changes to what we currently have. But we do a lot of
training. We have a very large training staff that works very
hard to train our adjudicators and our rating specialists in
making the right decisions.
These claims are difficult. For example, an undiagnosed
illness. Any of you who are physicians know that when a veteran
presents, or anyone presents, to you with a constellation of
symptoms, the first thing you do is try to diagnose it. Because
if you cannot diagnose it, you cannot treat it. If you treat
it, you possibly could do some hard if you treat it with the
wrong type of medication. So that is one reason why it is so
difficult, undiagnosed illness claims. We request an
examination. The examiners do all indicated tests to try and
determine what the veteran has. And if they cannot, we ask them
to report to use the veteran has an undiagnosed illness of the
respiratory system, the cardiovascular system, whatever body
system it may be. And when that gets relayed to us, we grant
the claim.
As I said, unfortunately a diagnosis often is made. And
then when a diagnosis is made, then the direct service-
connection criteria of statute comes into play. We must find
evidence that the veteran had that particular disability while
they were in service, they currently have it now, and then
determine how disabling it is.
Mr. Bost. Mr. Flohr, I do not want to interrupt but I do
have another question I have to get to while my time is
limited. You know, the VA issued a training letter on February,
2010 that details VA should develop a claim for Gulf War
Illness. For example, the letter instructs VA employees on when
to request a disability exam for Gulf War Illness. However, GAO
found that employees have different interpretations of VBA's
policy despite VBA's steps to clarify that with guidance. I
think we can all agree that adequate exams, if one was
requested, are critical to correctly process these claims. The
Fast letter that was issued seven years ago, even despite the
lack of additional clear guidance in the manual, so why is it
that VA employees still have such difficulty knowing when to
request an exam for these claims?
Mr. Flohr. That is a good question. As I said, our live
manual is pretty clear, at least in my view. But one of the
other, it was not a recommendation made by GAO, but it was an
expression that we should do perhaps a consistency study on
when to schedule an examination.
Mr. Bost. Maybe Ms. Emrey-Arras--I love just messing that
up. I am so sorry.
Ms. Emrey-Arras. Melissa is fine.
Mr. Bost. Okay. Melissa, what do you think the reason is?
Ms. Emrey-Arras. VA told us that they were in fact planning
to do a consistency study to evaluate just this issue, about
consistency in referrals for medical exams. And they told us
that they would be doing it the third quarter of this fiscal
year. So I think that is an excellent question to ask of VA, in
terms of what is the status of that consistency study.
Mr. Flohr. I am glad to tell you that it was completed in
April, which was in the third quarter. We gave it to a lot of
our VSRs, our veteran service representatives, when there was a
wrong answer. And as with most consistency studies, you find
some answers that are not quite right, and particular in Gulf
War claims which are very complex. But after the exam was
given, then the people who took the exam were taken to a room
and provided post-examination training to ensure that they knew
the right answer, what it is going forward, they would not make
the same mistakes again. So that was completed.
Mr. Bost. Can we get the results of those studies for the
record, please?
Mr. Flohr. Yes. I will be glad to provide those.
Mr. Bost. Okay. Thank you. My time is actually expired, and
I hate to do that to Ms. Esty when she first walks through the
door. But Ms. Kuster did have to leave to another meeting.
Ranking Member Esty is here, if she is ready for--I was going
to hope to do that for you.
Ms. Esty. Thank you all very much. I appreciate you being
here. Sorry, this is the fourth or fifth--I started at six a.m.
this morning. So it is just one of those days. It is going to
be long. NDAA days are long with many different commitments.
I really want to thank all of you very much for your
efforts and for really partnering with us. This Committee
prides itself on bipartisanship and on getting things done for
veterans, and making sure the VA works well, and that we are
serving people the way we need to. And as technology changes,
and as the needs of our veterans change, and who that
population is, that is going to change over time. And we will
not always get it right but we are always going to try. And we
count on you doing the same thing, too, and giving us a little
nudge sometimes when we do not, and figuring out how we can all
do this better.
An issue I want to really look at it, because I hear about
it all the time in my district, and we have talked about it
before in hearings here, is on decision letters. And on the
lack of clarity in decision letters. I am a lawyer. I read
those decision letters, I cannot tell what they mean. How can
our veterans know what they mean? It is disrespectful and it
leads to appeals and leads to frustration and a feeling of
disrespect. So if people could talk a little bit about what
actually can we do? This is an incredibly high priority for me,
not just because I am the Subcommittee Ranking Member and I
want us to deal with those claims. Because it is just wrong to
be sending out letters that do not have clarity. So what can we
do to get greater clarity in average people speak? This should
not, you should not have to have a Ph.D. to figure out what
these letters mean. And I do think it is disrespectful, which
is number one a problem. Number two, it leads to appeals. And
it leads people to disengage. So we have to find a better way
forward. So I would love to hear your thoughts on this, as we
are moving forward to make changes here. Thank you.
Ms. Emrey-Arras. This is Melissa Emrey-Arras, GAO. I would
say that we found that the letters did not specifically inform
veterans that their claims had been considered in terms of
presumptive eligibility. And the language made it seem like
only direct service-connection had been considered. So if you
were a veteran expecting a presumptive claim, and you saw the
letter, you would think that that was not evaluated
appropriately.
Mr. Flohr. And VA accepted that recommendation and we have
plans to change our letters by the end of August to provide
that information. But I think perhaps we need to look at it in
more detail to see where we can make it even more clearer and
we will do that as well.
Mr. Figlioli. Ms. Esty, Mike Figlioli from the VFW. This is
a great concern to our organization, as it is to the American
Legion and the other VSOs. The number one thing about these
letters, as you said, they are convoluted. They are not written
in English. They are not written in plain language that the
average citizen can understand. And it is not just related to
Gulf War Illness. This is for every disability. This is for
every communication with the VA. Every letter has to meet
certain requirements. But they can outline in that letter, to
prove your claim you need to provide, A, B, C, and D, not the
standard cut and paste blurb that there is evidence of record
but we had to deny the claim because there is no diagnosis that
this was occurred or was caused by service. That tells the
veteran nothing. We have been after the VA for a number of
years to make them simpler, make them straightforward, and
allow the veteran to understand the shortcoming and then
correct the deficiency so that we can go ahead and approve the
claim. Thank you.
Mr. Hearn. Good morning, Ranking Member.
One of the issues that we have noticed over time and
especially in the appeals inventory is that the VA kind of shot
themselves in the foot with these letters, right? Because a lot
of veterans are appealing cases or appealing their claims, but
they don't know what they are appealing, they don't know why
they are appealing. They just know that they feel like they
kind of got messed over by VA.
And so, like Mike was saying, they will sit there and they
will say to gain service-connection, you must have the
following. Well, why don't they identify it? Okay, you have a
diagnosis, you have an incident of service, but yet we don't
have a doctor's note linking the two conditions. And I think
that is what is creating a lot of confusion. Like you said, you
know, you shouldn't have to have a PhD or some sort of advanced
degree just to be able to figure this out.
And, unfortunately, this has been a problem that we have
been calling for years and years and years, and really in the
appeals modernization, that was a caveat for this whole thing.
And so we are very much looking forward to it.
Ms. Esty. Can I respectfully suggest that when VA has a
draft letter ready they circulate it to this Committee and they
circulate it to the VSOs?
And I fully agree, I think it ought to be broken out with a
checklist with numbered, so you can actually visibly see this
criteria must be met, the following was/was not met. These
would be documentation.
So it is really clear and it is really easy to do a
checklist that is the military way. Don't bury it in the middle
of a paragraph in lawyerese. Break it out so that you can
easily understand what that means.
So I would urge the VA to circulate that to us. I know I
work with some behavioral economists, I want them to take a
look at it, and I would like to have some actual veterans look
at it and say, does this make sense to you? If you read this,
what would you understand that you need to do? And I think that
would help us all get to the objective we share.
Thanks very much and I see I am over time.
My apologies, Chairman Bergman. Thank you.
Mr. Bergman. No apology is necessary. You know, quality,
you should never put a time limit on good quality.
Mr. Coffman, you are recognized for five minutes.
Mr. Coffman. Thank you, Mr. Chairman.
And I just want to say first, as a Gulf War veteran, how
disappointed certainly I was in the aftermath of the war and to
this day that the Department of Defense I think participated in
a cover-up, and that cover-up was the exposure to chemical
weapons.
And that I can remember the Marine Corps limit of advance
in the first Gulf War was kind of the northern end of Kuwait on
the Iraqi border and I can remember in the aftermath of the
fighting, and you have tremendous visibility in the open
desert, seeing this white cloud close to the ground, not
moving, and reported that in. And I didn't think there was a
question at that time--well, we knew, I knew later on, years
later on what it was, and it was that combat engineers of the
United States Army were blowing chemical weapons in place
because they didn't want to go through the hassle of all the
decontamination stuff.
And so we were fortunate, the Marines I was with were
fortunate that we were not downwind from it, that the wind
patterns were moving in the other direction. So none of the
Marines I served with came down with Gulf War Illness.
But the Department of Defense denied for I believe about a
five-year period in the aftermath of the war that the U.S.
troops were ever exposed to chemical weapons and it wasn't
until, you know, they were forced to admit it later on that
they in fact were, that they did blow chemical weapons in
place.
And so we got off to a very bad start in terms of research,
that that was not one of the aspects that were researched,
because the Department of Defense was so vehement in denying
that that was in fact true. And so it certainly left a bad
taste in my mouth as a Gulf War veteran in terms of the
integrity of the United States Government relative to veterans.
And so, but I think my question at this point is, in the
training of these disability folks that do the processing,
review the claims, there doesn't seem to be any uniformity in
the training. And as I understand it, there is a course that is
optional for them to take and I think it is online. And I guess
let me ask the VA, why isn't there mandatory training for the
folks that review these claims?
Mr. Flohr. Thank you. Are you referring to the training for
medical examiners who provide medical opinions or the people
that make the decisions?
Mr. Coffman. Well, I think that is a good question. How is
it for both?
Mr. Flohr. Well, for us, for VBA, every time we hire a new
group of individuals, we have a very large training staff and
they get sent away to either Baltimore or Denver, we have
training academies there. They go through a lot of training, at
least six weeks--
Mr. Coffman. Relative to the Gulf War?
Mr. Flohr. To all particular claims, all types of claims.
Mr. Coffman. Okay.
Mr. Flohr. So they get an initial group of training, then
every year they are required to complete training as well and
updates.
Mr. Coffman. Okay. GAO, maybe you can respond.
Ms. Emrey-Arras. The medical examiners are not required to
take training specific to Gulf War Illness issues. It is
elective and, because of their high caseloads and the fact that
they don't have a lot of time for elective training, only about
ten percent of the medical examiners have taken training on
Gulf War Illness.
Mr. Coffman. American Legion?
Mr. Hearn. Thank you, Congressman. The training--and that
is something that we have a lot of concerns about and I
addressed it during my remarks was that on the medical side, I
mean, you have to remember these are doctors and doctors are a
lot like mechanics, right? You don't take your car in to the
mechanic and say fix my brakes, and the guy comes out and says,
I don't know what it is. That goes against their DNA, they
naturally are going to create a diagnosis. I think that is just
how they operate.
So if the doctor comes back and says, I don't know, that is
a pretty rare circumstance. But then what the big concern is,
is that you have VA as a department has said this is a priority
of ours, but then only ten percent have taken it? It kind of
makes you wonder if there is just lip service being paid.
And then the second aspect of it is that we have started
going to these contracted examinations. If they can't get it
right with their own employees, what is going to happen when
QTC or one of these other providers in the private sector are
having these examinations, are they getting the proper
training? And so which Gulf War veterans are going to be
impacted by these private sector physicians?
Mr. Coffman. Thank you, Mr. Chairman. My time is up. I
yield back.
Mr. Bergman. Thank you, Mr. Coffman.
Ms. Brownley, you are recognized for five minutes.
Ms. Brownley. Thank you, Mr. Chairman.
And thank you all for being here this morning. This is a
very important topic.
So the GAO presented VBA with a set of recommendations on
this issue and you have said and agreed to all of those
recommendations. Can you in a general way, can you give me an
idea of when you might complete all of these recommendations
and have them operating in a way that is more effective?
Mr. Flohr. Yes. Thank you for that question.
We did accept and concur with the three recommendations. We
appreciate GAO's looking at this, they are always instrumental
in helping us do a better job of what we do and we appreciate
that.
The recommendation to ensure that VHA medical examiners
take this 90-minute training has been accepted by VHA, it is
going to be made mandatory, and as--
Ms. Brownley. Do you think 90 minutes is enough?
Mr. Flohr. I will let Dr. Joyce answer that.
Dr. Joyce. I would like to address that. The 90-minute
training course described by others as being optional is a mere
fraction of the training required to do a Gulf War examination
or any other kind of CMP examiner. These physicians, nurse
practitioners, or physician's assistants are first licensed,
privileged, and experienced before they do Gulf War
examinations.
This additional course of 90 minutes will be mandatory and
will be completed by November, but it is supplemental to their
underlying training as health care professionals which allow
them to address this very complex subject, a subject that is
not easy to define and has challenged even the learned
colleagues at the National Academy of Medicine.
Mr. Flohr. As far as number two, I think I already said we
concur with that as well and we will have our decision
notification letters completed, changes made to them by the end
of next month.
And number three is the single case definition. We do have
a plan to do that.
Ms. Brownley. What is the plan?
Mr. Flohr. The plan is to get a lot of smart people
together and try and figure it out.
Ms. Brownley. What is the timeline?
Mr. Flohr. The timeline is March of 2018 right now. But,
you know, we asked the National Academy of Sciences to do this
several years ago, they couldn't do it. It was that difficult,
so they threw it back to us, and we are going to try and do
that. We are going to get people from DoD, people from the
Veterans Health Administration, from VBA, from the National
Academies, if we can, whoever we can get who is smart about
this. People from our War-Related Injury and Illness study
centers here in D.C. and New Jersey, Palo Alto, they see a lot
of Gulf War veterans.
So we really will appreciate their input in trying to come
up with a single case definition, but we do have a plan and we
have already started.
Ms. Brownley. Well, certainly my expectation is that the VA
would be the experts when it comes to Gulf War Illness and the
VA should not have to look to other entities for that, the
research. I mean, this is what it is all about is, you know,
why the VA in its mission, is because they are serving our
veterans with all kinds of illnesses, but there are specialty
illnesses that are just not out in the world other than within
the VA.
And I think, you know, back to the medical training, yeah,
I agree that the doctors that come to the VA are well-trained
doctors, I don't dispute that for a second, but a 90-minute,
Web-based course to me seems like it is really not deep enough,
you know, to really understand, you know, sort of what veterans
are going through and understanding it. But certainly it is a
step in the right direction to require that everybody take the
course, so I certainly agree with that.
Dr. Joyce. I am in complete agreement with you: it is not
sufficient to take that 90-minute course and to call yourself a
Gulf War examiner. It is a mere supplemental course to make us
better able to answer the technical questions from the Veterans
Benefits Administration and I would be doing a disservice to my
colleagues to suggest you could be certified that quickly.
Ms. Brownley. So with regard to the manual has been spoken
of and you talked about it being live, you can make changes as
we go. The American Legion described it as clunky, you
described it as clear. Do you really think the manual is
fundamentally, absolutely clear?
Mr. Flohr. It is large, it is very large and it is full of
a lot of information. And I have not processed claims myself
for many, many years, so I don't necessarily always use the
live manual if I want to look up something. Like I looked up
what was in there on Gulf War Illness before I came here and
there is a lot of information there that needs to be digested,
and it may at times lead people to be somewhat confused. I am
not sure about that, again, but there is a lot there and when
we need to change something, we can do it immediately, and that
is what is the best part about it. Plus, everyone else can see
it as well.
Ms. Brownley. Well, I think that is good, the transparency
piece is good.
Mr. Flohr. Yes.
Ms. Brownley. But, you know, clarity is also important. And
I think that all goes back to the definition and other kinds of
things, you know, that we are talking about.
And I know my time is up, but I would just like to hear
from VBA, not now but if you can get back to me. You know, the
opening of this hearing started about a deja vu, that we have
had this conversation, we had it a year ago, and I would really
like to know the work that has been done since last year up
until this point. Now we are talking about a year later, we are
talking about meeting some recommendations yet into the future.
But, you know, I would like to have that conversation offline.
And I apologize, I yield back.
Mr. Bergman. Thank you, Ms. Brownley.
Dr. Dunn, you are recognized for five minutes, sir.
Mr. Dunn. Thank you very much, General.
I would like to channel a comment made by Mr. Hearn a
little earlier where doctors don't like to say they don't know
and you are absolutely right, we don't like that, but we can be
trained to say that. And my next comment is directed to Dr.
Joyce and Mr. Flohr.
So I want to stipulate something just among us here. Can we
agree we do not understand Gulf War Illness Syndrome is a
disease? None of us do and there are no experts anywhere that
have some comprehensive understanding of the pathology of this
disease. Do you agree with that?
Dr. Joyce. I do, Dr. Dunn.
Mr. Dunn. You do. Okay, good.
So, now we all agree that the claims are rising, the
denials are rising as well. Clearly, some of our Gulf War
veterans are not having their conditions properly recognized
and treated, we can agree on that?
Dr. Joyce. Yes.
Mr. Dunn. Yes? We can agree clearly that some of the
veterans are not being recognized and treated for Gulf War
Illness Syndrome?
Dr. Joyce. Some, but not all.
Mr. Dunn. Some, some? Not all of them, some?
Dr. Joyce. Dr. Dunn, using the word ``some'' as we medical
doctors do, I will agree with you.
Mr. Dunn. Thank you, thank you. In medical terminology.
That's good, because I haven't been up here long enough to use
anything other than that kind of terminology.
So given that and we know that the DoD has spent between
'94 and 2016 over $172 million on research in hopes of simply
clarifying the presumptive list of conditions, sort of that
basket of pathologies that fit into Gulf War Illness Syndrome,
and we have made no new changes or additions in seven years,
since 2010, you know, my question is this, that can we, can
you, can we together promptly finalize some diagnostic criteria
for Gulf War Illness Syndrome and then address the prompt
rollout of administrative, financial, and medical action to
help these deserving soldiers?
Emphasis on prompt.
Mr. Flohr. You are talking about prompt training for
medical providers, examiners?
Mr. Dunn. So you do have to. But just going back to Mr.
Hearn's remark, you know, doctors don't like to say they don't
know, but if you go to a doctor and say nobody knows, not just
you in this clinic, nobody knows Gulf War Illness Syndrome, but
here's this basket of symptoms that fit this criteria, use this
Chinese menu of pathologies, and if your soldiers fit these
criteria and they were in the Gulf War, then they presumptively
have Gulf War Illness Syndrome and they get their financial
disability, whatever, and medical treatment such as we know at
the time going forward. And we know there will be advances. I
spent my evening reading the proteomic and genomic and microRNA
studies on Gulf War Illness Syndrome, fascinating stuff, but
not clinically relevant just yet, but it is okay. I think you
can go to your doctors, I have worked at a VA hospital, and say
nobody knows, not just you. Can you make this diagnosis and
help this soldier?
Mr. Flohr. Well, you know, the Gulf War Illness is
described in statute and regulations. If a veteran has a
chronic, multi-symptom--medically unexplained, chronic, multi-
symptom illness, which is defined in the statute as, such as--
Mr. Dunn. Pretty clearly, the system isn't working yet for
them.
Mr. Flohr [continued]. --fibromyalgia--
Mr. Dunn. I mean, so defining it in statute, maybe getting
the lawyers involved was the wrong group, maybe we need to get
the doctors involved in it, you know.
Mr. Flohr. That would be good, but if a veteran has one of
those fibromyalgia, chronic fatigue syndrome, or functional GI
disorders, if a veteran of the Gulf War--
Mr. Dunn. Things we sort of understand.
Mr. Flohr [continued]. --has one of those, that is
presumptive and we should be granting those immediately. And if
we are not, please let me know, if you can--
Mr. Dunn. All right. So my charge I guess would be, you
know, and I heard you suggest you might do this by March of '18
to Ms. Brownley's question, is to roll this out really, really
promptly. No more fooling around with it, we have been fooling
around with it for a long, long time. We need to take some
clear action to help these poor soldiers.
And in my final 45 seconds I would like to ask, I guess
you, Mr. Flohr, what would you have us say to our constituents
who perceive that they have a medical condition, Gulf War
Illness Syndrome, arising from their service in the Gulf War,
and yet that is not being recognized by the VA? And that
happens to us on a weekly basis.
Mr. Flohr. Well, I would say--
Mr. Dunn. All of us, not just my office.
Mr. Flohr. Sure, I understand. I would say to them that if
they have a disability they think resulted from their Gulf War
service and if it has been diagnosed a chronic, multi-symptom
illness, they certainly need to provide that medical evidence
when they file their claim from their private provider or
whoever it might be. If they only have symptoms, if they don't
have a diagnosed illness, then we are going to do what we need
to do, which is request an examination.
And then under the law, if after all indicated tests are
done the examiner cannot arrive at a diagnosis, we want--
Mr. Dunn. But this should be cookbook, I mean, really, it
should be cookbook, right?
Mr. Flohr. Yes, it should.
Mr. Dunn. Okay. Well, let's get the cookbook out there
and--
Mr. Flohr. But it is not easy. That's the thing, it is not
easy.
Mr. Dunn. That is why we went to med school. All right.
Mr. Chairman, I yield back. Thank you.
Mr. Bergman. Thanks, Dr. Dunn.
Mr. Sablan, you are recognized for five minutes, sir.
Mr. Sablan. Thank you very much, Mr. Chairman.
Good morning, everyone. Thank you for joining us today.
I am new to this Committee and I asked to join because I
have seen a spike of veterans coming to the congressional
office asking for help. They go see a doctor or a medical
professional and they are told, no, nothing is wrong with them.
And here we are discovering that nobody really knows the entire
story or whatever it makes of some of the illnesses from the
Gulf War. And I am talking about Gulf War veterans primarily.
I had a week two months ago dedicated to just talking to
veterans in a group setting, in a one-to-one basis, and all of
these veterans have filed claims and they are still suffering.
Some of them suffer in quiet, they quietly suffer because they
are told nothing is wrong with them.
Now, Dr. Joyce mentioned that a VA physician who usually
examines a Gulf War syndrome or illness specializes in this
issue. So let me ask you--and that the GAO reports that only
ten percent do these Web service training--so let me ask you,
contracted medical examiners, I mean private doctors who are
contracted to do this, because I don't have a VA clinic in my
district, what makes you determine that that doctor knows what
they are doing, a general internist, internal medicine doctor?
Dr. Joyce. So as a general rule Gulf War exams are an
exemption to the regular contract exams done to these non-
specialist and CMP exams.
Mr. Sablan. Okay, but if they go see a doctor and the
doctor said nothing is wrong with them, they can't get a
referral to go to Hawaii. Some of these people have no money to
go to Hawaii, you know. It costs $2,000 to go to Hawaii. Plus
you have to get a car, you have to rent a hotel, get lodging
and everything, and you need an appointment. And the doctor is
saying nothing is wrong with you. So someone has to make that
appointment in Hawaii for them, they have to go to a doctor.
Dr. Joyce. I think I am going to have to say that we are
going to have to get back to you, because I am not personally
familiar with the referral system in your area.
Mr. Sablan. Well, I am sure that there are other private
doctors in the Nation.
And again, Mr. Flohr, thank you, sir, for your 42 years of
service, but let me ask you. GAO recommends that there should
be a requirement that medical examiners complete training
courses before conducting these exams for Gulf illness or such
a medical conduct--complete training, including such as the 90-
minute Gulf War Illness Web-based course, and only ten percent
do it. What do you do to the 90 percent who won't do it? Do you
give them a bonus? I heard you guys give out lots of bonuses.
Dr. Joyce. I can address that. When the course is now
mandatory, we will be required, myself included, to demonstrate
on a computerized record list that goes all the way to the
central office that we have completed the course and passed the
test showing we took the course; no one will be exempt.
Mr. Sablan. Thank you, Doctor. I am not pointing fingers,
Doctor, I am making just statements because I come from a
place, I represent a district where there is no VA clinic and
to go to Guam, to go to Hawaii requires a lot of money, and
these people don't have money. So they have absolutely no help
and so they suffer in silence. And they come to me, and
especially when they are told nothing is wrong with them, they
come to me and say, what can I do? What can you do for me? And,
you know, I can't file appeal papers for them, I don't have
their documents.
And does it take the GAO to tell you these things? You have
42 years of service, sir. Do you really need the GAO to tell
you some of these things that you have failed to do, that we
have discussed a year ago?
Mr. Flohr. That the medical--that is Dr. Joyce's claim but,
you know, we work with VHA to make sure that we get all that we
need to make proper decisions.
Mr. Sablan. Yeah, I'm sorry, I don't mean to be, you know,
very--if I appear critical, I don't mean to be. I am just
expressing. And I took the stories of veterans word-for-word, I
added nothing, I took out nothing, and I presented them to
Secretary Kelly--I mean Shulkin, I'm sorry, I am mistaken.
But I really need help in my district and I don't know what
else to do. I joined this Committee trying to find help, not to
be critical of anybody, and I appreciate that you guys are
doing this. I thank GAO also.
I am over my time, but I will tell you that some of the
best information I have learned over this series of hearings
have come from these people, the VSOs. Unfortunately, I only
have the VFW in my district, many of them are Vietnam veterans.
But I have put together a list of all VSOs in the Nation and it
is going on my Web site, and I am telling these veterans join
or go to these VSOs for help. I can't do your things for you,
but they could be helpful.
Mr. Chairman, I apologize for being out of time, General.
Thank you, sir.
Mr. Bergman. No apology is necessary.
My parents raised me to be kind. As a Boy Scout, I was
courteous. So I am going to try very hard to maintain my
parents' and my scout master's values here in my questioning.
You can tell by the questions from our Members, there is a
sense of urgency in this panel, a true sense of urgency; I am
not sure I feel that throughout the room.
So, Mr. Flohr, Dr. Joyce, I am going to look at you first.
Do you feel a personal sense of urgency in this?
Mr. Flohr. Yes. And not just for Gulf War veterans--
Mr. Bergman. Good.
Mr. Flohr [continued]. --but all veterans.
Mr. Bergman. Good enough. Yes, okay.
So now, since you do, can you give me any examples at the
VA over the last, pick your time, two years, ten years that
actually would show a sense of urgency from the top on down to
get some results?
Let me try it in a different way. Can you give me an
innovative program, innovative, that was based on a sense of
urgency to shrink the timeframe to develop the capabilities for
the individual practitioners necessary to begin to get a handle
on this problem? Can you give me one example of innovation
other than a 90-minute, optional, online training program?
Mr. Flohr. I can give you an example of an innovation that
is currently underway. It is called--
Mr. Bergman. Underway?
Mr. Flohr. Yes.
Mr. Bergman. How about in execution phase? Is underway
meaning we are working it up or does underway mean actually
being--
Mr. Flohr. It means that we are working with the Department
of Defense, the Veterans Health Administration, to achieve an
electronic availability of determining someone had an exposure
while they were on Active duty.
Mr. Bergman. That's it?
Mr. Flohr. Yes, sir.
Dr. Joyce. I would also add that in the testimony of Mr.
Flohr so far the increase in number of claims for Gulf War
Illness is a demonstrable manifestation that more have been
accepted--
Mr. Bergman. Great segue, thank you very much, because in
the military we--and you have heard this term, in fact General
Petraeus coined the term when he looked at changing how we were
looking at Operational Iraqi Freedom and he talked about
creating the surge, if you will, can you give me an example of
surge operations that have been instituted within the VA? Not
just asking for more money and more people, but taking already
existing assets that you have and that you pay every day of the
week, and redistribute those assets in a surge manner to begin
to grab a handle on this?
Mr. Flohr. I don't know if it meets what you are looking
for, but we--
Mr. Bergman. I am looking for a surge--
Mr. Flohr [continued]. --over the past several years--
Mr. Bergman [continued]. --of existing assets that you are
refocus--
Mr. Flohr. Yes, sir.
Mr. Bergman. --based upon a perceived need. Again, in war
fighting, it is real simple: if the enemy is over here, bring
your stuff over here to go after them.
Mr. Flohr. What we have done over the last several years
now is develop training academies for newly hired employees
where they get the training they need to make proper decisions
in a group setting, they get tested. It is working out very
well for us.
Mr. Bergman. Is there a sense of urgency?
Mr. Flohr. It is urgent that we get them trained, so they
can--
Mr. Bergman. Is there a sense of urgency?
Mr. Flohr [continued]. --process claims, yes.
Mr. Bergman. You feel a sense. Sensing is a feeling.
Someone can write the word ``urgent,'' but unless you sense
urgency, that is where I am going with this.
And from the top down, if the leaders and the people in
charge do not have a sense of urgency that is not going to
filter down into the organization. It doesn't come from the
bottom up, it comes from that leadership at the top.
Mr. Flohr. I believe that Secretary Shulkin definitely has
a sense of urgency and he is relaying that down to all of us.
Mr. Bergman. It is too bad it took this long to get the
Secretary, if you will. Now, I agree with you, Secretary
Shulkin does have a sense of urgency. I am trying to reinforce
our support for his efforts to develop that sense of urgency
throughout the VA.
Here's a question for you and I don't care who answers
this. What is the single biggest challenge for us moving
forward here? I am going to give you two of my choices: apathy
or bureaucratic red tape?
Mr. Hardie. Mr. Chairman, Anthony from Veterans for Common
Sense. I would like to suggest that, again, the biggest
challenge is that undiagnosed illness, since 1994, it doesn't
work and all the training in the world isn't going to fix it,
all the solutions, we can rewrite manuals all day long. It
simply doesn't work because these conditions are diagnosed.
I had a veteran this morning who contacted me and said, ``I
was diagnosed with sleep apnea, it is one of those nine
conditions that are listed under sleep disorders, why can't I
get this done?'' And I explained to him, well, it was diagnosed
and therefore doesn't qualify under undiagnosed illness. And he
said, ``well, that makes no sense.'' And I said, ``That's the
point.''
Mr. Bergman. So is it apathy or is it bureaucratic red tape
that is causing that? Anybody want to throw one out there? It's
okay, there are no right or wrong answers here. It is what you
perceive based upon your understanding and research into this
issue.
Mr. Figlioli. Mr. Chairman, Mike from VFW. I would say it
is bureaucratic red tape, in my opinion, VFW's opinion, too
many steps. The manual, as was said, is clunky, confusing.
Training is not conducted in a way that they can recognize
either it is or it is not Gulf War Illness and roadblocks
abound.
If it was made simpler, if the DBQ was developed to the
point that said this is in fact Gulf War Illness, or if we
started from Gulf War Illness and worked backwards, it might be
less so.
This has actually not been going on since last year, this
has actually been going on since 1997, Mr. Chairman.
Mr. Bergman. Thank you very much.
Question for Mr. Flohr, probably, and Dr. Joyce. What would
be the cost, dollar cost to just presumptively assume that all,
all Gulf War veterans had a base level of Gulf War Illness,
what would be the cost?
Mr. Flohr. I would have no idea.
Mr. Bergman. Would you take that for the record?
Mr. Flohr. I could take it to our staff that works on those
costs.
Mr. Bergman. Good. And I don't care whether it is ten
percent, twenty percent, I don't care--
Mr. Flohr. Are you talking about any disability claim by a
Gulf War veteran?
Mr. Bergman. Get them into the system, presumptively assume
that because they were there, they were exposed.
Now, again, we are product of our own experiences. I am
Agent Orange, I am Vietnam. Okay?
Mr. Flohr. I can tell you that right now Gulf War veterans
are service-connected for more than 14 million disabilities.
Mr. Bergman. Give me a cost to presumptively assume, if it
is on your DD214 that you were there in that specific
timeframe. Because when we talk about, number one, what are we
providing, what is the cost of providing it, and how quickly
are we going to come to some resolution.
Wait time, wait time is not--you know, wait time, as a
friend of mine, one of my Vietnam squadron mates told me about
a month ago, he is still grieving for the recent loss of his
wife to cancer and he is writing a book on our experiences in
Vietnam, but his quote he is going to use for all to know, and
I think it relates to his grieving for the loss of his spouse,
is you think you have time, but you don't.
I would suggest to you that that sense of urgency and
thinking about how much time you have, but you really don't, we
need more. We need a lot more and we need it sooner, and you
can do it with quality, I know you can.
So I have gone over my time and, unless there are any other
follow-ups, we are going to proceed here with a closing
statement.
First of all, I would like to thank all of the witnesses
for participating in the hearing today. The panel is now
excused.
And as you heard Chairman Bost and Ranking Members Kuster
and Esty say, you know, that our efforts as these Subcommittees
on behalf of the veterans are an example of true bipartisan
effort that we are all philosophically aligned that it is our
job as the Committee to do the right thing for the veterans.
These Subcommittees that we represent here will continue to
set the example for our 115th Congress about doing the right
thing for those involved. So I am very proud to be a Member of
this Committee.
For years this Committee has been working to address the
root cause of the high denial rate for Gulf War Illness claims.
In that time, we have been met with a list of excuses from VA
for failing to improve the process for Gulf War claims.
Last year, we held a hearing to assess the disability
claims process for Gulf War veterans and highlighted, just as
we have discussed here today, that VA's approval rate for Gulf
War Illness claims is less than 20 percent. VA often seems to
deny these claims because it demands to know the specific cause
of an illness, yet under the law presumptive conditions do not
require causality, because they are presumed to have been
caused by service in the Gulf War.
The Government Accountability Office report that we have
discussed in detail here today further substantiated that the
approval rates for Gulf War Illness claims are three times
lower than all other claimed disabilities.
The critical point to understand is that veterans cannot
receive appropriate VA care for symptoms of Gulf War Illness
when the majority of those claims have been denied by the VA.
To make matters worse, the reason for claims denials are also
not clearly communicated to veterans, we heard that in your
testimony--it is not written in English, if you will--or their
representatives. Failure to communicate the reason for denials
often leaves veterans with confusing or insufficient
information for a potential appeal, which further delays access
to care and compensation for injuries.
GAO's review of the medical examination process for Gulf
War Illness also highlighted that VA's medical staff are not
adequately trained to conduct the exam. And we talked about the
90-minute optional course here.
VHA medical examiners informed GAO that it is challenging
to conduct Gulf War general medical exams due to the range of
symptoms associated with the claims. Although their concerns
are legitimate, there is limited evidence to support that VHA
has taken the initiative to improve the examination process.
Again, that sense of urgency.
GAO reported that, as of February 2017, only ten percent of
examiners participated in the optional online training for
those examiners. This statistic is troubling, very troubling,
because the VBA cannot consistently and accurately provide
benefits ratings without a proper exam from VHA.
Furthermore, GAO found that another contributing factor for
claims denial was the lack of a single case definition of Gulf
War Illness. Establishing such a definition could lead to
improvement in diagnosis and treatment of Gulf War Illness.
Over the years, Congress has appropriated millions of
dollars for VA research programs and there is still strong
resistance against establishing a single case definition for
undiagnosed illness related to Gulf War service.
I am also extremely concerned that VA does not have a plan
to guide, to review of the existing medical data sets and
integrated information from recent and ongoing research to
identify areas of future research and establish a single case
definition. Again, that sense of urgency when it comes to
innovating and really coming together to move forward.
I look forward to continuing to work with VA, Veterans
Service Organizations, and other stakeholders to increase Gulf
War Illness claims approval rates. Improve the medical
examination process, prioritize research related to Gulf War
Illness, and ensure the VBA is providing straightforward
information to veterans regarding their benefits decisions.
With that, I now yield to Ranking Member Esty for any
closing remarks that you might have.
Ms. Esty. Thank you, General, and thank you to all of you
on the panel.
And I particularly want to thank Mr. Hardie. I know this
has been a passion of yours, and you have been a forceful and
persistent and, sadly, necessary advocate to put a human face
on what I know from my friend Mike Siccea, who has inspired me
to introduce a burn pits bill to try to move this along
further.
So I in particular want to thank you for your advocacy and
I don't think we would be here today if it were not for your
efforts. And I am sorry for the reasons that it has brought you
here, but I am glad that you are here and I want to thank you.
As a newer Member of this Committee, I am struck by how
much we need to learn the hard-earned lessons of Agent Orange
and not do what was done then. And I think the level of
frustration you are seeing from this panel is a deja vu that
this is taking too long and not everybody has got time, nor
should they have to wait.
The most important of those lessons is that we have to be
determined, we have to work together. The unwieldy and long
research process, which again I would agree with my colleague
Representative Brownley, the expert on Gulf War Illness, with
all due respect, is not the National Academy of Sciences, it
should be the VA. Nobody else actually should know--or DoD or
working together--nobody else is actually going to know that
other than, right here, the people who supervise.
The difficulty medical examiners have understanding the
multi-symptom health conditions of Gulf War, and these are
getting in the way of identifying and quantifying toxic
exposures on the front end, and providing timely, fair
compensation, services, and most importantly top-quality health
care for our Gulf War veterans on the back end. We owe it to
them not to let this happen, as we continue to owe it to our
Vietnam veterans and the Blue Water veterans who are still
trying to find a way to get the care that they need and
deserve.
I think it is very clear, and I want to acknowledge and
thank the VA for taking steps in a positive direction for
veterans who have Gulf War Illness, but it seems to me these
steps are too small; they are too incremental, they lack the
urgency, and they lack the surge, the surge that we need.
It has been 26 years since the first Gulf War started. Many
of the veterans who were deployed are very sick and they have
been beaten down by a claims process that is confusing, it is
unclear, and in almost every case it seems to deny what they
know to be true in their lives. That has undermined their faith
in the system as a whole, and they have disconnected and they
are discouraged, and that is, quite simply, wrong.
So I want to say for my part, and I suspect I am not the
only one on this panel, that if VA doesn't use its authority on
its own initiative, Congress will begin to take steps. We will
set timeframes, we will mandate training for all examiners,
whether they are in the VA or whether they are contract. I
think that has to happen. We will mandate timelines within
which we have to have a single definition that everybody can
use.
And most importantly, we need to do better. The General and
I were talking about this point about cost, which often seems
to me to be really the reason behind the red tape. The point
should be to care for our veterans and if we are spend so darn
much time and expense and people dedicated to making people who
are sick prove just how sick they are and how they got so sick,
what about just taking care of the people who defended this
country. What if we took those same resources that are deployed
now on saying no and deployed them to saying yes to those who
were deployed in the Gulf?
And I think it is not just an academic exercise to answer
the question that the General and I were talking about and he
directly asked you, what would be the cost of truly,
presumptively saying anyone who served, if you got any of this,
we are going to get you better and back on your feet. That is
our commitment to you. And not spend our time trying to
determine what percentage, where were you exactly.
The point is people served and they need help now. And we
should be able to expect, and they should too, that they can
get back on their feet and be productive members of society. We
shouldn't ask them to prove how disabled they are, we should be
helping them to get as abled as they could be.
And I think that is a really serious thing we all need to
be thinking about, because I am new to this Committee, but I am
not new to hearing from the veterans in my district and the
frustration that they feel, and the time and effort that goes
into these fine hair distinctions, when instead I would rather
see that money going to care for our veterans and get them back
on their feet.
So I would ask you all to think seriously about that and
ask everyone on this panel if the time hasn't come to rethink,
particularly when we are now at a point with a voluntary force.
Our veterans are changing and we need to think about changing
with them.
Thank you for your service, thank you for working with us.
And we look forward to seeing those letters in August and I
hope they will be shared with the VSOs, so we can get this
better and get this right.
Thank you very much and, with that, Mr. Chairman, General,
I yield back.
Mr. Bergman. Thanks, Ranking Member Esty.
I ask unanimous consent that all Members have five
legislative days to revise and extend their remarks, and
include extraneous material.
Without objection, so ordered.
I would like to once again thank, sincere thanks to all of
our witnesses and audience members for joining in today's
conversation.
With that, this hearing is adjourned.

[Whereupon, at 11:05 a.m., the Subcommittee was adjourned.]

A P P E N D I X

----------

Prepared Statement of Brad Flohr
Opening Remarks

Chairman Bost, Chairman Bergman, Ranking Members Esty and Kuster,
and Members of the Subcommittees, thank you for the opportunity to
discuss how the Department of Veterans Affairs (VA) processes Gulf War
Veterans' disability compensation claims for undiagnosed illnesses or
medically unexplained chronic multi-symptom illnesses. With me today is
Dr. Patrick Joyce, Chief, Occupational Health Clinics, Washington VAMC,
VHA. My testimony will provide an overview of VA's processing of these
claims and our training and quality assurance efforts.

Gulf War Illnesses

Service connection for undiagnosed illnesses or medically
unexplained chronic multi-symptom illnesses requires service in the
Persian Gulf after August 2, 1990, and a qualifying chronic disability
that rises to a compensable level of severity before December 31, 2021.
To ensure Veterans who served in the Southwest Asia theater of
operations continue to be entitled to benefits under the law, VA
recently updated the regulation in 38 Code of Federal Regulations Sec.
3.317 to extend the date for which service connection may be awarded
for a qualifying Gulf War illness from December 31, 2016, to December
31, 2021.
A medically unexplained chronic multi-symptom illness means a
diagnosed illness without conclusive pathophysiology or etiology. The
objective signs and symptoms of these disabilities, as well as
undiagnosed illnesses, include fatigue, skin conditions, headaches,
muscle pain, joint pain, sleep disturbances, and cardiovascular
symptoms, among others. The term ``medically unexplained chronic multi-
symptom illness'' also covers diagnosed illness defined by a cluster of
signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and
functional gastrointestinal disorders (excluding structural
gastrointestinal diseases).
Processing these types of claims requires a careful review of
service treatment records, military personnel records, and post-service
treatment records. Claims processors must carefully review the claimed
disabilities and symptoms. Medical examinations are generally required
where VA identifies these disability patterns to determine whether
there is a medical explanation of the disabilities.

Gulf War Claims Processing

In fiscal year (FY) 2016, approximately 18,681 Veterans who served
in the Southwest Asia theater of operations received a rating decision
for a claim for service connection for undiagnosed illnesses or chronic
multi-symptom illnesses. From this number, 4,594 Veterans were awarded
service connection for one or more undiagnosed illness or chronic
medically unexplained multi-symptom illness. This equates to a grant
(or approval) rate of 25 percent. When considering each type of claim,
the approval rate for a medically unexplained chronic multi-symptom
illness is 31 percent compared to 13 percent for an undiagnosed
illness. It should be noted that when a Veteran claims an undiagnosed
illness, if upon examination or if the medical evidence shows that
symptoms can be attributed to a diagnosed condition, VA will service
connect the diagnosed condition whenever possible rather than
characterizing the claimed condition as undiagnosed. Therefore, the
number of grants for undiagnosed illnesses or chronic multi-symptom
illnesses do not reflect the actual number of Veterans service
connected for known disabilities resulting from their Gulf War service.

Training

VBA has developed a total of thirteen courses for claims processors
that are focused on processing of claims for undiagnosed illnesses or
chronic multi-symptom illnesses. Over the last year, VA Central Office
mandated, as part of the FY 2017 National Training Curriculum for
Rating Veterans Service Representatives, required training of four
interactive lessons (eight hours) and one classroom-based course (two
hours) for a total of 10 hours of training. For Veterans Service
Representatives, a two-hour required class was mandated as part of the
National Training Curriculum. In addition, a new lesson titled,
``Southwest Asia/Gulf War Claims Development'' is currently being
developed and is scheduled to launch in FY 2018.
VA has implemented a number of other initiatives to improve Gulf
War claims processing. VBA is making necessary changes to improve the
notification process, specifically to require that decision letters
indicate that claimed issues were evaluated under both presumptive and
direct service-connection methods. This change is scheduled to go into
effect by the end of August 2017. VA has developed special tracking to
specifically account for Gulf War claims. VA has also amended its Gulf
War General Medical Examination template to include information for
examiners on undiagnosed and chronic multi-symptom illnesses, as well
as information on environmental exposures in the Gulf War.

Quality

The Veterans Benefits Administration (VBA) is constantly looking
for ways to improve the service it provides to America's Veterans,
including this cohort of Veterans. VBA works with the Veterans Health
Administration (VHA) in reviewing the research done by its Offices of
Public Health and Research and Development, as well as the National
Academy of Medicine's (formerly the Institute of Medicine) biennial
update on Gulf War issues. VBA also works with VHA and the Department
of Defense in joint workgroups that research occupational and
environmental hazards coincident with military service. VBA
collaborates with VHA to update training for its medical examiners, as
well as VBA's contract medical examiners. Finally, VA continues to
collaborate with the National Gulf War Resource Center (NGWRC) in
bimonthly meetings.
VBA has a national quality review staff, as well as quality
reviewers in its local regional offices, to ensure employees correctly
process and decide claims for Gulf War illness. As agreed upon with
NGWRC, VA conducted two distinct special-focused reviews of decisions
on claims for Gulf War-related illnesses in December 2015 and September
2016. The review in December 2015 focused on FY 2015 Gulf War illness
cases and showed a 94-percent accuracy rate. The September 2016 review
expanded the review to cases that involved claims for medically
unexplained chronic multi-symptom illnesses over a 4-year period
starting from FY 2011. This review showed an 89-percent accuracy rate.

Closing Remarks

VA continues to improve the efficient, timely, and accurate
processing of disability compensation claims involving service in the
Gulf War. Although the science and medical aspects of undiagnosed
illnesses and multi-symptom illnesses are complex, VA continues to
review scientific evidence and medical literature to gain a better
understanding of the impact of these illnesses on our Gulf War
Veterans.
This concludes my testimony. I am pleased to address any questions
you or other Members of the Subcommittees may have.

Prepared Statement of Melissa Emrey-Arras
Additional Actions Needed to Improve VA's Claims Process
Chairmen Bergman and Bost, Ranking Members Kuster and Esty, and
Members of the Subcommittees:
I am pleased to be here today to discuss our recent report on the
process the Department of Veterans Affairs (VA) uses to evaluate Gulf
War Illness disability compensation claims. VA estimates that among the
nearly 700,000 veterans who served in the Persian Gulf War in 1990-
1991, about 44 percent experience chronic medical issues commonly
referred to as Gulf War Illness. There are no similar VA estimates of
the prevalence of Gulf War Illness among veterans who were deployed to
the region after 1991. According to the Department of Defense, however,
these veterans may have also been exposed to certain environmental
hazards and many have developed similar medical issues upon their
return. The exact causes of Gulf War Illness are not always known and
veterans' symptoms vary widely, but include fatigue, headaches, joint
pain, indigestion, insomnia, respiratory disorders, skin problems, and
memory impairment, among others. VA refers to claims for Gulf War
Illness as ``undiagnosed illness,'' ``medically unexplained chronic
multisymptom illness,'' and ``infectious disease'' claims. For the
purposes of this testimony, we collectively refer to these three types
of claims as Gulf War Illness claims (see fig. 1).

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Note: The symptoms of undiagnosed illness and the chronic
multisymptom illnesses are examples-not an exhaustive list-of medical
issues that VA associates with Gulf War Illness.

(a) The symptoms listed below may be manifestations of either
undiagnosed illness or medically unexplained chronic multisymptom
illness. For simplicity, these symptoms are listed only once, under the
category of undiagnosed illness.
(b) Irritable bowel syndrome is one common type of functional
gastrointestinal disorder.
The VA provides disability compensation benefits to veterans with
disabling conditions that were incurred or aggravated during active
military service. \1\ Gulf War Illness claims are different in that VA
can award benefits to certain veterans who served in a Gulf War
conflict since 1990 and display any of the symptoms listed above
without the veteran having to prove the symptoms are related to their
military service. VA does require proof, however, of a veteran's
service in the Gulf War region and existence of the claimed symptoms.
Veterans Benefits Administration (VBA) claims raters review each claim
to determine if relevant criteria are met, including verifying the
veteran's deployment location; establishing whether the veteran's
symptoms have lasted for a minimum of 6 months; and assessing the
severity of the veteran's condition. \2\ As such, the VBA may request a
medical examination from the Veterans Health Administration (VHA) to
obtain additional information about the veteran's disability.
---------------------------------------------------------------------------
\1\ See 38 U.S.C. Sec. Sec. 1110 and 1131. This does not include
disabilities incurred by a veteran's own willful misconduct or abuse of
alcohol or drugs.
\2\ The minimum 6 month time period does not apply to claims for
certain infectious diseases.
---------------------------------------------------------------------------
From fiscal years 1994 through 2016, VA has funded more than $170
million for Gulf War Illness-related medical research, including $12.3
million in fiscal year 2016. According to the VA and a 2016 National
Academy of Medicine report, while much progress has been made in Gulf
War Illness research, more work is needed to better understand what
Gulf War Illness is and how to treat it.
My remarks today are based on our recent report, entitled Gulf War
Illness: Improvements Needed for VA to Better Understand, Process, and
Communicate Decisions on Claims. \3\ Accordingly, this testimony
addresses (1) recent trends in Gulf War Illness disability claims, (2)
challenges VA faces with accurately processing and clearly
communicating decisions on Gulf War Illness claims, and (3) how VA uses
Gulf War Illness research to inform its disability compensation
program. In addition, I will highlight several key actions that we
recommended in our report that VA can take to help address challenges
with its Gulf War Illness disability claims process.
---------------------------------------------------------------------------
\3\ GAO, Gulf War Illness: Improvements Needed for VA to Better
Understand, Process, and Communicate Decisions on Claims, GAO 17 511
(Washington, D.C.: June 29, 2017).
---------------------------------------------------------------------------
For our report, we analyzed VBA data on disability compensation
claims completed during fiscal years 2010 through 2015 and reviewed a
non-generalizable sample of 44 Gulf War Illness claims that were
completed in fiscal year 2015. \4\ We also visited 4 of VBA's 58
regional offices (selected for high numbers of Gulf War Illness claims
completed in fiscal year 2015 and geographic dispersion) and nearby VHA
health care facilities where medical examinations take place. \5\
Throughout our work, we interviewed staff from VA headquarters and the
4 regional offices we visited, as well as representatives from several
veterans advocacy groups. We also reviewed relevant federal laws and
regulations related to disability compensation benefits for Gulf War
Illness. Additional information on our scope and methodology is
available in our full report. We conducted the work on which this
testimony is based in accordance with generally accepted government
auditing standards.
---------------------------------------------------------------------------
\4\ We determined these data were sufficiently reliable for the
purposes of our reporting objectives and have noted in our full report
any limitations that are associated with the data we present on trends
in Gulf War Illness claims.
\5\ We visited the Cleveland, Ohio; Seattle, Washington; St.
Petersburg, Florida; and Waco, Texas regional offices and nearby VHA
clinics.

In Recent Years, Completed Gulf War Illness Claims Have Risen, Included
More Medical Issues, and Been Approved at Lower Rates Than Other
---------------------------------------------------------------------------
Service-related Disabilities

According to our analysis of VBA data, the number of Gulf War
Illness claims has substantially increased in recent years and these
claims often include multiple medical issues, which generally require
more time to process. Specifically, in fiscal year 2015, VBA completed
about 11,400 Gulf War Illness claims, which was more than double the
4,800 claims for Gulf War Illness it completed in fiscal year 2010. \6\
Many of these claims included multiple medical issues-or, symptoms-
related to Gulf War Illness. \7\ On average, we found that Gulf War
Illness claims had about twice as many medical issues per claim as
other disability claims, and took 4 months longer to complete.
---------------------------------------------------------------------------
\6\ VBA completed processing over 42,000 Gulf War Illness claims
during the 6 year time period we reviewed.
\7\ A medical issue is an illness or condition that a veteran
alleges was caused or worsened by their military service and may
entitle the veteran to disability benefits. A veteran may file multiple
claims with VA, and each claim may include multiple medical issues.
---------------------------------------------------------------------------
We also found that Gulf War Illness claims were approved at lower
rates than other types of disability claims. During fiscal years 2010
through 2015, we found that approval rates for Gulf War Illness medical
issues were about three times lower than for all other claimed
disabilities-17 percent of Gulf War Illness medical issues were
approved over the 6-year time period we reviewed in comparison to 57
percent of all other types of medical issues. \8\ According to VA,
several factors may contribute to lower approval rates for Gulf War
Illness medical issues including that these claims are not always well
understood by VA staff. Additionally, according to some VA staff we
spoke with, veterans sometimes file for Gulf War Illness disability
benefits but do not provide sufficient evidence that their symptoms
have existed for at least 6 months, as generally required by VA
regulations.
---------------------------------------------------------------------------
\8\ VBA makes a separate determination on each medical issue
submitted by the veteran and, therefore, we analyzed approval rates for
Gulf War Illness claims at the medical issue level.

Accurate Processing of Gulf War Illness Claims Is Hampered by Confusion
about the Gulf War General Medical Exam, and Claim Decision Letters
---------------------------------------------------------------------------
Lack Key Information

VBA has clarified its guidance and implemented additional training
for its claims rating staff, but the agency's ability to accurately
process Gulf War Illness claims is hampered by inadequate training for
VHA medical examiners who conduct medical examinations. VBA claims
rating staff often rely on medical examiners to assess a veteran's
disability before they make a decision on a claim. Medical examiners we
interviewed said that conducting Gulf War general medical exams is
challenging because of the range of symptoms that could qualify as Gulf
War Illness. The VHA has offered an elective 90 minute web-based Gulf
War Illness training for its medical examiners since June 2015.
According to a VHA official, as of February 2017, VHA training data
show only 10 percent of examiners had taken this training. Federal
internal control standards call for adequate training for staff so that
they can correctly carry out an agency's procedures. Medical examiners
who do not take this Gulf War Illness-specific training may not be able
to provide information to VBA staff to correctly decide whether to
grant or deny a veteran's claim. To help ensure that medical examiners
are well prepared to conduct Gulf War Illness medical examinations, we
recommended that VA require its medical examiners to complete training,
such as the 90-minute web-based course developed by VHA, prior to
conducting Gulf War Illness medical examinations. VA agreed with this
recommendation and plans to require that all its medical examiners take
the 90-minute training course.
We also found that decision letters VA sends to veterans denying
benefits for Gulf War Illness claims do not always clearly explain to
the veteran how their Gulf War Illness claim was decided, which can
leave a veteran uncertain about how the claim was evaluated and
potentially lead to unnecessary appeals. VA regulations require that a
clear statement be provided to the veteran regarding the agency's
decision on each claim. \9\ Without VBA including clear language in its
decision letters, veterans may be unable to make a fully informed
decision on whether to appeal VBA's decision. To improve communication
with and provide more complete information to veterans whose Gulf War
Illness claims are denied, we recommended that VA require decision
letters for Gulf War Illness claims to clearly explain how the claim
was evaluated. VA agreed with our recommendation and is in the process
of updating its guidance to the regional offices to clarify the
language required for its Gulf War Illness decision letters.
---------------------------------------------------------------------------
\9\ 38 C.F.R. Sec. 3.103(b).

VA Considers Research When Identifying Additional Disabilities Related
to Gulf War Service, but Lacks a Plan to Guide Its Work on A Key
---------------------------------------------------------------------------
Research Goal

VA considers research findings when adding to the list of
conditions it presumes are associated with Gulf War service for
disability compensation purposes, but it does not have a plan to
develop a uniformly used case definition of Gulf War Illness. Based on
research evidence, in 2010, VA added nine infectious diseases to the
list of recognized Gulf War Illness-related conditions in its
regulations. \10\ Since then, VA has not identified any new conditions
that it associates with Gulf War service, but agency officials say that
they continue to explore whether additional conditions should be added.
---------------------------------------------------------------------------
\10\ Presumptions of Service Connection for Persian Gulf Service,
75 Fed. Reg. 59,968 (Sept. 29, 2010). In 1998, legislation was enacted
that required VA to seek to enter into an agreement with the National
Academy of Sciences to study Gulf War Illness related topics. See Pub.
L. No. 105-277, Sec. 1603, 112 Stat. 2681, 2681-745 (1998). VA relied
on findings from one of these studies when determining that it should
provide disability compensation to Gulf War veterans who have these
nine infectious diseases.
---------------------------------------------------------------------------
Despite the progress made by VA's Gulf War Illness research
program, VA advisory groups have noted the lack of a single case
definition that can be uniformly used to study Gulf War Illness, and
emphasized that establishing a single definition could further improve
the research, clinical diagnosis, and treatment of veterans with Gulf
War Illness. VA's advisory groups recommended that in the near-term,
the agency analyze data from its existing datasets to better understand
how they can be used to contribute to a single case definition. For
example, VA has access to dozens of existing large-population datasets
from federally-sponsored research studies and data contained in several
federal Gulf War registries that include veterans' health information.
According to VA, if these data were merged with its administrative
datasets (for example, those containing clinical and benefits data),
the information could be leveraged by VA researchers to improve
understanding of Gulf War Illness and, ultimately, contribute to the
development of a single case definition. Merging these datasets could
provide researchers with additional information needed to develop a
case definition, including information on veterans' service and onset
of their symptoms. In addition, VA's research advisory groups also
noted the need for VA to plan for future research that is likely to
contribute to a single case definition in the long-term.
VA included in its 2015 Gulf War Research Strategic Plan a
strategic objective to establish a single case definition, but
according to a VA official, the agency has no action plan in place to
achieve it. Federal internal control standards call for agencies to
have documented plans that include specific action steps associated
with their objectives. VHA officials told us that they are considering
how to use existing federal datasets and ongoing research to better
understand Gulf War Illness but have not laid out specific actions,
such as what data to use and how using these data would contribute to
the development of a single case definition. VA officials attributed
the lack of a specific plan to challenges with developing a single case
definition and noted that it must be a slow and deliberate process.
However, without a plan, VA risks engaging in research activities that
are not cohesively targeted toward its goal of establishing a single
case definition.
To increase the likelihood of making progress toward developing a
single case definition of Gulf War Illness, we recommended that VA
prepare and document a plan to develop such a definition, including
near- and long-term goals and specific actions needed to meet those
goals. In response, VA agreed with this recommendation and will convene
a group of subject matter experts to work on a plan.
Chairmen Bergman and Bost, Ranking Members Kuster and Esty, and
Members of the Subcommittees, this concludes my prepared statement. I
would be pleased to respond to any questions you or other Members of
the Subcommittees may have.

GAO Contact and Staff Acknowledgments

If you or your staff members have any questions concerning this
testimony, please contact me at (617) 788-0534 or emreyarrasm@gao.gov.
Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this statement. Individuals
making key contributions to this testimony include Nyree Ryder Tee
(Assistant Director), Nora Boretti (Analyst-in-Charge), David Barish,
Deborah K. Bland, Alexander G. Galuten, Marcia A. Mann, Martin E.
Scire, Walter K. Vance, and Kathleen L. van Gelder. Other staff who
made contributions to the full report cited in this testimony are
identified in the source product.

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Prepared Statement of Zachary Hearn
In March 2016, The American Legion testified before a joint hearing
of the Subcommittees on Oversight and Investigation, and Disability
Assistance and Memorial Affairs to discuss the adjudication of Gulf War
Illness claims for veterans that served in the Persian Gulf since
August 2, 1990.
These veterans are prideful based on their honorable service, but
many remain frustrated due to their chronic and unexplained illnesses.
They defeated an aggressor, liberated a nation, and defended American
interests, but for some the cost of this service to our nation has
resulted in many veterans suffering with debilitating symptoms since
returning from the Persian Gulf. The specific etiology of the
conditions are mysterious, and the granting of presumptive claims
related to Persian Gulf service remains a painfully long process that
could result in years of appeals before receiving the positive
adjudication they have earned.
Chairmen Bergman, Bost, Ranking Members Kuster, Esty, and
distinguished members of the Subcommittees on Oversight and
Investigations, and Disability Assistance and Memorial Affairs; on
behalf of National Commander Charles E. Schmidt and The American
Legion, the country's largest patriotic wartime service organization
for veterans, comprising over 2 million members and serving every man
and woman who has worn the uniform for this country; thank you for the
opportunity to testify regarding The American Legion's position on
"Examining VA's Processing of Gulf War Illness Claims".
Background
The Department of Veterans Affairs (VA) currently identifies
numerous medical conditions or symptoms that are presumptively related
to Gulf War service. Presumptively awarding service connection for
conditions due to environmental exposures is not a new concept for VA.
Conditions such as diabetes, ischemic heart disease, and a variety of
cancers are presumptively related to herbicide exposure in Vietnam.
Additionally, veterans of radiation testing have had multiple
conditions presumptively ascribed to radiation exposure in service.
For Persian Gulf veterans, they face a unique set of challenges in
their quest to gain benefits derived from their military service.
Unlike herbicide and radiation exposed veterans, many Persian Gulf
veterans must prove they suffer from symptoms, or clusters of symptoms,
and endure years of medical tests to indicate that they suffer from an
undiagnosed illness.
"Undiagnosed illness" is a frustrating explanation to a complicated
medical situation. Numerous medical studies have revealed that veterans
who returned from Persian Gulf service face serious health concerns
following their deployments. However, a generation removed from
Operations Desert Shield and Desert Storm, the medical community is
still uncertain of how to properly diagnose or treat these veterans
resulting in VA routinely denying disability compensation to veterans
seeking service connection for Gulf War related conditions.
Due to the ambiguity in the application of presumptive conditions
associated with Persian Gulf service and the uncertainty within the
medical community, veterans have become increasingly frustrated while
trying to get their claims properly adjudicated. A common problem The
American Legion finds is that veterans who seek a claim for benefits;
and because of the complexity of Gulf War Illness (GWI); find that the
diagnosis may have changed multiple times. VA raters are not medical
specialists and are often unaware and unable to detect that the rapidly
changing diagnosis is essentially the same condition. Moreover, the
situation is further complicated by the fact that if one medical
professional renders a diagnosis, by definition it is no longer an
undiagnosed illness; even if the veteran received a multitude of
differing diagnoses related to the same symptoms; and is therefore no
longer undiagnosed according to VA raters.
The American Legion has over 3,000 accredited representatives
located throughout the nation. Through their dedicated efforts, The
American Legion represented over 800,000 veterans in Fiscal Year 2016.
We are fortunate to have trained professional service officers in each
of VA's 56 regional offices (VAROs) and were able to refer to our
national network of service office in March 2016, while testifying
about Gulf War Illness claims. Some of the veterans' experienced the
following road blocks while seeking service connection ratings:

Medical professionals hesitate to connect conditions to
Persian Gulf service;
Some veterans have elected not to pursue benefits because
a perception exists that there is more desire to service connect
veterans with service in Vietnam;
Medical professionals will assign symptoms to aging; and
Medical professionals suggest the veteran is malingering,
stating they are too young for the symptoms.

According to American Legion's Department Service Officers (DSOs),
little if anything has changed regarding the development and
adjudication of claims in more than a year since the March 2016
hearing. Many DSOs report limited GWI research combined with
adjudicators' denial of claims have led to many appeals that result in
years of waiting and increased anguish for veterans and their families.
The American Legion's concerns were confirmed in the recently
released Government Accountability Office (GAO) report \1\. GAO concurs
with years of complaints from veterans and veterans service
organizations (VSOs) regarding the treatment, development, and
adjudication of Gulf War Illness claims. GAO's report provides insight
into VA's lack of providing training to medical staff and VARO
employees. VA's lack of training has resulted in various
interpretations of guidance provided by VA Central Office resulting in
vastly different outcomes for veterans. Furthermore, GAO concludes that
VA's lack of clarity in its decision letters pertaining to Gulf War
Illness claims leads to more questions than answers.
---------------------------------------------------------------------------
\1\ Gulf War Illness: Improvements Needed for VA to Better
Understand, Process, and Communicate Decisions on Claims, GAO, June
2017
---------------------------------------------------------------------------
Many DSOs and veterans have discovered they may fare better if
they ultimately appeal Gulf War related conditions to the Board of
Veterans' Appeals (BVA). One DSO stated that he encourages veterans to
submit lay statements from friends and family members detailing the
symptoms the veteran has experienced to bolster the claim. He also
states that a VA rater will likely ignore the lay statement that may
detail the chronic symptoms; however, BVA veterans' law judges will
take the lay statements into consideration when rendering a decision.
Each year The American Legion visits VAROs to review recently
adjudicated claims and meet with VA employees. It is not uncommon to
hear VA employees tell us that BVA has greater latitude than VA raters
in adjudicating claims. It was concerning when we heard these
statements from raters and decision review officers (DROs), and it was
alarming when we heard it from a veterans' service center manager, and
it was stunning when we heard last year from a senior official within
the Veterans Benefits Administration (VBA) that the BVA has greater
authority. When asked to clarify the statement and cite a regulation or
statute, the official simply stated, "They just do", when in fact -
they do NOT. The VA and the Board both adjudicate from the same
statute.
Based on this common misconception The American Legion contacted
VA's Office of General Counsel (OGC) for input. OGC agrees with The
American Legion that no greater authority is given to a BVA judge than
a VA rater or DRO adding, "It is not accurate to say that the Board has
greater authority than the (VARO) to grant benefits, or any authority
at all to circumvent the law and award benefits at will." In short, a
rater has the ability to grant the same claim as the BVA judge.
VBA has routinely stated that BVA's combined 75 percent grant and
remand rate for all appeals is due largely to the submission of
additional evidence or the passage of time. There is some truth to that
statement - however when considering that at least one senior official
at VA Central Office stated that the BVA has greater authority, and
numerous individuals at VAROs employed in management, as well as front
line employee concur with that belief - VBA must own its routine
inadequate development and premature denial of claims.
OGC's response to why the perception may exist that BVA has greater
latitude sheds light on one of the issues that hamper VBA - its own
manual. According to OGC, "One provision that may further misconception
is 38 C.F.R. Sec. 19.5 which provides that the Board is not bound by
Department manuals, circulars, or similar administrative issues." VBA's
manual was designed to provide "procedures for the adjudication of
claims for compensation, pension, dependency and indemnity
compensation, accrued benefits and burial allowance." \2\ Considering
the routinely different outcomes between VBA and BVA decisions, it
stands to reason that VBA needs to reconsider the manual and its use of
the document.
---------------------------------------------------------------------------
\2\ VBA M21-1 Adjudication Procedures
---------------------------------------------------------------------------
The use of lay statements in VBA decisions by VBA raters has become
far less common. One reason for this is VA's implementation of its
"Evaluation Builder" within the Veterans Benefits Management System.
The Evaluation Builder tool was designed to provide uniform outcomes in
decisions regardless of adjudicator. Discussions with line employees
and VARO management at numerous offices have concluded that lay
statements cannot be taken into account within the tool. This is
further complicated by the fact that if a rater overrides the suggested
decision, the quality review team (QRT) is notified and a review of the
decision is initiated by QRT. Many employees report they will
adjudicate in accordance with the Evaluation Builder tool's suggestion
in order to avoid a QRT review. This lack of use of lay statements
omits significant evidence, severely disadvantages veterans who submit
this evidence, and causes significant harm to veterans who are denied
benefits because raters refuse to consider all legal evidence. As an
example, statements that support a continuity of symptoms could be
evidence toward receiving a grant of benefits, or photographs would
support the existence of an undocumented temporary duty assignment that
wasn't properly documented in the veteran's official military record.
It is absolutely critical that all levels of the VBA adjudication
process fully support the use of lay statements, and The American
Legion calls on VA to immediately cease the practice of largely
ignoring this type of important legal evidence.
The American Legion finds that training continues to be an issue at
VBA. One of our DSOs tells us that according to a VARO employee "VBA
employees receive less (GWI) training than (VSOs)." The employee
further states that any training received has been through VA's Talent
Management System (TMS) web-based training, and that TMS training is
not typically treated with the same level of focus as classroom
training which has led to frustration with GWI claims.
DSOs also question the level of training that medical providers are
receiving regarding Gulf War Illness claims and question if minimal, or
if any training at all is being provided. VBA's expansion of contract
compensation and pension exams is also raising concerns. Contractors
may be hired with little to no training regarding GWI which will result
in negative nexus statements and an ultimate denial by VBA.
The American Legion understands and appreciates the challenges VA
faces regarding GWI. Unlike Agent Orange related claims or radiation
exposure claims, a decision has to be rendered on an undiagnosed
illness creating an inherent ambiguity. The American Legion suggested
changes to Disability Benefits Questionnaires (DBQs) in March 2016
which have not been adopted. DBQs are a standardized form used by
medical providers to evaluate the level of disabilities suffered by
veterans; both VA and private sector medical professionals have the
ability to access these forms.
As previously stated, many veterans are denied compensation
benefits for Persian Gulf related conditions upon receiving a
diagnosis, even if the diagnosis changes over the course of months or
years. This lack of access to benefits can result in unequal and
extraordinary hardship to veterans and their family members - all while
their health continues to deteriorate. The American Legion calls on VA
to identify veterans with Persian Gulf service and allow medical
professionals to opine on DBQs if the sought medical conditions could
at least as likely as not be related to Persian Gulf service despite
having a diagnosis. This would provide the necessary path for medical
providers, VA, and most importantly, our veterans, to finally receive
their VA disability compensation. Through this additional language
examiners and VA would have the necessary latitude to provide proper
benefits.
The American Legion calls on this Committee to have ongoing
roundtables regarding GWI between Congress, VA, and VSOs so that we can
improve the delivery of benefits for those suffering GWI. The appeals
modernization effort that began in 2016 is proof that when we
collaborate on a common problem, we can arrive at a successful
solution.
The American Legion has been concerned about the effects of
environmental exposure on our servicemembers, and the resulting health
effects years following service for more than 20 years. During The
American Legion's 98th National Convention, we called upon "the
scientific community to focus its efforts on the most likely causes of
Gulf War veterans' illnesses" and for VA to "closely monitor the
implementation of changes to title 38, United States Code, section
1117, to ensure proper application of the law at the Department of
Veterans Affairs regional office(s)", through passage of American
Legion Resolution 122. \3\ Additionally, the resolution states The
American Legion supports a "liberalization of the rules relating to the
evaluation of studies involving exposure to any environmental hazard
and that all necessary action be taken by the federal government, both
administratively and legislatively as appropriate, to ensure that
veterans are properly compensated for diseases and other disabilities
scientifically associated with a particular exposure."
---------------------------------------------------------------------------
\3\ The American Legion Resolution No. 122 (Aug. 2016): Gulf War
Illnesses
---------------------------------------------------------------------------
Conclusion:
The American Legion appreciates the level of difficulty associated
with claims pertaining to Persian Gulf service; however, veterans have
now suffered for a quarter of a century. VA's continuous reliance on
the medical community to discover the etiology for a syndrome they have
yet to define has cost too many veterans years of disability
compensation. We call for an immediate liberalization in the way Gulf
War claims are adjudicated so as to provide an opportunity for our Gulf
War veterans to finally receive the benefits they have earned through
their honorable service. The American Legion thanks this committee for
their diligence and commitment to our nation's veterans on this topic.
Questions concerning this testimony can be directed to Derek
Fronabarger Deputy Director in The American Legion Legislative Division
(202) 861-2700.

Prepared Statement of Michael Figlioli
Chairmen Bost and Bergman, Ranking Members Esty and Kuster and
members of the Subcommittees, on behalf of the men and women of the
Veterans of Foreign Wars of the United States (VFW) and its Auxiliary,
I would like to thank you for the opportunity to testify on the
Department of Veterans Affairs (VA) disability claims process with
respect to Gulf War Illness.
As professionally trained, accredited advocates, VFW service
officers work extraordinarily hard to ensure our veterans and their
families receive the maximum benefit allowable by law from the VA. All
too often, however, this does not happen for a myriad of reasons and
contributing factors. In relation to the topic of today's hearing, I
refer to a signature condition of the Persian Gulf War referred to
largely across the veterans' community as Gulf War Illness (GWI) or
more commonly in VA, as ``Medically Unexplained Chronic Multisymptom
Illness.''
Unlike nearly all other claimed conditions, Gulf War Illness is
intrinsically difficult to diagnose and treat. GWI has no clear and
concise set of rules. In other words, no one distinctive set of
symptoms that allow for a single, unmistakable diagnosis. Gulf War
Illness presents itself as a conglomeration of possible symptoms to
which countless members of the general public with no military
experience can also be subject. As such, Persian Gulf veterans have a
steeper hill to climb in relating the symptoms to service--the most
critical link in establishing service- connection.
None of this is remotely possible without the benefit of a VA
examination (VAE), either at a VA medical facility or with a VA
contracted provider. As VA continues to evolve on a number of fronts,
mostly with regard to the transition to electronic filing and continued
concentration on managing the current claims inventory, VA developed
the Disability Benefits Questionnaire (DBQ) with an eye towards
efficiency and timeliness.
Last year, the VFW strongly advocated for the elimination of the
parsing out of symptoms and placing greater concentration on the
clustering of these indicators of potentially one illness affecting
multiple body symptoms, as opposed to specific conditions related to
each symptom. Put more simply, the VFW feels GWI claimants would be
better served by VA eliminating the assignment of multiple DBQs for
seemingly unrelated symptoms upon the receipt of a diagnosis, and posit
from the outset that the evidence meets the criteria for Gulf War
Illness, as opposed to its current form of considering the possibility
as a last resort. It was and remains our contention that the current
system of assigning separate DBQs for each symptom being claimed in
association with GWI promotes the potential for incorrectly assigning a
diagnosis to a condition linked to GWI. Thus, either improperly or
inadvertently negating the requirements of section 3.317 of title 38,
Code of Federal Regulation (CFR), which ultimately results in the
veteran's claim being denied.
Regrettably, in the 479 days since these distinguished committees
last met to discuss this topic and pressed VA to develop a single DBQ
for GWI that would assist in empirically establishing service-
connection, VA's Office of Disability Assistance, has not reported any
progress in the development of a single Gulf War Illness DBQ as
Congress suggested, and veterans suffering from these chronic
conditions that may give the appearance of a confirmed etiology
continue to have their claims denied. VA continues to rely on a ``Gulf
War Illness General Medical DBQ'' that is not singular in nature for
claims of GWI, but instead rely on the subjective, non-medically
trained construal of a claims assistant to interpret a veteran's
claimed conditions and schedule the appropriate VA examinations. When
asked about the possibility of the creation of a more favorable DBQ,
the response of record was that ``VA would look into the issue'' and
``First, we have to confirm that [lack of a single DBQ] is a real
problem.'' However, every Veterans Service Organization sitting at this
table has offered data, verifiable stories, and written statements as
to that very point, yet the problems in rating these claims continue.
Beyond the VFW's continued concern with the illogical requirements
of service-connection for Gulf War Illness, is the downstream effect of
the appellate process. VFW advocates who represent those whose claims
were denied continue to recognize the numerous inconsistencies when
decisions from the Board of Veterans Appeals (BVA) are remanded to the
VA Regional Office. In assessing pending appeals for GWI, the VFW
professional staff at the BVA notes that VA appears to clearly favor
finding a diagnosis for each reported system and, thereby, rule out
GWI, rather than further developing and accurately applying the rating
schedule to a diagnosis that is even a minimally supported one. The VFW
urges VA to consider both possibilities as existential. Since the
preponderance of evidence shows the possibility that GWI may exist, the
balance of evidence as to GWI's nonexistence is equal or in
``equipoise.'' Therefore, in accordance with section 3.102 of title 38,
CFR, there exists enough ``Reasonable Doubt'' that VA should develop
the claim for the potential grant of Gulf War Illness disability.
The VFW suggested in prior testimony that inconsistencies in the
application of the rating schedule is universal across the VA Regional
Office spectrum with regard to claims for Gulf War Illness
disabilities. While we are not in any way suggesting that this is
deliberate, we continue to put forward that a grant for Gulf War
Illness in Maine should be exactly the same in Ohio, Iowa, or any other
VA Regional Office based on the same evidence and fact pattern. VA's
Office of Performance Analysis and Integrity has demonstrated their
capability to track data nearly to the key stroke. This presents the
perfect opportunity to identify and develop best practices across the
Veterans Benefits Administration in properly adjudicating claims for
GWI and eliminate the disparities that currently exist. At the very
least, now that the National Work Queue (NWQ) is in effect, VA could
easily distribute these ``specialized'' claims to the regional offices
that have a proven track record in proper application of section 3.317
of title 38, CFR, with an eye toward the centralization of Gulf War
Illness claims as is the case with claims for exposure to toxic water
at Camp Lejeune, Lewisite, Spina Bifida and other ``non-routine''
issues.
Over the past six years, much of VA's effort has been focused on
the backlog of existing claims. In the attempt to reduce this inventory
as efficiently and expeditiously as possible, VA has relied exceedingly
further on the use of contract examiners to meet demand and relieve the
burden from the Veterans Health Administration (VHA). While this has
allowed VHA to direct resources to provide health care to those already
service-connected or otherwise enrolled in the VA health care system,
far too often we are alerted to contract exams that are hastily
conducted, not performed to VA standard (not compliant with the DBQ
required to evaluate the disability), or not properly scheduled. For
this reason, the VFW believes that developing a single DBQ intended
specifically for identifying and rating Gulf War Illness and accurate,
continuous training on how to complete these exams will result in the
proper application of the law and the veteran receiving the
appropriately awarded benefit their service has earned.
As one of the nation's largest VSOs responsible for providing
direct assistance to veterans seeking their earned benefits, the VFW
continues to urge Congress to employ its oversight authority regarding
the development of a single use DBQ for Gulf War Illness, proper
training for VA examiners and claims adjudicators, and the
consideration of centralizing these claims through the NWQ to ensure
consistency.
Messrs. Chairmen, this concludes my testimony. I will be happy to
answer any questions you or the Subcommittee members may have.

Prepared Statement of Anthony Hardie
Thank you, Chairmen Bergman and Bost, Ranking Members Kuster and
Esty, and Members of the Subcommittees for today's hearing and for the
invitation to speak with you today.
I'm Anthony Hardie, National Board Chair and Director of Veterans
for Common Sense (VCS), and a U.S. Army veteran of the 1991 Gulf War
and Somalia. VCS and I have provided testimony on many previous
occasions, most recently in February and March 2016 for Gulf War health
and benefits hearings.
Today's hearing is focused on the latest Government Accountability
(GAO) report related to Gulf War Illness (GWI) issues, with bottom line
finding of an 87 percent overall denial rate that is three times worse
than any other type of claim the Veterans Benefits Administration (VBA)
adjudicates. However, the GAO report delves deeper into these GWI
claims issues and their intertwined relationship with medical research.
These serious issues have profound real-world impact on Gulf War
veterans. Please see Exhibit 1, attached to this testimony, that
provides a number of Gulf War veterans' accounts of how their own VA
claims for GWI issues were denied. The negative impact on these
veterans compels us today to seek to find solutions to favorably impact
them and help to relieve their suffering however we can.

2017 GAO REPORT ON GWI CLAIMS

Specifically for Gulf War Illness (Chronic Multisymptom (CMI) and
Undiagnosed Illness (UDX)) claims, this new 2017 GAO report \1\ found:
---------------------------------------------------------------------------
\1\ U.S. Government Accountability Office, ``Gulf War Illness:
Improvements Needed for VA to Better Understand, Process, and
Communicate Decisions on Claims'' (GAO-17-511), June 2017.

TRIPLE THE DENIAL RATE: ``.the approval rate for Gulf War
Illness medical issues was 17 percent (about 18,000 of 102,00 issues
rated), which was about 3 times lower than all other medical issues at
57 percent (about 14 million of 24.7 million issues rated).''; ``This
approval rate was consistently lower than that of the non-Gulf War
Illness medical issues.'' (p. 18)
WORSE FOR UDX CLAIMS: ``.eight VBA regional offices had
approval rates of 5 percent or less for undiagnosed illness medical
issues.'' (p. 22)
WORSENING OVER TIME: ``Approval rates . decreased from
fiscal year 2010 to fiscal year 2015.'' (p. 18)
VA UNDERREPORTED GWI CLAIMS: ``.the number of completed
[GWI] claims . may be underreported due to unclear guidance and
inconsistent data entry over time by VBA's claim rating staff.'';
``.staff had not been consistently identifying these medical issues as
Gulf War Illness-related.''; ``[GAO] tested the data to determine the
potential magnitude of the underreporting [of GWI issues]. and found
approximately 57,000.''; ``The number of veterans associated with
claims for these medical issues was about 41,000.''; ``.VBA is not
planning to correct these data from prior years.'' (pp. 15-16)
GWI CLAIMS TAKE 50% LONGER: ``.[GWI] claims took about 4
months longer for VBA to complete than all other types of claims,
averaging about 1 year compared to about 8 months.'' (p. 17); And,
``.[GWI] claims with eight or more medical issues took on average 1
month longer to complete than Gulf War Illness claims with seven or
fewer medical issue.'' (p. 17, footnote). This means veterans who are
the worst off have to wait the longest for the help they need.
DECISION LETTERS ARE FLAWED: ``.decision letters for
denied claims do not communicate key information to veterans'',
including, ``why the claim was denied'' (p. ii), and, ``.could lead the
veteran to conclude that their claim was denied because . VBA had not
considered it under the presumptive method of service connection.''
(pp. 24-25). This is despite a 2002 GAO report (GAO-02-395) that noted
that ``unclear decision letters can confuse claimants.'' (p. 25,
footnote).
NO CONSISTENCY BETWEEN EXAMINERS: ``Medical examiners
have different views on and approaches for how to assess veterans for
undiagnosed illnesses, in part, because of the challenge of identifying
something as an undiagnosed or unexplainable illness.'' (p. 22)
UDX IS UNWORKABLE: ``Medical examiners at one clinic told
us that they could nearly always attribute a veteran's symptoms to a
diagnosable illness, which would mean the veteran does not qualify for
benefits under the undiagnosed illness presumptive category.''; ``.two
examiners said that to determine that a veteran should be categorized
as having an undiagnosed illness, they would have to rule out all known
diseases that could cause the veterans symptoms. Doing so, however, is
beyond the scope of a medical exam for disability compensation
purposes.'' (p. 22)
INADEQUATE TRAINING IMPEDES ACCURACY: ``VA's ability to
accurately process GWI claims is hampered by inadequate training'';
``VA has developed elective GWI training for its medical examiners, but
only 10 percent of examiners had taken the training as of February
2017'' (p. ii), an ``.optional 90-minute web-based training course.''
(pp. 22-23). By contrast, ``.they must complete training courses before
performing certain specialty medical exams, such as for traumatic brain
injury or post-traumatic stress disorder.'' (p. 23)
EXAMINERS' ERRORS MAY RESULT IN CLAIM DENIAL: ``.VHA
medical examiners sometimes provide a medical opinion related to
service connection when one is not necessary because the veteran has a
presumptive condition.. This opinion may include language that
indicates the veteran's presumptive condition may not be relate to
their service.''; ``.if VBA claim raters do not recognize that the
medical examiner has provided an unnecessary medical opinion about
service connection for a presumptive condition, they may inadvertently
deny a claim that should be presumptively granted.'' (p. 22)
WITH AN 87% DENIAL RATE, TRAINING ISN'T THE ONLY ISSUE:
This is evidenced by the finding that ``.98 percent of VBA's rating
staff had completed . training.'' Despite this level of training, VA
still denies GWI claims at extraordinary rates. (p. 21, footnote)
NO CONSISTENCY BETWEEN REGIONAL OFFICES: ``VBA provides
guidance to its claims staff regarding when to request this medical
exam; however, we found different interpretations of the guidance among
staff in the four regional offices we visited.'' (p. 20)
VA STAFF DON'T UNDERSTAND GWI: ``These Gulf War Illness
medical issues may be denied at a higher rate, in part, because
according to VA officials, Gulf War Illness is not always well
understood by VA staff..'' (p. 19)
NO GWI CASE DEFINITION, NO ACTION PLAN TO DEVELOP ONE:
``The National Academy of Medicine and VA's Research Advisory Committee
on Gulf War Veterans' Illnesses both recognize that establishing a
single case definition has been challenging and noted the risks of
adopting one that is either too narrow or too broad. Nevertheless, they
both identified steps VA can take toward this goal.'' (p. 30,
footnote). ``In its 2015 Gulf War Research Strategic Plan, VA included
an objective to develop a single case definition, but an official told
GAO that VA had no action plan in place to achieve it.'' (p. ii);
``.the persistent lack of a single case definition for Gulf War Illness
contributes to many of the current challenges with the Gulf War Illness
disability compensation program.'' . ``Without a documented plan to
establish a single case definition, VA may miss opportunities to focus
its efforts and advance knowledge about Gulf War Illness, and
potentially improve the lives of hundreds of thousands of affected
veterans.'' (p. 32)
NO VA REPORTING: ``According to VBA officials, VA does
not publicly report on the total number of Gulf War veterans who
receive disability compensation benefits for Gulf War Illness.'' (p. 1)
VBA CAN'T ADEQUATELY REPORT ON OTHER PRESUMPTIONS: ``VBA
officials noted that it may be more useful to compare Gulf War Illness
approval rates to those of other types of presumptive disability
claims, such as those for presumptive illnesses VA associates with
exposure to Agent Orange during the Vietnam War. However, the data
provided to us by VBA did not allow us to conduct this analysis.'' (p.
18, footnote)
STILL NO CONSISTENT VA USE OF THE TERM ``GULF WAR
ILLNESS,'' despite strong NAS recommendations to use this term. ``In
2015, VA's Office of Research and Development officially adopted the
term `Gulf War Illness presenting as chronic multisymptom illness' to
describe symptoms of undiagnosed illness or medically unexplained
chronic multisymptom illness.'' (p. 6, footnote)
VA DOESN'T HEED RECOMMENDATIONS: ``According to a June
2014 report published by [a VA] internal workgroup, VA had yet to
implement many recommendations related to programs and services for
Gulf War veterans made by internal task forces and external advisory
committees to senior VA leadership over the years. In June 2014, this
workgroup's environmental scan identified several deficiencies
regarding VA's response to Gulf War Illness, including that there is:
*no overarching Department-level strategy for Gulf War veterans; *no
well-coordinated process for receiving recommendations or implementing
plans to respond to recommendations; and *no clear consensus on a
single case definition for Gulf War Illness.'' (p. 12)
PROCESS FOR NEW PRESUMPTIVES FLAWED: GAO notes that some
VA research, ``.is directly relevant to the disability compensation
program; for example, it has been used to establish additional
presumptive conditions.'' (p. 26). However, no examples are cited
because, beyond nine infectious endemic diseases, VA has found none.
``VA has not identified any new presumptive conditions that it
associates with Gulf War service since adding the nine infectious
diseases in 2010.'' (p. 29). ``Some presumptive conditions have been
added through legislation. As we previously noted, in 1994 a
presumptive service connection for ``undiagnosed illness'' for Gulf War
veterans was established, and in 2001 legislation was enacted
establishing ``medically unexplained chronic multisymptom illnesses''
as being presumptively service connected for these veterans.'' (p. 27,
footnote)
BRAIN CANCER PRESUMPTIVE DENIED: ``VA officials said the
agency decided not to proceed, citing limited scientific evidence from
a 2016 National Academy of Medicine report.'' (p. 29)
GAO RECOMMENDED VA: ``.require medical examiners to
complete training . before conducting these exams.''; ``. require that
decision letters indicate whether Gulf War Illness medical issues were
evaluated under both a presumptive and direct service connection
method.''; and, ``...prepare and document a plan to develop a single
case definition of Gulf War Illness.'' . ``This plan should include
near- and long-term specific actions, such as analyzing and leveraging
information in existing datasets and identifying any areas for future
research to help VA achieve this goal.'' (p. 32)
VA AGREED: ``VA said it plans to make its 90-minute web-
based training course mandatory for its medical examiners who conduct
Gulf War Illness exams. VA also stated it will improve how it
communicates decisions to veterans and is in the process of updating
its guidance to the regional offices to clarify the language required
for its Gulf War Illness decision letters. Finally, VA said it will
convene a group of subject matter experts to work on a plan-as
described in our report-to establish a single case definition of Gulf
War Illness.'' (p. 33)
GAO ADMONISHMENT - ACTION PLANS: ``According to federal
internal control standards, an agency's objectives should be defined in
specific terms, including clearly defining how the objective is to be
achieved and who is responsible for achieving the objective, as well as
establishing time frames for meeting the agency's goal. These measures
allow agencies to track progress toward achieving their goals.'' (p.
31, footnote)
GAO ADMONISHMENT - COMPETENCE IS A BASIC PRINCIPLE:
``Demonstrating a commitment to competence is a principle of federal
internal control standards.'' (p. 23, footnote)

PREVIOUS INVESTIGATIONS

This latest GAO report is just the latest in a long line of GAO,
Congressional, and other investigations. In 1996, a GAO investigation
found that VA had denied Gulf War veterans' undiagnosed illness (UDX)
claims under the 1994 law at a rate of 95 percent. \2\ Additional
hearings, legislation, advocacy, and major public outcry by the
nation's ill Gulf War veterans eventually resulted in two major bills
enacted in 1998 that sought to fix these issues with what appeared to
be a clear, comprehensive framework for Gulf War veterans' healthcare,
research, and disability benefits. \3\
---------------------------------------------------------------------------
\2\ U.S. General Accounting Office, ``Veterans' Compensation:
Evidence Considered in Persian Gulf War Undiagnosed Illness Claims''
(GAO/HEHS-96-112), May 1996, p. 3.
\3\ As I noted in our testimony of February 23, 2016 to the
Subcommittee on Oversight and Investigations (O&I), and our written
submission for the record of March 6, 2016 for a joint O&I and
Disability and Memorial Affairs subcommittees, these were the Persian
Gulf War Veterans Act of 1998 (Title XVI, P.L. 105-277) and the
Veterans Programs Enhancement Act of 1998 (P.L. 105-368, Title I-
``Provisions Relating to Veterans of Persian Gulf War and Future
Conflicts'') were two landmark bills, that, ``for those of us involved
in fighting for the creation and enactment of these laws, they seemed
clear and straightforward, with a comprehensive, statutorily-mandated
plan that would guarantee research, treatments, appropriate benefits,
and help ensure that lessons learned from our experiences would result
in never again allowing what happened to us to happen to future
generations of warriors.''
---------------------------------------------------------------------------
The next major update followed shortly thereafter. Legislation in
2001 added signs and symptoms of undiagnosed illness, and ``medically
unexplained chronic multisymptom illness (such as chronic fatigue
syndrome, fibromyalgia, and irritable bowel syndrome) that is defined
by a cluster of signs or symptoms.)''. \4\ This was the last
significant legislative change to Gulf War Illness claims.
---------------------------------------------------------------------------
\4\ Public Law 107-103, the ``Veterans Education and Benefits
Expansion Act of 2001,'' was enacted December 27, 2001; Section 202,
``Payment of Compensation for Persian Gulf War Veterans with Certain
Chronic Disabilities,'' took effect March 1, 2002.
---------------------------------------------------------------------------
However, as we described last year, the implementation of all of
these Gulf War laws aimed at helping ill Gulf War veterans has been
fraught with challenges. Myriad VA-contracted National Academy of
Medicine (formerly the Institute of Medicine (IOM)) literature reviews,
at a cost of millions upon millions of dollars, have resulted in no new
presumptive conditions related to Gulf War Illness, no new case
definition of Gulf War Illness, no better assistance for ill Gulf War
veterans seeking VA healthcare or benefits.
Last year, detailed testimony \5\ to the House Veterans' Affairs
Subcommittee on Oversight and Investigations documented that the
negative conclusions of these reports reflected the refusal of the NAM
(with the blessing and at times collusion of VA) to follow the clear
language of the statute requiring the reports as to the appropriate
standard review.
---------------------------------------------------------------------------
\5\ Statement of James H. Binns, U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Oversight and
Investigations, hearing entitled, ``Persian Gulf War: An Assessment of
Health Outcomes on the 25th Anniversary'', February 23, 2016,
Washington, DC. http://docs.house.gov/meetings/VR/VR08/20160223/104497/
HHRG-114-VR08-Bio-BinnsJ-20160223.pdf
---------------------------------------------------------------------------
Meanwhile, the challenges with VA continue, some specific to GWI
and some more generally applicable. For example, in 2002, GAO found
that VBA letters to claimants needed to be improved. \6\ However, this
2017 GAO report - with its major findings related to flawed GWI
notification letters to claimants - shows that these 2002
recommendations to VBA were not fully heeded.
---------------------------------------------------------------------------
\6\ U.S. GAO, ``Veterans Benefits Administration: Clarity of
Letters to Claimants Needs to Be Improved'' (GAO-02-395), April 23,
2002.
---------------------------------------------------------------------------
Then, in two 2004 reports, GAO found that the federal GWI research
strategy needed reassessment, \7\ and that federal GWI research efforts
had waned. \8\ In FY06, Congress created the Gulf War Illness Research
Program (GWIRP) within the Congressionally Directed Medical Research
Program (CDMRP) portfolio that is managed by the U.S. Army Medical
Research and Materiel Command (USAMRMC). Also in 2004, GAO found that
DoD conclusions about Gulf War troops' toxic exposures couldn't be
supported. \9\
---------------------------------------------------------------------------
\7\ U.S. GAO, ``Department of Veterans Affairs: Federal Gulf War
Illnesses Research Strategy Needs Reassessment (GAO-04-767) June 1,
2004.
\8\ U.S. GAO, ``Gulf War Illnesses: Federal Research Efforts Have
Waned, and Research Findings Have Not Been Reassessed'' (GAO-04-815T),
June 1, 2004.
\9\ U.S. GAO, ``Gulf War Illnesses: DOD's Conclusions About U.S.
Troops' Exposure Cannot Be Adequately Supported'' (GAO-04-821T), June
1, 2004.

---------------------------------------------------------------------------
GWI CLAIMS DENIAL RATES

Advocacy by Gulf War veterans brought limited attention to the
ongoing issue of VA denials of these GWI claims. In 2007, analysis of
publicly reported VA data showed a 74 percent denial rate of all GWI
claims. \10\ Advocacy related to these continued denials of GWI claims,
and in 2010, VA intervened to clarify that the CMI's listed in the 2001
law were merely ``examples'' of, and not an exclusive list of CMI's.
\11\
---------------------------------------------------------------------------
\10\ As noted in my March 6, 2016 submission for the record, a May
2007 report from VA's Gulf War Information System (GWVIS) showed that
of 13,027 GWI claims, only 3,384 had been approved - a 74 percent
overall denial rate.
\11\ U.S. Department of Veterans Affairs, ``All VA Regional Offices
Training Letter, SUBJECT: Adjudicating Claims Based on Service in the
Gulf War and Southwest Asia'' (10-01), stated in part: ``The chronic
disability patterns associated with these Southwest Asia environmental
hazards have two distinct outcomes. One is referred to as ``undiagnosed
illnesses'' and the other as `diagnosed medically unexplained chronic
multisymptom illnesses'' that are without conclusive pathophysiology or
etiology. Examples of these medically unexplained chronic multi-symptom
illnesses include, but are not limited to: (1) chronic fatigue
syndrome, (2) fibromyalgia, and (3) irritable bowel syndrome.'''
[Emphasis added]
---------------------------------------------------------------------------
Fast forward a few years, and VA once stopped its public reporting
of GWI data. Data obtained in 2014 by a Congressional office from VA
showed a nearly 80 percent overall denial rate of GWI claims. \12\ That
data also showed that VA approved 52 percent of denied GWI claims for
other conditions, demonstrating an implicit VA bias against approving
GWI claims; however, two in very five (38 percent) of Gulf War veterans
were denied in totality.
---------------------------------------------------------------------------
\12\ U.S. Department of Veteran Affairs data, provided to the
office of then-Representative Kerry Bentivolio, March 28, 2014.
Analysis by VCS - Out of 54,193 GWI claims filed: 11,216 approved
(20.7%), 42,977 denied (79.3%); 22,470 approved for other non-GWI
conditions (41.5% of GWI claims filed, 52.3% of denied GWI claims),
20,507 denied for GWI and all other conditions (37.8%); average
disability rating granted for GWI claims was 67 percent.
---------------------------------------------------------------------------
Rounded off, according to VCS analysis of VA data, this most recent
data shows a 78 percent VA denial rate of Chronic Multisymtom Illness
(CMI) GWI claims, an overall denial rate of these GWI claims of 87
percent, and a staggering 90 percent denial rate of Undiagnosed Illness
(UDX) GWI claims. Data shown in in this new GAO investigation \13\ is
entirely consistent with the exceedingly high denial rates reported
over the last two decades.
---------------------------------------------------------------------------
\13\ U.S. Government Accountability Office, ``Gulf War Illness:
Improvements Needed for VA to Better Understand, Process, and
Communicate Decisions on Claims'' (GAO-17-811), June 2017.
---------------------------------------------------------------------------
That UDX denial rate is approaching the 95 percent denial rate
identified by GAO in a 1996 report that was part of the impetus for
1998 Persian Gulf War veterans legislation.
In more detail, the rates of VA denial of GWI claims continues to
worsen. From a VCS analysis of VA data, for chronic multisymptom
illness (CMI) \14\ claims, VA's denial rates were as follows: in Fiscal
Year 2011 - 72.5%, in FY12 - 72.1%, in FY13 - 75.3%, in FY14 - 77.0%,
and in FY15 - 77.5%, as shown by VCS's analysis of GAO's newly reported
FY15 full year VA data.
---------------------------------------------------------------------------
\14\ ``CMI = Chronic Multisymptom Illness (Fibromyalgia DC 5025;
Irritable Bowel Syndrome, DC 7319; Chronic Fatigue Syndrome, DC 6354)
in either the hyphenated or primary code. If condition is both UDX and
CMI, it is included in UDX counts.''
---------------------------------------------------------------------------
For undiagnosed illness (UDX) \15\ claims, veterans' odds of
approval are even worse and that VA's denial of these UDX claims is
worsening: in FY11 - 80.5%, in FY12 - 78.4%, in FY13 - 78.6%, in FY14 -
83.1%, and in FY15 - 89.8%, again using the same methodology.
---------------------------------------------------------------------------
\15\ ``UDX = Undiagnosed Illness, defined as diagnostic codes
containing 88xx in either the hyphenated or primary code.''
---------------------------------------------------------------------------
Combining these CMI and UDX data, VA's overall denial rates for GWI
claims show a true downward spiral: in FY11 - 76.3%, in FY12 - 74.7%,
in FY13 - 76.6%, in FY14 - 83.1%, and in FY15 - 86.7%, again using the
same methodology.
This data also shows that that the rate of denial for UDX claims
was higher than that of CMI claims in all but five of the 58 VA
Regional Offices for which GAO reported FY15 GWI claims data. This is
also significant, and demonstrates the disparity between Gulf War
veterans getting a UDX GWI claim approved versus a CMI GWI claim
approved. It also suggests that the Congressional intervention in 2001,
which introduced CMI's to GWI claims, improved the plight of Gulf War
veterans.

VBA REGIONAL OFFICES VARY WILDLY WHILE BAD PERFORMERS ARE DOING MORE
CLAIMS

One aspect of these denials of GWI claims that went unremarked upon
by GAO in this 2017 report is that one-third (9,875) of all the
adjudicated FY15 GWI claims (28,250) were in just six of the 58 VA
Regional Offices: Muskogee, OK (2,431, 94% denied); Roanoke, VA (2,124,
95% denied); Nashville, TN (1,763, 83% denied); Atlanta, GA (1,339, 93%
denied); Columbia, SC (1,130, 90% denied); and Waco, TX (1,088, 92%
denied). This implied that VA is sending claims from elsewhere in the
country to at least these six offices, five of which have worse or far
worse denial rates than the 86.7% national average.
GAO also did not remark on the discrepancies between VA Regional
Offices, which are profound and imply extreme variation in claims
processing standards of these claims depending on location and local
management. Overall FY15 GWI denial rates ranged from 47% at Boston to
100% at Anchorage. CMI denial rates varied even more widely, ranging
from 36% in Manila and 38% at Boston to 92% at Roanoke and 100% again
at Anchorage.
Since VA has this data (it is VA-provided data, after all), it is
entirely unclear why there has not been an internal investigation not
only of these discrepancies, but also why there hasn't been a complete
overhaul of GWI claims adjudication at the worst performers like
Roanoke and Muskogee. Given that it can be inferred that VA is sending
GWI claims to these offices from elsewhere, and that the data shows
these regional offices have far higher than average denial rates, a
cynical person might conclude this consolidation of GWI claims
processing to high-denying offices was intentional.

RECOMMENDATIONS FOR LEGISLATION

In past testimony, we have provided numerous recommendations for
legislative action. Today, we will focus on just a few.

A) Fixing GWI Claims should be the centerpiece of a legislative fix
to help Gulf War veterans. After years of critiques, recommendations,
hearings, investigative reports, and bad press, VA has yet to fix the
GWI claims problem. Despite enactment in 2001 of legislation that
created the new CMI presumptive and fine-tuned the original 1994 UDX
presumptive, VA still remains hampered by training issues and
inconsistent implementation between locales. However, though GAO
reported VBA assertions of a training rate of 98 percent of its claims
examiners, the issues continue.
In short, underlying these issues is that the ``Undiagnosed
Illness'' claims adjudication framework utilized by VA simply doesn't
work as Congress intended in 1994 and subsequent updates. This premise
is supported by several factors, including the persistence of near-
total denial rates of UDX claims and GAO's 2017 finding that some
claims examiners will in essence never find in favor of an
``undiagnosed illness'' and ``always attribute a veteran's symptoms to
a diagnosable illness''.
However, there may be another option. First, we note that that
Congressional intervention in 2001, with the introduction of CMI's,
consistently shows a better approval rate over claims adjudicated as
UDX under the 1994 law that instituted these claims.
Next, we note that both PTSD and TBI claims have seen dramatic
overhauls in recent years that made significant improvements over
earlier processes. As a potential model of sorts for a future GWI
claims schema, the current TBI rating system (DC 8045) uses a system of
``buckets'' of symptom sets, scored for severity as mild, moderate, or
severe. While not perfect, it's not hard to envision major GWI symptom
sets as a parallel to these TBI symptom ``buckets'' under DC 8045.
And, just like for TBI claims, it would be important to ensure that
there are direct tie-in's for diagnosed conditions related to GWI. For
example, sleep apnea, gastro-esophageal reflux disease (GERD), and
chronic sinusitis are three of several commonly reported conditions
among ill Gulf War veterans. However, due to epidemiological research
inadequacies and the inherent requirements of undiagnosed illness
claims, once diagnosed these conditions - more likely symptoms of the
underlying GWI - no longer qualify to be rated under the UDX
presumptive.
Given VA's track record of failure on these issues, including the
failure to heed recommendations as noted in this 2017 GAO report, the
process to create this new GWI claims schema should also be statutorily
mandated. It should include a statutorily-mandated panel to lead this
process composed of VHA and VBA key personnel and subject matter
experts (including those involved in the process to create the new TBI
claims rating schedule), clinical and research experts on GWI including
as identified by the Gulf War Illness Research Program within the DoD
Congressionally Directed Medical Research Program, representatives of
stakeholder veterans service organizations, and engaged Gulf War
veteran advocate stakeholders.
It should be given a timeline to conclude its work, as short as
feasible given the many years ill Gulf War veterans have been suffering
under the present unworkable UDX and CMI GWI claims system. And, with
these medical experts included, a scientific case definition that may
still be years in the future may not be needed to create a workable GWI
claims adjudication mechanism favorable to ill Gulf War veterans.
Finally, the new rating schedule developed under this process should be
published by VA as regulation with sufficient opportunity for public
comment.
We want to work with VA to fix this. To that end, in collaboration
with other veterans service organization we have requested a meeting
with top VA officials to seek resolution. However, given that VA has
had decades to find a solution on its own but hasn't, active
Congressional involvement and statutory mandates seem likely to be
necessary to mandate this process.
Recommendation: As the centerpiece of a legislative package to
right as many ongoing wrongs as possible for Gulf War veterans,
Congress should statutorily mandate a process to create a new, more
viable GWI claims adjudication rating schedule in as short a timeline
as possible.

B) Mandatory Training. In this new report, GAO identified areas of
concern related to staff training as one probable cause of GWI claims
denials. Therefore, it is worth referencing VA's new performance
standards for claims rating staff (Rating Veterans Service
Representatives, or RVSR's) that went into effect on July 1st. In these
new performance standards, staff training was listed as a ``non-
critical element'' of performance. Similarly deemphasized in these new
performance standards was ``Organizational Support - qualitative and
quantitative measurement of positive internal and external customer
service and organizational support.''
By contrast, the ``critical elements'' of these new performance
standards include only accuracy, speed, and output. And, it remains
unclear how appropriately VBA measures accuracy, given the high rates
of success among veterans who appeal their denied claims (not GWI-
specific).
It is unconscionable that Gulf War (and other) veterans' disability
claims rely upon being reviewed by untrained medical examiners and
claims staff, and that VBA has deprioritized training and customer
satisfaction over speedy output. These new performance standards help
underscore how these negative GWI claims outcomes are, in part,
systematically allowed to occur.
And last year, we reported to your Subcommittees in our statement
for the record that VA had amended Gulf War provisions in the M21-1
``Veterans Benefits Manual,'' which is used by VBA for rating claims.
However, the spiraling VA claims denial rates and GAO's most recent
findings of untrained staff and an array of reasons underlying VA's
denial of Gulf War veterans' claims suggest that this intervention had
far too little positive effect, if any.
Indeed, last year the Senate Appropriations Committee included the
following proviso in report language accompanying the FY 2017 Defense
Appropriations Bill: ``While the Committee commends VA on its efforts
to revise the Compensation and Pension manual for ``Service Connection
for Certain Disabilities Associated with Gulf War Service,'' concern
remains that VA claims adjudicators are not consistently following
these changes.''
However, it is presently unclear whether there was any response by
VA to this or any of the sixteen (16) Gulf-War veteran-related provisos
included by the Senate Appropriations Committee or the several similar
provisos included by the House Appropriations Committee and by the
conference committee in its Joint Explanatory Statement.
Recommendation: Specialized training related to the type of claim
involved should be statutorily mandated for all VA claims staff,
including medical examiners and rating staff.
Recommendation: VBA should be statutorily mandated to report data
to Congress that emphasizes and measures training, and the consistency
of training and claims adjudication between each VBA regional office.

C) Gulf War Veterans Who Aren't Gulf War Veterans to VA. The
federal government has two different definitions for service in
Southwest Asia (SWA), the geographic location of the Gulf War. The U.S.
Department of Defense (DOD) uses a more expansive definition for
military service with its criteria for awarding the Southwest Asia
Service Medal (SWASM). Meanwhile, the U.S. Department of Veterans
Affairs (VA) uses a narrower definition of SWA to determine eligibility
for benefits.
As a result of these two different definitions, a small number of
U.S. service members who deployed to Israel, Egypt, Turkey, Syria, and
Jordan, including airspace and territorial waters, are eligible to
receive the SWASM as Gulf War veteran but are not eligible for Gulf
War-specific benefits administered by VA.
Recommendation: VA should be statutorily mandated to amend the
definition of SWA at 38 CFR Sec. 3.317(e) to include the additional
geographic locations in 32 CFR Sec. 578.27(b) listed above.

D) VA Needs to Track, Analyze, and Regularly Report VA Utilization
Data for 1990-91 Gulf War Veterans. In 2010, VCS testified, ``At
present, VA has no idea how many UDX claims have been granted or
denied.'' This 2017 GAO report makes it clear that VA has not been
consistently tracking GWI claim denials and approvals, with about
41,000 veterans' GWI claims not included in VA's data reporting.
VA should have a statutory mandate to report quarterly and in
perpetuity a comprehensive package of VBA and VHA usage and benefits
data. These reports should include raw and analyzed data on the numbers
and rates of claims filed, approved, and denied by era and actual war
service (i.e., 1991 Persian Gulf War, etc.), and healthcare utilization
also broken down by cohort. For 1991 Gulf War data, the recommendations
adopted unanimously in 2012 by the Research Advisory Committee on Gulf
War Veterans' Illnesses (RAC) should be implemented. These new
quarterly data reports should be publicly accessible to enhance VA
accountability.
Recommendation: VA should have a statutory mandate to publicly
report quarterly and in perpetuity a comprehensive package of VBA and
VHA usage and benefits data that includes the 2012 recommendations
adopted unanimously by the RAC.

E) Other recommendations for legislation. Along with comprehensive
reviews of the 1994, 1998, and 2001 laws, our numerous recommendations
for legislative action made in previous testimony that should now be
reviewed, including :

Added Presumptives. As part of a tie-in with a new claims
schema for GWI claims, there should be consideration of statutory
mandates for presumptives for Gulf War veterans for brain cancer, lung
cancer, migraines, GERD, chronic sinusitis, and the numerous other
conditions shown in one or more VA epidemiological studies as occurring
at higher rates than control populations.
National Toxic Exposures Advisory Committee. Creation of
a new, interagency (HHS, DoD including CDMRP, and VA including both
VHA-ORD and VHA-PDHS) national advisory committee on toxic exposures,
with a scope that spans quality of life measures from healthcare to
benefits. Examples of toxic exposures include Agent Orange, 1991 Gulf
War exposures, chemical warfare agent exposures, burn pits and airborne
hazards, Camp Lejeune drinking water, and so on.
WRIISC's. Expanding VHA's War Related Illness and Injury
Study Centers to make them more accessible and for clinical treatment,
not just one-time clinical evaluation and medical research.
Gulf War Registry. Enhancing VA's Gulf War Registry to
make it a meaningful medical surveillance tool to help identify
emerging medical trends among Gulf War veterans.
Gulf War Spouses and Children Registry. Consider
restoring this former registry, also as a meaningful medical
surveillance tool to help identify emerging medical trends.
Reform of the relationship between VA and the National
Academy of Medicine. Congress depends on the National Academy of
Medicine for unbiased judgment medical issues involving veterans.
Congress orders VA to contract with the NAM for reports on these
issues. Too often, the reports fail to live up to this unbiased
standard. VA routinely fails to contract for the report as specified by
Congress. And NAM committees frequently include former VA officials and
contractors in the areas addressed by the reports. Legislation is
sorely needed to restore the impartiality of NAM reports on veterans'
medical issues.
RAC restoration. In 2013, the U.S. House passed
legislation under unanimous consent that would restore the Research
Advisory Committee on Gulf War Veterans' Illnesses (RAC) to its
original intent, though it failed to be taken up in the Senate before
the Congress ended. That legislation should be reviewed for potential
revision and reintroduction.

EXHIBIT 1: GULF WAR VETERANS AFFECTED BY VA'S GWI CLAIMS DENIALS

Collected July 2017

The following are accounts from Gulf War veterans - in their own
words--whose claims have been denied by VA for Gulf War Illness
presumptives, including undiagnosed illnesses (UDX) and chronic
multisymptom illnesses (CMI's) like fibromyalgia, chronic fatigue
syndrome (CFS), and functional gastro-intestinal disorders (including
irritable bowel syndrome (IBS)).

Arizona

I just moved to Arizona from being in California for past 7 years.
I was diagnosed with Multiple sclerosis and Lhermitte's while working
up in Oregon. This was in Sept 2015. The VA kept me overnight to run
more tests, and next morning the Neurology team came in and asked how
long I had this disease, and I said 3 weeks. They said I had this at
least 15 years or more. The main neurologist was surprised that I was
not blind, paralyzed, or both by looking at my charts.
* I filed my claim when I got back to Huntington beach CA. in July
26th 2016.
* After getting more exams from Long beach VA, and getting my Rep
with Paralyzed Veterans of America, we filed a claim. My presumptive
conditions are: Multiple sclerosis and Lhermitte's, Chronic Fatigue,
Chronic Joint Pain, degeneration discs and right hip, shooting pain in
feet.
* I have a Nexus letter from my primary doctor from Salem OR, that
was a specialist in MS. Stating that my condition was highly rated from
being triggered from the Gulf War exposure of Oil well fires and
possible Gas exposure. He had gone through my records to confirm of my
unit and locations. I have x-rays of my joints, spine, and hip to
confirm degeneration. I have multiple MRI's to confirm of the lesions
on my brain and my spine for Multiple sclerosis and Lhermitte's.
Paralyzed Veterans of America have my first contact info from 1994 of
the first Gulf War Registry of me having the same issues that I have
today, only now they are more extreme. I have letters/statements from
veterans, current military servicemen, and family members. I have
followed the book on preparing my case to file my claim only to be
denied. I have a mountain of evidence and doctors to back my claim up.
Doctors have been actually shocked that I am not on disability.
*The only reason I have from the VA for being denied is ``Not
service connected''.
* My next step as of Monday July 10th, 2017, is getting my Rep with
Paralyzed Veterans of America to get me answers and sent a letter of to
an Accredited Claims Agent to see my next step.
*Not sure what an appeal would do except wait another 2-5 years for
a response.
*Impact on me is that now that I have heard the stories of the VA
and now that I am in the process of being pushed aside is appalling. It
is completely amazing how bad the process is for all of us Veterans.
Just disgusted.

Arkansas

I was diagnosed with a myoclonus (research this condition, it is
the perfect example of an undiagnosed condition) a few weeks (May 1991)
after I spent 8 months during desert shield/storm. I was told it was a
seizure disorder and prescribed seizure medication. Not knowing that
the medication side effects would cause me to get discharged, I was
told at the time I did not have a claim. This diagnosis was re-affirmed
in 1992, 2007, and 2010. And I'm still fighting the validity of the
claim of ``Gulf War Illness'' and seizure disorder, as the V.A. has
denied both and reworded my claim. That is a small example of the many
medical conditions that I have that fall under GWI that I am fighting
since 2007 when GWI was recognized by congress.

California

Around 1990 I was invited to attend SFOD-D, during the selection
process I was given a flight physical which I passed with no issues and
was given a class date in March of 1991. Desert Storm kicked off not
long after this and I was cross-levelled to 2nd ACR for Desert Storm
where I served as a Bradley Cmdr. Upon my return I was ordered to the
101st. Where I was seen for rash, heart rhythm disturbances and
tachycardia (POTS) and vertigo, also present was persistent flu like
body aches after physical exertion. I was informed these issues were
psychological. I left the Infantry in 1994 and filed a claim which was
denied. I filed another claim in 2007 which was denied.
I filed another claim in 2009 for IBS which was granted.
In 2015 I had a serious flair which again brought the heart rhythm
disturbances (NSVT, PSVT and POTS) along with many of the issues
associated with GWI:

Neuropsychological deficits (documented by exam)
Cardiovascular signs or symptoms (documented by exam with
no explanation or identifiable pathology)
CFS, (documented by WRIISC) and recently Dr. Baraniuk.

These and a few others were included in a claim filed in May of
2015, all of which were denied.
It was not until [VSO's] took my case before the director did I
receive a partial award for CFS, all other issues are on appeal with no
end in sight.
There is no way I can cover everything, I am too cognitively
compromised and intend to hire an attorney to engage the VBA from this
point forward.
[VSO's] have some of these documents but I assure you there is
evidence to back up each of these claims. The VBA has it in their
files.
Most, if not all denials were ``Not service connected `` per the
VBA.

Florida

I live in the Tampa bay area in Florida. I made a claim for CFS in
2008 and subsequently in 2010 pointing specifically to the presumptive
law. Both were denied for lack of evidence. I included doctors' notes,
and diagnosis from the VA primary care and chronic pain clinics. I did
not appeal as I was at my wits end at this point given the VBA denied a
claim with diagnostics from the VAMC. (The VA denied a claim based on a
diagnosis for a presumptive condition by the VA) I am contemplating
reopening the claim and adding more evidence in terms of diagnosis and
treatment records however the previous two attempts were denied
specifically because there was no evidence in my service medical
records. At least I presume that given ``lack of evidence'' is a broad
statement. At the time I was being treated for chronic fatigue and
chronic pain. This again is for a presumptive...
I was informed by a claims examiner that if they can offer a
diagnosis then undiagnosed illness is out the window given it is then
diagnosed. This leaves a veteran suffering with a now known condition
that the VA can comfortably deny any claim against. That is a huge
loophole given often a diagnosis may not be well grounded and based
solely on symptoms presented. Often the symptoms may fit many diagnosis
and they pick one. I claimed CFS specifically along with physical
symptoms that were at the time present but undiagnosed.
The impact of the denial has both a psychological and a physical
impact. It makes you feel like you are being brushed away and are
wasting energy and time on an impossible brick wall of bureaucratic red
tape. This seems to encourage you to abandon hope of any successful
claim. I do not have the resources to mount a legal challenge and
frankly do not have the energy to either. Physically this leaves me
paying out of pocket often to treat the conditions if I seek treatment
outside of the VA. The medical supports would be wonderful but seem out
of reach. The compensation would assist in support of life in general
that tends to revolve around managing chronic conditions first and
working when and where one is able so as to survive without becoming
homeless.
This feeds stress generally which exacerbates said chronic
conditions. Ultimately if we are really dedicated to the care and
wellbeing of our veterans then it is Congress that must act to clarify
title 38 and end this debacle. It is Congress that as well needs to
properly fund the VA or other programs that will provide care and
compensation. It is a cost of war and it is hard to define... how much
is a Semi-normal life worth over what time span and by how many
hundreds of thousands of impacted persons? We stood up... we are still
paying a price... help please.

Indiana

I live in Indiana (Jeffersonville) and I filed in 2015 for
gastrointestinal issue and IBS problems. I submitted a direct
questionnaire from my personal doctor on these issues.
The VA denied saying that it was not service related. I appealed
and got denied again.
Without the meds I take I couldn't do the job I do every day with
an approved claim I could go back to school and do something easier on
my body.

Iowa

I am a retired Army MSG. I am also disabled through the VA. I
served in the Gulf War from October 1990 through June 1991. I served
all over the theater from Saudi Arabia, Southern Iraq, Kuwait, and
Northern Iraq. I am a combat veteran. I currently live approximately 45
miles from Des Moines Iowa.
I originally filed with the VA for Gulf War Illness in the summer
of 1998 while living in NC, just after I retired at the end of May. I
was just getting my notices for exams when my Gulf War veteran wife
took her own life. Due to circumstance and the severe depression and
other health issues I was unable to comply with those notices. The VA
denied everything due to that failure.
My second filing was in Iowa in 2008. I filed for the same issues.
I had been seeing medical professionals continuously since retirement.
All of that information was either directly obtained by myself or
provided or the VA obtained it through permission from me. My first
compensation and pension examination was right after Memorial Day 2009.
I was unable to comply because I was hospitalized with pancreatitis
during that weekend.
Even though my physician notified the VA my file was pulled for
non-compliance. I fought and involved my congressman and eventually the
file was returned and I was examined the first time in 2009 and other
times into 2010. None of the exams were for GWI specifically. That exam
was referred to Public Health.
However, I had claimed Chronic Fatigue Syndrome/Fibromyalgia,
Irritable Bowel Syndrome, as well as sleep disorder/sleep apnea and
much more symptomology that was unexplained and still is. All was
denied except 10% for IBS. All were appealed and again IBS was approved
at 30% and all other denied. IBS was not approved as a GWI presumptive.
All denials were stated to be unrelated to my service although most if
not all were recorded on my retirement physical. The appeal awarded me
100% P&T with only one GWI related issue. Due to the huge backlog in
claims I was advised not to pursue at that time.
I still suffer all the symptoms I had following the GW and they
have progressively worsened. The lack of diagnoses prohibits possible
treatments. The entire merry go round of seek and deny exasperates the
depressive disorder I share with my PTSD.

Kentucky

I am in Louisville, Kentucky.
I filed for a constellation of neurological symptoms with no
diagnosis in 2013, and was denied for each symptom of my undiagnosed
illness.
I appealed in 2014 with a new diagnosis of cramp fasciculation
syndrome on the argument that I should have been approved for
undiagnosed illness, but now should be approved for an idiopathic
chronic multisymptom illness. I was then denied for no service
connection.
I appealed that decision citing the presumptive in 2015. My appeal
has been reviewed by the Star team twice and sent back to the regional
office and denied each time. The examiner's opinion, a nurse
practitioner, seems to carry more weight than my VA neurologist who
diagnosed me, and the Chief Examiner in DC. The last statement of the
case said the nurse practitioner's opinion was more compelling.
The claim is now awaiting a hearing with the board of appeals.
I filed for IBS in 2016. The same examiner stated it could not be
service connected. I was denied for no service connection. The Star
team sent it back for correction. The examiner literally described my
severe symptoms, and stated I experience them moderately. I am
currently rated at 10%, and have appealed for 30%. This claim is also
going to the board.
I am facing an early retirement due to my health. The failure of
the VA to provide me with adequate care, and then basing the rating
decision on that same inadequate care is causing me an unnecessary
amount of distress and financial hardship.

Louisiana

I am in Louisiana and continue to be denied for fibromyalgia since
2000. I have documentation signed by a rheumatologist in a Gulf War
exam in 1994 with that diagnosis. I am currently on Cymbalta with VA
medical records stating that I declined Lyrica because it has not
worked for me in the past. An NP at a C&P exam recently told me that I
was never diagnosed with fibromyalgia, and I am not on any medications
to treat fibromyalgia. I received a call last week from a VA employee
at the central office stating that there was enough evidence in my file
for service connection, and that I need to get my case out of my
regional office.
There is more to the story. I was sitting in my VSO's office on 27
March 2017, discussing which conditions we would forward to DC on
appeal, when my phone rang, it was an employee from legal at the RO. He
told me there was enough evidence for a CUE. As he was talking, my VSO
was typing. That too has been denied. After several calls, to include
one to the White House complaint line, a supervisor from the RO called
me and told me that the VBA judges have ``more leniency'' than she has,
and that she would need a nexus letter. I informed her that it was my
understanding that for presumptive conditions, with a diagnosis, no
nexus was needed.
I came home from vacation today and this was in my mail. I might
find the irony in this funny if they had not been denying me since
2000. ``Dear [Veteran's name], We received your correspondence
indicating that you would like to file a claim for benefits. VA
regulations now require all claims to be submitted on a standardized
form. What Should You Do? In order for us to begin processing your
claim, you must submit an application for benefits.'' [From the U.S.
Department of Veterans Affairs]

Maryland #1

I have been diagnosed with fibromyalgia, CFS, IBS, and migraines.
VA states I'm only eligible for migraines and Fibromyalgia. They sent
my appeal to board without a review. Stating all my symptoms are
fibromyalgia related.
This case was done at the Baltimore RO, it was expedited to clear
the backlog. The VBA's Star Team review, but only looked at the IBS and
agreed it was separate from the fibromyalgia and recommended that a
claim for IU be submitted. They didn't look at the Chronic Fatigue
Syndrome diagnosis. The case was denied because supposedly [the]
diagnosed condition of CFS isn't related to military service, the
decision is in violation of the statute.
The RO never communicated that they received diagnosis of IBS, they
did in fact communicate receiving diagnosis and DBQ for Chronic Fatigue
Syndrome, but stated that the CFS wasn't related to military service.

Maryland #2

I now live in Maryland. I filed for the first time in 1991 three
months after coming home for headaches and fatigue and was denied.
There are other issues that I have filed for over the years that fall
under the Presumptive Illness List but I will concentrate on these two
diagnoses.
I never had a migraine in my life until 3 months after I returned
from the Gulf. The headaches over the years went from here and there to
daily occurrences that included migraines thrown in every few days. I
am on daily medication to help keep the headaches from turning into
migraines on a daily basis.
The fatigue is just as bad. Some days it hits me out of the blue
and I literally can't get out of bed for days on end. I just sleep. As
an example, I just went through a phase this week: I slept 14 1/2
hours, woke up for 3 hours, slept for another 8 1/2. This is right off
my Fitbit.
Yet, after filing in 1991 again in 2012 and again last year I have
been denied each time. How am I supposed work when I LITERALLY can not
get out of bed? I wish I could work EVERYDAY! This is not how I saw my
life at 47 years old. But I would go and serve all over again knowing
where I am now. Because I know that I helped people while I served my
time in the sandbox with my unit, Fleet Hospital 15.

Ohio

I suffer from dizziness. It's constant, but comes with episodes of
severe debilitating loss if muscle control. I call it dizziness because
it feels like I don't have my balance, but it's more than that, I get
unreasonably depressed, can't walk, feel like I'm falling all the time.
It started years earlier, but being young I just wrote it off as being
hungry or tired.
When it became debilitating i went to the best neurologist at the
Cleveland clinic. They have no idea what it is, but tried treating me
with anti-seizure medicine, migraine and multiple other things. None of
them worked. He believes they are caused by constant migraine headaches
without aura or pain. He found the VA presumptive conditions and
suggested I should pursue it because he couldn't solve it.
In about 2013 I applied under the gulf war presumptive conditions
first for dizziness. They denied me because in the 90s I had positional
vertigo, they said it was the same thing. I appealed in 2014, they
denied me.
I then filed in 2015 for migraine induced dizziness, they denied me
for chronic fatigue syndrome. You will note, I did not apply for
chronic fatigue syndrome, I applied for migraine induced dizziness,
which meant not only was I denied, I could not appeal it because I had
no evidence for chronic fatigue. It was no mistake on my or my VSC
representative's fault, they just changed it.
So we refiled, with another note and more evidence from my
neurologist, headache with a secondary condition of dizziness. They
denied it because I once had a tension headache.
We appealed with another note from my neurologist stating I was not
having tension headaches, listing the clinical and medical definitions
of both, and quoting the VAs presumptive description which didn't
specify any particular type of headache anyway.
It's been about eight months since that. I'm still disabled,
employed by the grace of my employer that understands and gives me time
off any time I am ill. I pass out randomly and have symptoms mimicking
heart attack because of also having a rating for irritable bowel.
I'm tens of thousands in debt for the bills I've incurred. My life
is changed forever. There are days that I can't get out of my chair.

Pennsylvania #1

I live in Pennsylvania. The following is my statement of claim for
denial of CFS and Fibro:
The AOJ provided a VA examination dated April 7, 2017 unfortunately
the exam was inadequate. The exam was not based upon the medical
record, specifically the Georgetown University Progress Notes dated
March 02, 2017 in which James N. Baraniuk, MD (Professor of Medicine,
Division of Rheumatology, Immunology and Allergy, Director of the
Chronic Pain and Fatigue Research Center, Georgetown University)
diagnosed me with Chronic Fatigue Syndrome using the Centers for
Disease Control (Fukuda 1994) criteria, and he diagnosed me with
Fibromyalgia using the 2010, & 2011 Modified American College of
Rheumatology criteria (SEE: Georgetown University Progress Notes dated
March 02, 2017). A medical examination is considered adequate ``where
it is based upon consideration of the veteran's prior medical history''
(SEE: Ardison v. Brown, 6 Vet.App. 405, 407 (1994).
The examiner falsified the April 7, 2017 exam; he never touched me
on any area of my body to check for tenderness, in fact the only
contact with this examiner was to shake my hand upon arrival and
departure. He spent approximately half of the allotted time for the VA
examination admiring my service dog which had nothing to do with my
claimed conditions of fibromyalgia and chronic fatigue syndrome. He
then leafed thru the Georgetown University progress notes and asked
about Dr. Baraniuk's credentials, but apparently investigated no
further because he stated that my condition (fibromyalgia) ``was never
confirmed by a specialist.'' (SEE: VA Form 21-4138, statement
concerning exam of April 7, 2017).
If this examiner had taken the time to investigate the credentials
of Dr. Baraniuk, he would have found with a simple search on the
internet that James N. Baraniuk, M.D. is the Associate Professor of
Medicine, Division of Rheumatology, Immunology and Allergy, at
Georgetown University. He is the Director of Georgetown's Chronic Pain
and Fatigue Research Center and is one of the nation's leading experts
on both fibromyalgia and chronic fatigue syndrome (SEE: me-pedia.org
James Baraniuk printable). He is also one of the nation's leading
experts on disabilities occurring in Persian Gulf veterans. His
curriculum vita (CV doc) is 41 pages long (SEE: James N. Baraniuk,
M.D., curriculum vita).
The examiner errored in his rational when he stated that because
exposures to environmental hazards were about 25 years ago, he could
not confirm any disability pattern that would be related to Southwest
Asia service. The Department of Veterans Affairs' Employee Education
System and the Office of Disability and Medical Assessment (DMA) offer
a Gulf War General Medical Examination Course. If the examiner had
participated in this training or referenced the notice to examiners in
Southwest Asia claims, found in Part IV, subpart ii, 1.E. 19.g of the
M21-1 manual he would have understood that the examiner is to provide a
medical statement explaining the Veteran's disability pattern.
Fibromyalgia and Chronic fatigue Syndrome are both diagnosable but
medically unexplained chronic multi-symptom illnesses of unknown
etiology, and they are disability pattern 2, a diagnosable but
medically unexplained chronic multisymptom illness. The notice to
examiners in Southwest Asia claims tells the examiner that he or she
shall not provide a medical opinion (nexus) for disability pattern (1)
or (2) as to whether the condition was incurred - caused by service.
Clearly the notice to examiners in Southwest Asia claims was not
followed as this examiner, in violation of the statue, imposed a nexus
requirement.
The AOJ's adjudicator failed to recognize that a Gulf War veteran
does not have to prove any link to the veteran's service and the VA
cannot impose a nexus requirement under the provisions of 38 CFR Sec.
3.317. Fibromyalgia and chronic fatigue syndrome are presumptive
illnesses for Gulf War veterans; VA presumes that these conditions were
caused by military service. The decision of May 12, 2017 is clearly and
unmistakably erroneous as it is in violation of statue, VA regulations
and VA procedures.
This C&) was done April 7, 2016. Denial was dated May 26, 2016.
Less than 32 days. (working days)

Pennsylvania #2

I am a 20 year Marine Corps Veteran (1984-2004) who served in the
Persian Gulf from August 1990 - April 1991.It was mandated that I
receive the Anthrax Vaccinations (Series of 6 shots) but I only
received 5 shots because the program was Temporarily halted prior to my
6 shot and at a later date restarted. No explanation! I was also
required to take the progesterone Bromide Pills (3 weeks) while serving
in country during Operation Desert Storm.Prior to and since my
retirement from Active Duty, I have reported numerous medical problems
that have not been adequately treated or document to include:I am from
Pennsylvania (Pittsburgh VA Healthcare System).
2006 - MAJOR DEPRESSIVE DISORDER: I was diagnosed and medicated for
the treatment of Major Depression. I filed a claim through the VA that
was DENIED and the examiner inappropriately diagnosed me, based off of
personal opinion as being an Alcohol Abuser. I never drank in the
military and have only been a Social drinker since being discharged. I
have NEVER abused Alcohol or any other Illegal drugs.
On February 6-9, 2017, because of the intense pain and Fatigue that
I suffer from among other things on A DAILY BASIS, I applied for, was
accepted and participated in a DOD Gulf War Illness Research Study
conducted at Georgetown University by Dr. James N. Baraniuk M D. My
decision to participate in the aforementioned study was based off of
the fact that Dr. Baraniuk is an Associate Professor of Medicine,
Director of Rheumatology, Immunology and Allergy, Director of Chronic
Pain and Research at Georgetown University. He is also one of the
Nation's leading experts on both Fibromyalgia and Chronic Fatigue (SEE;
me-pedia.org James Baraniuk). I found this information through a simple
search on the internet.
Through this intense 4 day study Dr. Baraniuk spent more than 15 1/
2 hours with me, one on one, after the testing. I also had my service
Medical Records and Deployment Records with me for review. As a result
of the study, I received a POSITIVE diagnosis for GWI (per the Kansas
Criteria), Fibromyalgia (per the 1999, 2010 & 2011 standards), IBS-C
and Chronic Fatigue. The doctor also noted, utilizing my VA treatment
records, PTSD, DEPRESSION and SLEEP APNEA.
Upon completion of the study, I spent the next 3 Months conducting
follow up appointments through the Pittsburgh VA for testing evaluation
and treatment. I also filed claims through the VA.
The Medical Examiner, who lacked the specialized credentials that
Dr. Baraniuk possesses, proceeded to discredit Dr. Baraniuk's progress
notes by stating ``that study is done for research purposes only... Not
for diagnosis proposes'' the Medical Examiner, a Nurse Practicioner...
NOT an MD, wow these remarks in her notes.
My claims for IBS and Fibromyalgia were DENIED under the Chronic
Multisymptom Illnesses (CMI) because the medical examiner noted that I
have clear and diagnosable illnesses.
I clearly have a Medical diagnosis for IBS and Fibromyalgia (both
are Gulf War Presumptives seperate from CMI) From Dr. Baraniuk and also
from the VA since 2016 yet both were DENIED by the VA 's Rating
Specialist.
The constant delay and deny and the Lack of understanding of the
Gulf War Symptoms cause me daily anguish and pain. As a result of the
lack of a proper diagnosis and treatment, my conditions have
continually worsened to the point that I had to quit working at the age
of 49 due to my mental and physical conditions yet the VA has still not
recognized the importance of training their medical staff to understand
and identify the issues that we, Gulf War Veterans, suffer from even
though there is medical knowledge and research that has confirmed these
issues that has been paid for and conducted by the Department of
Defense!
I was also Service Connected at 0% from the VA in June 2017 for the
frequent headaches that I suffer from (another Gulf War Presumptive).
I've also had my CFS and Sinus (respiratory) claims denied twice. I
have Sinusitis all through my Service Medical Records but the VA calls
it Sinus Rhinitis

South Dakota

South Dakota, 1994 CFS, degenerative disease of the joints, memory
issues, headaches Denied for not being noted on Service Records, same
story on the Appeal. ``filed as joint pain, headaches, memory issues,
and being tired constantly'' x-rays, lab work, Doctors reports
submitted. 2001 Doctors claim it is arthritis, and not degenerative
disease of the joints. New Claim, denied, Appeal Denied. Did not appear
in Service. Doctors notes submitted. 2006 Doctor said I have CFS, New
Claim, New Evidence denied again, Appeal Denied. Did not appear in
Service. All records were forwarded with all claims from V.A. Doctors
since 1993. Presumptive Laws never applied for my claims, I asked.
Frustration with the whole V.A. claims system!

Texas

I'm writing this letter on behalf of my recently deceased husband,
whose death took almost 26 years to complete, and waiting for
compensation took a chunk of years as well. My husband came back from
Dessert Storm with several symptoms, ranging from burning eyes, chronic
fatigue, rashes, sore throat and various other flu like symptoms.
Within 3 months of coming back while doing an exercise with the unit,
was flipped over in his kayak. He came home pretty sore.
The next day his leg was swollen and very painful, he was rushed to
Walter Reed and diagnosed with Antiphospholipid Syndrome, sticky blood?
He had many other illnesses pop up such as a parathyroidectomy, scalp
cysts removed, anemia and with these came much suffering. He was
adamant about pushing forward, not complaining, being a soldier. His
commander had a special meeting with a board at NSA regarding the need
to keep this soldier because he was necessary for the missions due to
his extensive language abilities. he was to stay stateside and work
from here. During this time he had many bouts of illness without much
complaining. In 2001 he retired after 21 years' service. At discharge
he was giveb 30% disability.
By 2003 my husband had an attack of Retroperitoneal Fibrosis. Then
Rhabdomyolysis and again the chronic fatigue was taking its toll. He
applied to VA again, was denied and we presented more evidence taking a
year to finally receive 60%. In the meantime we were in Fort Lewis and
Madigan felt they could not help this man with such complicated
problems so gave him the ability to use a private doctor. Then things
got worse, he was diagnosed with Raynaud's Syndrome, toe removed,
Sympathectomy surgery, and we were having to pay out of pocket up
towards the thousands. The Autoimmune diseases seemed to cascade to 7
active diseases. My husband's dream was to move to New Braunfels, Texas
and I researched the doctors in San Antonio. The trek across country
began. This time I realized we had to have a doctor that would
understand GULF WAR SYNDROME. This doctor did. My husband applied again
in 2015 and by Jan. 2016 he was awarded 100% with the help of the
doctor advocating for him. Twenty-six years of suffering and one year
of that time he was 100% . He died, and written on the death
certificate was pulmonary fibrosis as a result of Antiphospholipid
Syndrome. He gave his all and had to fight to get just a piece of what
was rightfully his!

Wisconsin

I am a Gulf War Veteran from Wisconsin. Entering the Marines out of
High School, I was very experienced long distance runner at the peak of
my health. In basic training, I very proudly placed second in the
``Company Iron Man''. Ultimately out performing all but one of 402
other Marines from all over the United States. Little did I know at the
time however that within two years of that performance and my return
from the Persian Gulf, I would never run or regularly participate in
athletics again without debilitating consequences. Ultimately I left
the Military Reserves directly due to my inability to physically
perform. Despite a written request for legal support and medical
testing, I was denied this examination and given a General Discharge. I
still had my honorable discharge from active duty and the war so I
didn't really care.
I have fought my physical battle completely on my own for the last
thirty years until visiting the VA for the first time about 5 years ago
at the urging of my former company Gunny and other members of my Unit.
I first applied for connected disability in May of 2014. If there ever
was a text book case of Gulf War Illness, it is me. Due to a VSO error
my claim was not placed until November of that year. Approximately one
year later, I was denied all issues claimed to include Chronic Fatigue,
Gastrointestinal Issues, Sleep Deprivation, Joint and Tendon Issues
(Fibromyalgia), Depression, and a chest injury which occurred while in
active service.
Evidence provided was my SRB, and all of my medical records from
the VA to that point which included all labs and imaging. I had also
participated in a War Related Illness Study which I also provided
records of. It was the conclusion of this VA Department that all of my
current medical conditions and symptoms ``are consistent and meet the
VA Case definition of Gulf War Illness. I have now been invited to
participate in no less than four gulf war illness studies through the
VA.
While some aspects of my initial denial were from ``conveniently''
missing components of my service records, the common thread across
nearly all denials was a ``lack of diagnosis''. I had also tested
positive for RA so they were able to apply that to anything else that I
claimed. I was being treated for all of these issues but apparently
none were diagnosed? I was amazed one arm of the VA could conclude I
met the criteria while the disability governing body could not. I
brought this up to a doctor at the VA Hospital and he explained they
treat symptoms and do not diagnose! I thought to myself this ultimately
would make it impossible to ever be granted anything!! This seemed to
defy sanity that one department of the VA was demanding diagnosis and
the hospitals were saying they could not be provide any! It is very
apparent to me the hospital staff has been groomed to very carefully
stay away from the issue of Gulf War Illness. Every time I bring it up
to this day, I have never been provided any written or even oral
connection from the Hospital to Gulf War Illness. It was finally eluded
to me in confidence that hospital staff could get into trouble for
referencing Gulf War Illness in their treatment records and that they
could not provide that nexus.
With this apparent and deliberate conflict of my interests for my
VA Doctors to provide me the diagnosis I needed, I ultimately decided
to leave the VA and go to a third party provider. I applied for copies
of all of my medical records from the VA and traveled with them at my
own very significant expense to the Mayo Clinic in Rochester MN for
some real answers. I got a hotel and stayed there for three days in
hopes of finally finding out what was so wrong with me.
Within three days, YES ONLY THREE DAYS I had the following
diagnosis. This is something I have been unable to get at the VA in the
four years I have been going there for treatment.

DIAGNOSES #1 Rheumatoid arthritis #2 Bilateral peroneal
tendinopathy #3 Subpatellar degenerative arthritis of the left foot #4
Chronic fatigue, fibromyalgia #5 Gastroesophageal reflux disease #6
Chronic diarrhea #7 Prior chronic lower abdominal pain #8 Major
depressive disorder, recurrent, moderate symptoms #9 Obstructive sleep
apnea #11 Insomnia
So now in addition to the War Related Illness Center, I have
diagnosis of all of the above from the Mayo Clinic. Clearly a
connection right?? WRONG. While I considered this the smoking gun
evidence I needed, I have still have not been awarded any connected
disability to this day. ZERO PERCENT.
I have since resumed my treatment at the VA. I was told from my VSO
there is approximately a two year wait before my appeal will even be
opened. I have heard more recently that this wait is now up to four
years. Over the last ten years I have lost two jobs and have lost my
home and land due to bankruptcy. We have had to move twice and change
schools which was really tough for my kids. I feel like I am on the
verge of losing another job and I am afraid I can't rebuild things
again. I am very fortunate to work from home where I have been able to
hide and disguise my fatigue and sleep from my employer. My prayer is
that I am granted some partial disability (50%+) so I can be honest
with my employer and try to reduce my hours to accommodate the severe
fatigue.
My VA psychologist told me Wednesday that it was an awful long time
to hold onto life by my fingernails and I agreed. I have put a belt
around my next twice and told my Doctor Wednesday that I would blow my
brains out if I am denied again. 22 per day don't kill themselves
because of PTSD-it's for being continually denied and called a liar by
the administration that is supposed to be helping us. Veteran's and
particularly those of war like me look at life very differently than
most. If I have no hope- I will not continue to be a burden on myself,
family, or country. I will however do my best to let them know I was
destroyed by the Veterans Administration.

BRAIN CANCER (Not yet presumptive) - Missouri

My husband passed away from Glioblastoma Brain Cancer stage 4,
three Brain tumors on March 21, 2013. He was diagnosed on January 20,
2013 with the tumors. Although this is not a presumptive, this is to be
examined on a case by case bases. The claims examiner is to evaluate
the available evidence to determine if it is at least likely that the
Veteran's Brain Cancer is related to his or hers exposure to
environmental hazards while Serving in the Gulf War.
Environmental hazards include but are not limited to reports of
chemical alarms sounding of in Saudi Arabia as early as Jan 1991 and
Sabotage of Kuwait Oil Wells in Jan 1991.
I have provided the Veterans Affairs Office and claims examiner
over 59 medical files for review, However, the Denial determined by the
V. A. Compensation claim examiner was denied with a review of only TWO
medical files. I must say I have felt like a dog and pony show jumping
through Circus hoops chasing down medical records, faxing. Following
up, hand delivering notices. The V.A. faxed a small Death Certificate
that was not legible and I had to hand carry the document to the
Physicians and Providers. This did stir up much emotion, to say the
least.
I reside in Missouri, a small town close to Whiteman Air Force
Base. I laid him to rest on our Wedding Anniversary. The most precious
gift I could give him, His Military Honors.
My husband suffered with many illnesses for over nine years prior
to the Glioblastoma Brain Cancer, some would have been presumptive, the
headaches, undiagnosed neurological disorder, irritable bowel syndrome,
degenerative disc disease, many surgeries. He had seven shots in his
hands every four months. He immediately went to the V.A. and was put on
the Gulf War Registry when his illnesses first started in 2002. We
never ever thought he would pass away. It all happened so fast. I
didn't have time to process anything. I lost the Love of my life. I was
mentally and completely broken. I went to Therapy, eventually was
treated with in- patient therapy as the Loss was so great I couldn't go
on with my life. I never thought of contacting the VA until a little
over a year of his passing. I made the funeral arrangements and paid
for the marker myself. I wasn't aware he could be laid to rest in the
National Cemetery just 20 minutes away with a Proper Military Marker.
Although I Love the marker I purchased, I feel a bit cheated that His
Air Force isn't displayed. I called the VA after getting my Gulf War
Newsletter, to tell them in case they were keeping track and they told
me to file a claim. I filed in July 2014. I provided so much medical
evidence and proof, there is no way any Medical person could deny this.
I am a common housewife and I can see the evidence clear as day. I have
had two denials. I am currently collecting more Medical Evidence. I was
asked to get Buddy Letters. Now that's impossible. The government
admits the exposure, admits it causes Cancer of the Brain, yet throws
ridiculous and impossible task on the Surviving Spouse. I can't ask my
husband who his Buddies were now can I ? The ongoing fight for Justice,
I am HIS VOICE is a Daily struggle for me. I have panic attacks, I want
to give up at times. Then I think about Him. His Strength. His Love for
me. He fought to stay with me when he was suffering because I was
crying and weeping and couldn't let him go.
Now it's my turn to fight for Him.
He wanted to take care of His Wife. He fought hard on His Death Bed
for me. Now it's time for me to fight for him. I am His voice. May
Justice and Truth Prevail for Our Hero's.

Statements For The Record

RONALD E. BROWN
Thank you, Chairman Bergman, Bost, Ranking Members Kuster, Esty all
other members of the House Veterans' Affairs Subcommittee on Oversight
and Investigations and Disability Assistance and Memorial Affairs. I
thank you for holding this joint investigative hearing on the VA's
Disability Claim Process with Respect to Gulf War Illness claims.
My name is Ronald Brown; I'm President of the National Gulf War
Resource Center (NGWRC). The NGWRC is a small 501 (c) (3) non-profit
veteran service organization, which is comprised of sick Persian Gulf
War veterans who volunteer our time to advocate for our fellow veterans
suffering from the complexities of modern warfare. We specialize in
Gulf War Illness claims, we work with veterans to educate and assist
them in the claims process. We also work with policy makers inside the
VA, to accomplish two goals: first, to insure clinicians are better
trained about conditions facing this group of veterans to insure the
veterans receive the best health care possible.econdly, we are working
to address and correct issues affecting this group of veterans, such as
the high denial rate of Gulf War illness related claims.
We, the NGWRC have been working on addressing problems within the
Gulf War Illness-related disability claim process with senior VA
leadership for over the past three years. Everything in this GAO report
has been addressed, corrective recommendations have been offered, but
corrective action promised by the VA clearly wasn't carried out. I'm
left scratching my head on exactly what has been accomplished, Our
brain cancer presumptive has come to a standstill, those affected
veterans and their families still can't obtain service connection, Gulf
War presumptive claims are still denied at 80% plus rate, Examiners are
still not trained on Gulf War related C&P exams. Adjudicators from
around the country are poorly trained on Gulf War Illness-related
presumptive conditions; the priority is to clear the claims backlog,
causing many wrongfully denied veterans to wait years for a long drawn
out appeals process.
After last year's hearing (PERSIAN GULF WAR: An Assessment OF VA's
Disability Claim Process with Respect to Gulf War Illness) we was
contacted by the Government Accountability Office (GAO) concerning an
investigation Congressman Coffman had initiated on Gulf War claims. We
provided data the Veterans Benefit Administration (VBA) had shared with
us on these claims to GAO representative Nora Boretti. This data
Ssuggested to us that the VBA has a serious problem with presumptive
Gulf War Illness claims. The data provided Gulf War presumptive claims
denial and approval rates from 2001-2017. In addition to the VBA data,
we also provided actual blacked out presumptive condition claims that
had been wrongfully denied. These claims had actual language the VBA
used in its denial, and showed that the examiners and adjudicators had
failed to follow statue, regulations (38 CFR Sec. 3.317), and VA
procedures. With each claim, we also provided blacked out medical
evidence that proved that the veteran suffered from a medically
unexplained chronic multisymptom illness. We also provided C&P exams,
some in which the examiner failed to follow the guidance in the notice
to examiners and provided an unnecessary medical opinion which caused
the claim to be denied. Prior to providing these claim examples to the
GAO, we first highlighted the errors and sent them to senior VBA
leadership, who had them reviewed by VBA's quality control (Star Team)
and the decisions had been overturned.
As previously stated, the NGWRC has been working to address the
problems adjudicating Gulf War Illness-related disability claims for
over three years. One of our first meetings was with Under Secretary
Allison Hickey which led to a special focus review Gulf War Illness-
related disability claims. VBA was instructed to randomly pull a
statistical sample from claims dated 2011-2015 and have the Star Team
review them. The findings of this Special focus review follows:

Special focus review overview:

During the period of August through December 2015, Compensation
Service (the Quality Review staff) conducted a special focus review
(SFR) of Gulf War (GW) cases. This review was the result of a meeting
that took place on August 17th, 2015 with Under Secretary for Benefits,
Allison Hickey; Tom Murphy, Director of Compensation Service; and Brad
Flohr, Senior Advisor, Compensation Service, along with Ron Brown,
President, National Gulf War Resource Center. It was noted that the
National Gulf War Resource Center had numbers that reflected GW cases
were not being decided correctly. From this meeting, a decision was
made to have Compensation Service (the Quality Review staff) do a SFR
on GW claims that were denied.
This review involved Veterans of the earlier Gulf War period that
served between August 1990 and July 1991.
A total of 311 cases from the first two quarters of Fiscal Year
2015 were reviewed. Although some of these cases included claims for
other disabilities that were not related to Gulf War, this review was
restricted to the Gulf War related illnesses on each claim. The
findings below are presented based on a claim based review. This means
that if an error was found with a specific issue denied, the entire
case was erroneous.

FINDINGS:

Of the 311 cases reviewed, 291 were properly denied, and 20 were
improperly denied. This corresponds to a 94% accuracy rate within our
sample.
The VBA testified as to the special focus review findings at last
year's hearing. After the hearing we (NGWRC) received the special focus
review findings from the VBA. After reviewing the findings we
determined that the VBA had not done the review as was agreed upon in
the meeting with Under Secretary Allison Hickey, only claims from the
first two quarters of Fiscal year 2015 were reviewed instead of claims
from Fiscal years 2010-2015 as agreed upon. We contacted Secretary Bob
McDonald who instructed the VBA to do a second Special focus review in
which claims from Fiscal years 2011-2015 would be reviewed. The VBA
drew 111 less claims than what was agreed upon (311) in this second
special focus review. The findings are listed below:

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

From the fairly small numbers of veterans the NGWRC has helped with
the claims process, it is abundantly clear that the VBA has a systemic
problem with Gulf War Illness-related disability claims. Adjudicators
are not well trained, the emphasis isn't on accuracy; rather, on
clearing the backlog of claims. The statue, VA regulation and VA
procedure (M21-1 manual) often aren't followed. To complicate the issue
C&P examiners aren't properly trained on these types of claims, despite
VAs insistence that they are, this GAO report found the examiners
training on these types of claims is optional, not mandatory as we were
led to believe, and only about 10% of VA's examiners have completed the
optional Gulf war Illness course. In the claims we have reviewed, got
the VBA to overturn, and provided to the GAO (15 - 20 claims), it is
abundantly clear that most examiners who preform Gulf War exams don't
understand guidance in the Notice to Examiners in Southwest Asia claims
(below) that they are to provide a medical statement, and not a medical
opinion about service connection for disability type (1) an undiagnosed
illness, and (2) a diagnosable but medically unexplained chronic multi-
symptom illness. As pointed out in this GAO report, adjudicators often
fail to recognize that the examiner has provided an unnecessary medical
opinion concerning service connection, and the veterans are wrongfully
denied.

j. Notice to Examiners in Southwest Asia Claims

Please examine this Veteran, who has service in Southwest Asia, for
any chronic disability pattern. Please review the claims folder as part
of your evaluation and state, with your findings, that it was reviewed.
The Veteran has claimed a disability pattern related to [insert
symptoms described by Veteran].
Please provide a medical statement explaining whether the Veteran's
disability pattern is:

(1) an undiagnosed illness

(2) a diagnosable but medically unexplained chronic multi-symptom
illness of unknown etiology

(3) a diagnosable chronic multi-symptom illness with a partially
explained etiology, or

(4) a disease with a clear and specific etiology and diagnosis.

If, after examining the Veteran and reviewing the claims file, you
determine that the Veteran's disability pattern is either (1) an
undiagnosed illness; or (2) a diagnosable but medically unexplained
chronic multisymptom illness of unknown etiology, then no medical
opinion or rationale is required as these conditions are presumed to be
caused by service in the Southwest Asia theater of operations.
If, after examining the Veteran and reviewing the claims file, you
determine that the Veteran's disability pattern is either (3) a
diagnosable chronic multi-symptom illness with a partially explained
etiology, or (4) a disease with a clear and specific etiology and
diagnosis, then please provide a medical opinion, with supporting
rational, as to whether it is ``at least as likely as not'' that the
disability pattern or diagnosed disease is related to a specific
exposure event experienced by the Veteran during service in Southwest
Asia.
Many of veterans that we assisted in the appeals process were
wrongfully denied because the Regional Benefits office imposed a nexus
requirement. The decision letter stated that the claim was denied
because ``your service treatment records are silent for complaints,
treatment, or a diagnosis for your claimed condition of [Fibromyalgia,
Chronic Fatigue Syndrome or Irritable Bowel Syndrome]''. These types of
denials are direct violations of U.S.C. 38 Sec. 1118 which states that
these conditions (diagnosable but medically unexplained chronic multi-
symptom illnesses) are presumptions of service connection associated
with service in the Southwest Asia theater of operations and ``shall be
considered to have been incurred in or aggravated by service
notwithstanding that there is no record of evidence of such illness
during the period of such service.'' The United States Court of Appeals
for Veterans Claims upheld the statue when it ruled in the case
Gutierrez v. Principi, 19 Vet.App.1 (2004), that a Gulf War veteran
does not have to prove any link to the veteran's service and the VA
cannot impose a nexus requirement under the provisions of 38 CFR Sec.
3.317. The Courts ruling follows:

Gutierrez v. Principi:

``In this case, the Board finds that the veteran's initial claims
for VA compensation, the initial VA evaluations, and the veteran's
initial statements to the VA following his discharge from active
service (in which he fails to mention any disability associated with
joint and muscle pain, fatigue, dizziness, decreased vision, memory
loss, and loss of concentration) provides affirmative evidence that the
undiagnosed illnesses were not incurred during his active military
service. It further fundamentally undermines the veteran's credibility
in that it is his central contention that he has had these disabilities
over an extended period following his discharge from service. If this
was the case, the Board finds no rational reason to believe that there
would not be at least some evidence or indications in support of the
veteran's contention or that the veteran would not have noted these
difficulties earlier or during his initial examinations. The Board
finds that these facts do not support the veteran's case. The only
evidence of record before the Board specifically linking the veteran's
current alleged disabilities to his service or to Gulf War syndrome
consist[s] of the veteran's own evidentiary assertions. Such evidence
is of limited probative weight. While the veteran is competent to
describe manifestations perceivable to a lay party, he is not competent
to diagnose himself with disabilities and then associate those
disabilities with his active service or with any form of Persian Gulf
syndrome R. at 14-15 (emphasis added). If this were a claim for direct
service connection, a nexus between Mr. Gutierrez's disabilities and
his period of active service would be required. See Caluza, supra. In
this case, however, evidence is not required ``specifically linking''
Mr. Gutierrez's disabilities to his service or the Gulf War. See Brock,
supra. Congress has decided as a matter of policy, stemming at least in
part from difficulty of proof, that, even though a Persian Gulf War
veteran's symptom may not at this time be attributed to a specific
disease, the symptoms may nonetheless be related to conditions in the
Southwest Asia theater of operations and, for that reason, are presumed
to be service connected. See 38 U.S.C. 1117; 38 C.F.R. 3.317 (a)(1)(i).
Thus, Mr. Gutierrez was not required to provide evidence linking his
current conditions to events during service and the Board erred by
imposing such a nexus requirement. Further, as stated above, section
1117 and 3.317 require that undiagnosed illnesses become manifest to a
degree of 10% or more during the presumption period that ends on
December 31, 2006. See 38 C.F.R. 3.317(a)(1)(i).
Accordingly, the Board erred by failing to account for that, as
well as the other factors discussed below, in determining that Mr.
Gutierrez's complaints were not credible because he had not sought
treatment for these conditions earlier or did not complain about them
during his initial medical examinations. The Board also found that,
although Mr. Gutierrez had complained of joint and muscle pain,
fatigue, dizziness, and loss of concentration, the objective medical
evidence failed to show any such disabilities. R. at 15. The evidence
of record reveals that Mr. Gutierrez consistently complained during VA
medical examinations about fatigue, muscle and joint pain, neurologic
signs or symptoms (loss of concentration and memory), and sleep
disturbances. See R. at 98, 106-108,125-28, 228-29, 329, 348-53, 423,
426-27. These symptoms are specifically identified by VA in its own
regulation as possible manifestations of an undiagnosed illness in Gulf
War veterans. See 38 C.F.R. 3.317(b).''
Another troubling and frequent problem we see in Gulf War Illness-
related disability claims is that often the examiner, usually a Nurse
Practitioner, will override the diagnoses from a medical specialist.
Medical specialists are the ones who have run all the necessary testing
to rule out all other clinical diagnosis that could produce symptoms
before they diagnose a CMI such as fibromyalgia. The specialist often
is the one treating the veteran or at least advising the veteran's
primary care provider. As recently as two weeks ago, we assisted a
veteran whose claim for fibromyalgia and chronic fatigue Syndrome was
denied because the examiner stated that the veteran's diagnosis wasn't
confirmed by a specialist. Ironically the veteran was diagnosed by
James N. Baraniuk, MD (Professor of Medicine, Division of Rheumatology,
Immunology and Allergy, Director of the Chronic Pain and Fatigue
Research Center, Georgetown University). Dr. Baraniuk is one of the
nation's leading experts on disabilities occurring in Persian Gulf
veterans.
We have also seen exams where the veterans have a clinical
diagnosis of Fibromyalgia, Chronic Fatigue Syndrome, and Irritable
Bowel Syndrome and the Adjudicator's try and lump the veteran's
conditions under one rating even though all three conditions carry
their own rating criteria in 38 CFR Sec. 3.317. Generally this hurts
the veteran as they are given a lower rating percentage.
After three years of trying to get the VA to correct issues with
Gulf War Illness-related disability claims; I honestly feel that the
only way to a viable fix is thru legislative action. I believe that
Congress needs to reevaluate the statue; I don't think it was
congressional intent for a process in which most Gulf War Illness-
related disabled veterans are denied service connection for their
illnesses. In the last hearing in March of 2016 Representative Kuster
had mentioned that perhaps Congress needs to go back and look at the
legislation they did to create Undiagnosed Illness and I agree I think
this desperately needs to happen.
I also think that Congress needs to reevaluate USC 1117 and 1118.
It is almost impossible to add presumptive conditions for Gulf war
veterans in part because this stature requires positive proof
concerning exposures. How's this possible, Gulf war veterans were
exposed to a variety of environmental and chemical hazards, unlike our
Vietnam veterans whose main exposure was herbicides? I honestly believe
Congress needs reevaluate this legislation and change the positive
proof wording to benefit of the doubt since there are so many exposure
variables that will never be known.
Without, guidance from Congress, I do think that the VBA or VA will
take action to address problems within the Gulf War Illness-related
disability claim process. I say this because I have spent the last
three years addressing the same issues identified in this GAO report
with Senior VA, VBA and VHA leadership with very little to show for it.
They have had 26 years to get this correct and it's still not even
close. So, I honestly hope Congress can assist in providing legislative
help for Gulf War veterans. Below are the same recommendations I
provided at the last hearing, with a new recommendation highlighted in
yellow.

Recommendations:

Have VA report back to Congress quarterly with the type of training
being conducted and with proof the Gulf War medical and adjudicator
training has indeed been done by all required VA employees. Make it
mandatory and ongoing!!! ONE AND DONE TRAINING ABSOLUTLY HAS NOT WORKED
ON GULF WAR MEDICAL AND AJUDICATOR TRAINING (NEW Recommendation).

Training. Training the front-line adjudicators concerning Gulf War
illness related claims would be the most effective tool in solving the
high denial rate of Gulf War illness related claims.ulf War illness
related claims make up 29% of the current back log.his training would
further serve to reduce the growing number of appeals.f the policy
makers in the Central office are serious about fixing the high denial
rates of Gulf War illness related claims, they need to ensure that each
regional office around the country is doing mandatory training. The
upper management in the Central office should direct the directors of
each Regional Benefits Office to ensure their front-line adjudicators
are using the M21-1 manual.his manual provides the adjudicators all the
references needed to accurately adjudicate claims.eferences in this
manual include U.S. code, VA Regulation (CFR) and related U.S. Court of
Appeals for Veterans' Claims cases.his manual is an excellent tool if
used.
Transparency, the VBA must continue to provide Veteran Service
Organizations with data on these types of claims.his ensures that VSO
organizations can monitor and keep tract of denial and approval rates
as well as provide critical information to the veterans they represent.
Have VA report back to Congress quarterly with the type of training
being conducted and with proof the Gulf War medical and adjudicator
training has indeed been done by all required VA employees.
In closing, below is the Data VBA furnished the NGWRC on Gulf War
presumptive claims from Fiscal years 2002-2017 This data covers more
years than the GAO's report and paints an even darker picture of the
systemic problems VA has with Gulf War presumptive claims!!

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Respectfully,

Ronald E. Brown
President
National Gulf War Resource Center

Paul Sullivan
Thank you, Chairmen Bergman and Bost, Ranking Members Kuster and
Esty, and Members of both Subcommittees for your support of Gulf War
Veterans and for holding today's hearing about the processing of Gulf
War illness (GWI) disability compensation claims administered by the
U.S. Department of Veterans Affairs (VA).
My name is Paul Sullivan, and I am a disabled Veteran who served as
a cavalry scout in the Army's 1st Armored Division during the first
ground invasion of Iraq and Kuwait during the 1990 - 1991 Gulf War. I'm
also the Director of Veteran Outreach at Bergmann & Moore, LLC, a
national law firm based in Maryland representing Veterans with claim
appeals before VA, including the Board of Veterans Appeals (Board) and
the Court of Appeals for Veterans Claims (Court).
Since becoming ill in the war zone and returning home, I've
dedicated my professional life to assisting fellow Veterans. For more
than two decades, I continue working closely with Veterans who were
denied VA benefits, including fellow ill Gulf War Veterans.
Since my first appearance on July 16, 1998, I've had the honor of
testifying several times before the House and Senate with the goal of
improving government policies regarding Veterans, including several
hearings on GWI claims. My statement today again focuses on government
policies and practices.
However, there is an important addition in my statement for this
hearing. For the first time, I am providing Congress with a description
of VA errors, delays, inadequate exams, lost records, and retaliation.
I am still waiting on VA to decide my GWI claim originally filed on
July 28, 1992. It remains deferred and undecided at a regional office.
The Subcommittees are rightfully concerned to focus on GWI claims.
Congress acted properly in 1994, 1998, 2001, and 2010 with new laws to
assist Gulf War Veterans with obtaining VA service connection in order
to obtain free VA treatment (38 USC 1117 and 1118). Congress acted
wisely and carefully based on the urgent needs of hundreds of thousands
of ill Gulf War Veterans who reported ailments associated with toxic
exposures after deploying to Southwest Asia during Desert Shield and
Desert Storm.
Many fellow Gulf War Veterans and family members worked diligently
with Congress for years to help pass the laws because VA research
indicates as many as 250,000 Gulf War Veterans remain ill. Your
continued involvement is welcome and appreciated.
With some exceptions, in order for Veterans to obtain free
treatment at a VA medical center, Veterans need to be granted service
connection via VA's highly complex and often adversarial disability
compensation claim process. One of the most important exceptions is a
law providing free healthcare for Veterans who deployed to a war zone
for five years after discharge from active duty (38 USC 1710). The law,
enacted as part of the landmark ``Persian Gulf Veterans Act of 1998,''
was expanded by Congress from an initial two years to five years in
2008. Hundreds of thousands of Veterans who deployed to our current
conflicts in and around Iraq and Afghanistan have used this new VA
healthcare benefit, and I thank Congress for passing and expanding the
law.

GAO FINDINGS

Today's hearing was prompted by the new report issued by the U.S.
Government Accountability Office (GAO) into VA's mishandling of GWI
disability compensation claims (``Gulf War Illness: Improvements Needed
for VA to Better Understand, Process, and Communicate Decisions on
Claims,'' GAO-17-511, June 2017). Bergmann & Moore thanks Congress for
requesting the GAO investigation into VA's processing GWI claims.
However, GAO's conclusions raise serious concerns for Congress to
address:

Hundreds of thousands of Gulf War Veterans remain ill:
``Nearly 30 years after the Gulf War conflicts began, hundreds of
thousands of veterans continue to experience chronic medical conditions
that may be related to a host of hazardous exposures they faced while
serving our country..''

Gulf War Veterans were exposed to toxins: According to
the GAO, Gulf War Veterans were exposed to ``pesticides, smoke from oil
well fires, and depleted uranium that could be linked to their medical
conditions.'' Other hazardous exposures include pyridostigmine bromide
chemical warfare agent pre-treatment pills and chemical warfare agents
such as sarin and mustard gas.
VA examiners lack training: Only 10 percent of VA medical
professionals conducting Compensation and Pension (C&P) exams for
Veterans seeking service connection for GWI were trained using VA's
voluntary 90-minute video.
VA examiners are confused: VA medical professionals
conducting C&P exams for GWI expressed ``confusion'' on how to conduct
and report a GWI C&P exam.
VA lacks a case definition: VA has no case definition for
GWI, and that hampers C&P exams, rating decisions, and treatment.
VA remains fixated on identifying a diagnosis to make it
fit: Some VA C&P examiners told GAO that ``they could nearly always
attribute a Veteran's symptoms to a diagnosable illness, which would
mean the Veteran does not qualify for benefits under the undiagnosed
illness presumptive category.'' VA's action arguable defeats the
purpose as it circumvents the law.
VA issues unnecessary opinions: ``According to several
[VA] claim rating staff we interviewed, [VA] medical examiners
sometimes provide a medical opinion related to service connection when
one is not necessary because the Veteran has a presumptive condition.''
Untrained C&P examiners thus ``inadvertently deny'' a claim that should
be presumptively granted (Gutierrez v. Principi, 2004).
VA issues incomplete rating decisions: When VA issued a
Gulf War Veteran a GWI rating decision, VA often did not include key
information on why it was denied. For example, when VA issued a Veteran
a claim rating decision, VA may not have listed or considered both
direct and presumptive service connection. VA's lack of clarity causes
Veterans frustration when trying to determine the next step in the
claim process, such as appealing VA's rating decision.

According to GAO, the impact of VA's challenges cause severe and
adverse consequences for ill Gulf War Veterans seeking service
connection and healthcare:

VA forces Gulf War Veterans to wait longer: VA takes four
months longer to process a Gulf War illness claim than other claims
because GWI claims involve multiple and complex medical conditions.
VA denies Gulf War Veteran claims more often:

-VA's Alaska regional office denied all GWI claims.

-VA granted GWI issues ``about 3 times lower than all other medical
conditions.''

-VA granted service connection to only 10 percent of the Gulf War
claims under Undiagnosed Illness in 2015 (the 1994 law, 38 USC 1117).

-VA granted service connection to only 22 percent of the Gulf War
claims under chronic multisymptom illness in 2015 (the 2001 law, 38 USC
1118).

While the GWI laws have provided tens of thousands of Gulf War
Veterans with some relief and access to VA medical care and disability
compensation, an unknown number still face unreasonable obstacles
before obtaining VA treatment and benefits. GAO estimated the number of
completed yet unreported GWI decisions to be in the tens of thousands
because of underreporting ``due to unclear guidance and inconsistent
data entry over time'' by VA.
The bottom line for ill Gulf War Veterans is that we are often
prevented from obtaining the VA treatment and benefits we earned and
urgently need due to VA's problems confirmed by GAO. Thus, a large
number of ill Gulf War Veterans continue suffering.

EXAMPLES OF VA CLAIM ERRORS

Bergmann & Moore, managed by former VA attorneys, has assisted
several thousand Veterans with VA claim appeals over the past 14 years.
Here are common VA errors in GWI claims identified by Bergmann & Moore
that go beyond those identified by GAO.

War dates: VA denied a Veteran's GWI claim based on
deployment to Southwest Asia during 1992, implying the war had ended.
VA should have granted the claim because the Gulf War continues and
existing laws apply to Veterans deployed to Southwest Asia starting on
August 2, 1990, and continuing through the present (38 USC 101(33)).
War locations: VA denied a Veteran's claim based on
service aboard a ship in the Persian Gulf, mistakenly believing the
nearby body of water was not part of the war zone. VA should have
granted the claim because the Persian Gulf is considered part of the
geographic area of Southwest Asia (38 CFR 3.317(e)(2)). VA should
update the definition of Southwest Asia so the tens of thousands of
Veterans who deployed to Turkey, Syria, Israel, Afghanistan, and other
locations since August 2, 1990, can rightfully obtain VA healthcare and
benefits.
VA used the wrong DBQ: VA denied a Veteran's claim
because the C&P examiner relied upon one or more incorrect Disability
Benefits Questionnaires (DBQ) to evaluate the Veteran's condition(s).
VA should use the more appropriate GWI DBQ for GWI claims and VA should
train staff to use it.

Some VA errors are simple to correct on appeal, such as knowing the
correct dates and locations for the Gulf War. According to the GAO,
other VA denials may require the Veteran to submit additional evidence.
However, some VA errors appear to be harmful to Veterans, such as
using the wrong DBQ or taking unreasonable and unwarranted steps to
diagnose GWI. The GAO report indicates that VA appears to be
inappropriately developing evidence or providing an unfavorable nexus
in order to deny a Veteran's GWI claim. VA's adverse actions are
counter to what Congress intended and Court mandate (Mariano v.
Principi, 2003).
In light of VA's high denial rate and errors, Bergmann & Moore
encourages Veterans with situations similar to those listed above to
consider appealing VA's rating decision. Veterans should seek an
accredited representative to assist with filing a claim as well as when
filing a Notice of Disagreement (Form 21-0958) or Substantive Appeal
(Form 9).

VA USUALLY PERFORMS WELL IN OTHER AREAS

For nearly two decades, I testified in person several times in
support of new laws designed to improve VA so our Veterans would
receive timely and quality VA care and benefits. Congress listened and
took decisive action. My statement today is the first time I have
provided Congress with information about how VA maliciously and
incompetently mishandled my GWI claim for nearly a quarter century. My
goal is for Congress to have a rare view into the extreme challenges
Veterans face.
Before I begin describing my VA claim nightmare, allow me to
compliment VA medical professionals. As a former project manager
working at VA's central office here in Washington, DC, and as Veteran
who receives all of my care at VA, treatment for routine conditions is
exemplary. VA staff are usually polite, caring, and professional. Yet
my observation is that they are overworked with too many patients and
not enough time, especially in order to provide care for Veterans with
complex conditions. Although VA physicians continue trying, VA remains
unable to provide me with an effective treatment for my GWI.
Similarly, nearly all VA claims processors are doing the best they
can under difficult circumstances. However, training, staffing, and
oversight must improve at regional offices. VA regional offices should
focus on quality rather than on speed and production quotas.

MY 25 YEAR VA CLAIM ODYSSEY

My VA disability claim odyssey began on July 28, 1992. I walked
into a VA medical center for the first time and sought care because I
was suffering from several serious medical conditions. The previous
day, I called and asked VA what to do in order to receive care as an
ill Gulf War Veteran. The VA clerk advised me to arrive early in the
morning, bring my DD 214 discharge papers, and ask to see a physician.
Upon arrival at the VA medical center, VA refused to treat me. The
VA clerk said I was not service connected and that I did not serve in
the Gulf War. The clerk did not know that the military refers to the
Gulf War combat zone as Southwest Asia. My DD214 confirmed I deployed
to Southwest Asia and received the Southwest Asia Service Medal. The
clerk insisted I was not in the Gulf War because my DD214 did not
mention the Gulf War, Desert Shield, Desert Storm, Iraq, Kuwait, or
Saudi Arabia. The clerk never mentioned the need to file and win a VA
claim before receiving treatment.
A second VA employee who happened to walk by asked me if this was
my first visit to a VA medical center. I said yes, and the second VA
employee suggested I meet with someone who could explain how to file a
claim and obtain VA healthcare. I then met a Veteran Service
Organization (VSO) representative who explained VA's complex claim and
healthcare rules. That day, the VSO and I filed my original claim, even
though I was visibly suffering from a fever, sinusitis, migraine,
erythromelalgia, and other conditions. Like other Veterans, I filed my
VA claim in order to obtain VA medical care.
VA's poor handling of my claim could be summarized by saying, ``if
something could go wrong at VA, then it did.'' VA's significant
mistakes processing my GWI claim mirror the VA errors identified by
GAO's investigation. Here are examples:

VA transferred and lost my entire claim file: After
Congress passed the 1994 Gulf War illness benefits law, VA sought to
consolidate all Gulf War claims at four VA regional offices. That
didn't work out well. Then VA tried consolidating all GWI claims at a
single VA regional office. That failed as well. VA's repeated transfers
of my paper claim file resulted in my file disappearing between 1995
and 1999. My VSO advocate appealed and protested the transfer of my
claim file to no avail. My medical conditions worsened, and my medical
bills mounted. My paper records were eventually located by my VSO in
1999.

VA lost my C&P exams and medical records: VA lost C&P
exams and medical records needed to process my GWI claim. As a result,
even when VA had my file, VA issued partial rating decisions without
deciding my GWI conditions. VA deferred portions of my claim related to
GWI in 1995, 1999, and 2000.
My VSO located my file and reported VA retaliation:
During 1998 and 1999, attorney William ``Bill'' Russo searched for my
claim file for several months. At that time, Mr. Russo was the director
of benefits at the Vietnam Veterans of America (VVA), my VSO advocate.
He found parts of my file in four different VA regional offices. My
file inexplicably contained newspaper clippings about me, records of
other Veterans, and duplicate copies of my records. Missing from my
file were C&P exams and other salient DoD, VA, and private medical
records. After spending an entire day reconstructing my claim file, Mr.
Russo told VA's regional office director the situation was the worst
case of VA retaliation and mishandling of a claim he had ever seen. Mr.
Russo would go on to become the Deputy Director of Regulations at VA's
central office in Washington, DC. I thank Mr. Russo for his tenacious
advocacy. He died in 2016.
VA used untrained C&P examiners: In one example in 1992,
a VA physician conducted an exam without asking me any health
questions. In the ensuring appeal, VA provided a new exam and granted
the condition. In another example in April 2017, an untrained VA
physician conducted a GWI C&P exam. The physician used the wrong DBQ,
found a diagnosis, and provided a negative nexus opinion when none was
required. This is exactly what GAO concluded was wrong with VA. The
physician asked me to provide my military, VA, and private medical
records because the physician had not reviewed them. In a related
matter, VA sent me a letter asking me to call VA by a fixed due date
for a GWI C&P exam. However, VA's letter was postmarked after the due
date.
VA ignored key evidence: When rating my claim in 1993,
1995, 1999, and 2000, VA regional offices ignored probative evidence
from military, VA, and private doctors. For example, my military
records show the onset of my GWI while deployed to Southwest Asia and
Germany during 1991. In another example, a 1999 VA Gulf War registry
exam linked my GWI to toxic exposures.
VA admitted CUE: In April 2000, VA made an admission of a
Clear and Unmistakable Error, or CUE, in a November 1999 VA rating
decision. VA erroneously established an effective date of November
1999, instead of September 1991 (I filed my claim within one year of
leaving Active Duty, so the effective date is retroactive to my
discharge date). The silver lining in VA's April 2000 rating decision
was that VA did grant some of my conditions and opened the door to VA
treatment. The remaining dark cloud in VA's April 2000 rating decision
was that VA again deferred my GWI claim for a third time.
VA's failed Gulf War registry exam: During a Gulf War
registry exam in 2017, the VA physician was unaware of any new Gulf War
research or treatments. Furthermore, the physician, who regularly
conducts GWI C&P exams, confided that VA provided no training for GWI
C&P exams and that a supervisor issued orders to deny all GWI claims
except in cases where the Veteran was diagnosed with fibromyalgia,
chronic fatigue, or irritable bowel. The physician's comments confirm
what the GAO reported. I wrote a letter and brought the physician's
comments to the attention of the VA medical center's director, chief of
staff, and C&P director. I have not yet received a reply.
Other malicious VA acts - inexplicable change of my
address and release of my medical records: VA changed my address in
error to a location where I did not live. VA never explained how that
happened. VA sabotaged a meeting with legislators by releasing my
medical records without authorization. VA later apologized.
VA improperly cancelled my deferred Gulf War illness
claim: In the most egregious example of VA retaliation, VA improperly
erased my deferred GWI claim from VA's computerized Pending Issue File
(PIF) in September 2000. VA took action without notification or
permission from my VVA advocate or me. Even though VA granted a portion
of my claim and then deleted my claim from VA's electronic work queue,
my GWI claim still remains pending and deferred because VA never
decided it. I learned about VA's actions in July 2017 when VA provided
me a copy of a VA letter dated September 2000 that contained hand
written notes by VA employees improperly cancelling my deferred GWI
claim.
My appeals were timely and written: With the assistance
of my advocate, all of my notices of disagreement and substantive
appeals were timely and written. VA's actions described above are
unacceptable and unconscionable. VA should have decided my pending and
deferred claim at the regional office decades ago. My health continues
worsening since 1991. The cost in my time and medical bills is
staggering. I receive solace advocating for VA reform and assisting
fellow Veterans. I am still waiting a VA rating decision from a
regional office for my claim originally filed in July 1992, and in 25
years, my claim has never reached the Board or Court.

LOOKING FORWARD: SUGGESTED REFORMS

VA's concurrence with GAO represents a watershed step forward by VA
in acknowledging and resolving the issue of tens of thousands of denied
GWI claims. Bergmann & Moore agrees with GAO's recommendations.
Specifically, VA agreed to begin mandatory VA training for medical
professionals conducting GWI C&P exams, more detailed VA rating
decisions provided to Veterans, and the development of a case
definition for GWI.
Going beyond the GAO's recommendations, GWI disability compensation
claim laws and regulations need an urgent overhaul. Congress and VA
should take advantage of the disturbing new information about GWI
claims in order to collaborate with VSOs and other stakeholders to
improve claims processes so Veterans can receive prompt and quality VA
care and compensation for service-connected conditions.
Congress should act swiftly based on the momentum created by the
GAO report, VA's acknowledgement, and the testimony of advocates today.
Any new legislation should provide for scientific research, medical
treatment, training for claim processors at VA regional offices,
training for claim examiners at VA medical facilities, an updated
definition of Southwest Asia, and continued oversight through mandatory
reporting of healthcare use and claim activity.
The most critical component of any new legislation remains VA's
willingness to embrace change and understand the reasoning behind a new
benefits law. In the case of ill Gulf War Veterans, the main route to
free VA treatment and disability benefits comes after VA grants the
Veteran service connection.
VA should work with VSOs so the training to implement any future
laws and regulations meets the expectations of VA C&P examiners, VA
claims processors, VSOs, and Veterans. As part of training VA claims
processing staff about Gulf War illness claims, VA should share copies
of VA's training materials with VSOs and Congress so that advocates,
legislators, and Veterans have a better understanding of how to apply
for and prevail on a GWI claim. This would also include describing the
evidence needed, what to expect during a C&P exam, and what to look for
in a VBA rating decision.
In 1992, Congress mandated public reporting on the costs of the
Gulf War. GAO described how VA stopped creating and distributing the
reports. I was the person, while working at VA, who created the reports
in 2000. VA should resume the reports on a quarterly basis. Such
reports are consistent with the ``Veterans Health Care Act of 1992'' in
identifying Gulf War Veterans and reporting on various aspects of their
VA healthcare and benefit activity (Public Law 102-585).

CONCLUSION

It is an uncomfortable truth, however, that the issue of GWI claims
is here to stay for several more decades. As Gulf War Veterans age, we
will file more claims, including GWI claims. This is because our
conditions continue manifesting and worsening, thus revealing the true
long-term cost of war and toxic exposures on our health.
In the alternative, without reform legislation, Congress should
mandate that VA train C&P examiners and claims processors on the proper
processing of GWI claims, reopen all denied GWI claims, and then
complete adequate C&P exams and new rating decisions with retroactive
dates going back to the original date of the Veteran's claim.
Otherwise, the only remaining recourse may be litigation.
No Veteran should have to endure a lengthy, complex, and tortuous
VA claims process. After working on this issue for 25 years, I am
frequently confronted by countless Veterans who constantly share
similar VA claim horror stories with me. Our goals as Gulf War Veterans
remain the same today as they were in 1991, when we began falling ill
due to toxic exposures while deployed to Southwest Asia or after
returning home. Gulf War Veterans seek research to understand why we
are ill, treatments to improve our health, benefits for those in need,
training for those who assist us, and rigorous oversight and
accountability of VA from our elected officials.
I am available if the Subcommittee Members or staff have questions.
Thank you.

Kirt P. Love
Dear Subcommittee Members

My name is Kirt P. Love, and Im a disabled Gulf War Veteran, 19
year advocate, and former member of the Veteran Affairs Advisory
Committee on Gulf War Veterans back in 2008.
The nature of this hearing is a important one in what it can do,
provided its given the right content to move forward with. So I hope to
elude to points that Ive also covered with the committee the last 3
years.
Much of the 1990's there were various committees that set in motion
a flawed methodology that really never got corrected. From 1995 on even
with the GAO's involvement - recommendations mostly fell flat on ways
to steer VA. By 1998 the veteran community ( and myself ) rallied
around PL 105-368 and PL 105-277 hoping to steer things in a more
positive direction. The laws got passed into sudden over time and with
much of the content lost to the omnibus bill edits.
VA promptly took advantage by dragging out implementation 2 years
after it was signed. Only to take the clinical aspect and pervert it
into the War Related Illness and Injury Study Center rather than the
Gulf War Illness clinic we had set out for. Over the years it was made
into a one time throw away visit you could not get a referral for. Once
in, unless you knew what you wanted and demanded it - you got very
basic exams coupled with a psyche evaluation. No follow-up exam or long
term programs.
Then VA taunted the very nature of the Research Advisory Committee
and made it clear to them they could not operate on anything but
research. So they were not vetted for healthcare or benefits. This
later would become a ploy to eradicate vocal members and finally rig
the committee for silent running in 2015.
As the years passed, nothing was done about healthcare or benefits.
VA played down the Gulf War Registry, and the independent efforts of
the GWVIS to keep any kind of records of any trends not research
related. After the passing of Helen Malaskiewicz as the senior
coordinator of the program, it fell into silence and disrepair. The
Austin Automation center would no longer share any information with
outside sources.
VA was so glib that it altered the GWVIS reports outright to play
down the numbers, and my committee set up a task force to get answers.
Yes, VA was white washing the numbers to under report them by 11% or
more. VA's answer, get rid of the report. Then back the one time
printing of the pre and port 911 reports that show nothing of value.
Years would pas with no annual public data tracking.
Other borderline programs fell into disarray. The Spouse and
Children Registry of GW vets never got support, and it died quietly in
2003. Vaccine tracking, exotic diseases,
and such fell upon the Armed Force Institute of Pathology. The AFIP
refused to catalog the samples in such a way researcher could request
them at the time brain tumors surfaced in there vaults. It to took the
thousands of Gulf War tissue samples it collected them and buried them
at its new location once the staff was disbanded.
The National Academy of Science was tasked to provide reports
sanctioned by VA. The very nature of that was perverted, and the
committee never allowed anything but peer reviewed materials for
review. What was peer reviewed at that time wasn't helpful to the vets,
and volumes where left out on a technicality. By the time it came to
the ALS in Gulf war vets, the very name of the report was changed to
``ALS in the military'' to diffuse the situation as Gulf War vets
became part of the ``Deployment Health'' picture rather that helped
make the number seem smaller.
So by 2007 I pushed to get a federal advisory committee through
congress to address the items others could not. Even managed to get on
the committee. What I didn't allow for was this wasn't congressional
mandate, so VA put a very short tenure on the committee of 18 months
and then set it with ringers that would not oppose VA openly. The
chairman waited till enough time had passed, and then mocked many of my
issues - mostly the issue of 3.317. The very term UDX / MCI which VA
showed was easily dismissible due to its title. When I pushed, I was
shut down for ``telling VA how to suck eggs''.
In 2008 the final report was not what I wanted, and it had taken a
unpleasant turn groveling to the PDICI that Dr. Stephen Hunt headed up.
The Post Deployment Initiative Care program was a scam, it was a
psychiatric clinic looking for somatic issues which made me a instant
critic. Enough so to I dissented on the committees final report, and
make me a pariah in the VSO circles. Only to find out later the Gulf
War Illness Task force had secret meetings at VA endorsing Dr. Hunt,
and making none of this public for others to keep track of. The
committee, and its report was all but hidden from the public. My letter
of dissent never published by them on the page, and VA did its very
best the last 9 years to pretend it never existed.
The end result to all this is at the anniversary of the Gulf War 25
years later, you cant even get a claim processed if you file under
3.317 and you certainly have no where to go that isn't disposable or
secretive. The WRIISC serves no value, and is nothing like what it was
intended yet its massive and secretly funded between its locations. The
funding diverted to ``Deployment Health'' projects and a less than
savory person who stays with that behind the scenes to keep it going
for her DOD comrades. All the while supporting a program in Seattle
Washington that the vets have grown to despise.
Everything about this is vile, to include the fact that 6 million
records held by OSAGWI that should have been released last year are not
going to made public any time soon. That 25 years after the war, NARA
is going to keep these records beyond allotted storage time because of
exclusion clauses towards ``Weapons of Mass Destruction'' and such. Of
which 1.7 million are medically relevant to Gulf War veteran claims.
What we need is a revision of Gulf War Public Laws, and a
consolidation of the intent without having to recreate all this from
scratch. That we need a 20 year review of how and what failed, and what
can be repurposed. We also need to change CFR 3.317 and get rid to the
bottleneck terminology that keeps it a obstacle. Get rid of terms like
MCI and UDX that have no unique ICD 9, and link this to service, time,
region just like VA spells out on its VA Gulf War web page.
PL 105-368 is now a very flawed law that VA abuses in many ways.
Its given them funding, leverage, and the ability to wait vets out on
time. Its in desperate need of revision to not only make it more
current, but get rid of the bastardization such as the WRIISC that
insult its very purpose. To scale back, bring it all under one roof,
and make it veteran friendly, and always visible. Getting away from the
white washing terms of ``deployment health'' and start addressing the
specifics VA wants to ignore. Make this very specific and ongoing for
GW vets that need specialized long term follow-up such as myself.
I apologize for the condensed format and seemingly vague points in
this letter. What I really want to write is hundred of pages of extreme
details since 1998 that would show a pattern. So if I dont keep this
short, I loose the crowd to nap time. It is my wish that this be
followed up, and that my committee also be reinstated in some other
format with no termination date to deal with healthcare and benefits.
Leave the defunct current RAC to not have to violate its charter. That
3.317 is a dysfunctional code starting with its very
terminology. That after 25 years we need to get this back on track
to serve what little time I and my fellow vets have. As my own time is
running out soon.
Thank you for your time and consideration. Have good day.

Sincerely

Kirt P. love
Director, DSBR
Former member VA ACGWV

Montra Denise Nichols, MAJ, RET, USAF, RN RET, BSN, MSN
National Vietnam and Gulf War Veterans Coalition
I am Montra Denise Nichols a Desert Storm Veteran and Gulf War
Illnesses Advocate from 1992-2017 and giving testimony which gives the
overview of the problem with gulf war illnesses claims. In order to
cover this issue, one must understand it starts with when you walk in
the door at VA seeking care and help. Our issue started with changes in
our health and then progresses to benefits i.e. claims for compensation
and answers and treatment which is now being found in research.
Since 1991 when we return from our service in Desert Storm, our
group of veterans have been suffering without adequate health care and
effective claims service. This has continue for going into our 26 year
of returning home despite hearings, legislation, advisory committee on
benefits, advisory committee on gulf war illness research, IOM
contracted studies, GAO studies, countless committee hearings,
countless meetings and task forces, and legislative actions leading to
public laws but here we are still feeling as though nothing has
changed! It appears DOD has not totally been forth coming to help and
VA care and benefits has us feeling like third class citizens. Many
have tried, many have given up, many have died in a younger age group
than should have normally occurred to a group of service members that
went into service fully healthy and accepted physically the only
intervening factor was our service in a war theater during Desert
Storm. Many years ago we had a law put in place to cover the
undiagnosed illness, the chronic multi-symptom illnesses, chronic
fatigue syndrome, fibromyalgia, Irritable bowel syndrome and numerous
other health complaints as presumptive conditions. Still after all
these years the VA Benefits, Compensation and Claims process is broken
as each GAO study has documented. Others today in person and in written
for the record testimony will discuss in detail with examples given
from members of our community of veterans.
But in order to really understand the problem I believe you need an
overview of the total problem that we Desert Storm Veterans have
experienced because it all ties together one leads and impacts the
other area of the VA. We in our overall community believe our
government we swore to defend has not lived up to the due care and
benefits earned by the giving of our services and our very lives. TOO
MANY of our fellow veterans have died prematurely from Cancers
especially brain cancers, heart disease i.e. Myocardial infarcts,
pulmonary embolisms, and neurological conditions none of these have
been added as presumptive conditions. They have been left without
adequate care, no compensation for them or their surviving spouses,
they have become homeless, families have broken over the health and
financial distress, and some have given up leading to suicides. All of
this has happened due to all portions of our government failing us the
veterans of Desert Storm. This is totally UNACCEPTABLE and must have
immediate real action no more promises, no more words, no more denial,
no more ineffective responses, and no more excuses.
Others today will testify in person and on submissions for the
record on details of the claims for desert storm veterans situation I
am here to provide a total overview of the problems that have occurred
and the total interwoven situation from our service in theater to
approaching the VA for care to seeking answers and effective,
appropriate treatment, to getting research that should answer the
physiological damage done and methods of real treatment, to how the
total government system has failed, to how care and documentation from
VA health has direct implications to our claims and benefits, and how
legislative efforts have failed the Desert Storm Veterans. This has
impacted 1/3 to + of us Desert Storm Veterans. Many veterans took the
systems missteps and gave up. Many were suffering quietly having been
trained not to be gold brickers and not to complain. They struggle
valiantly and heroically to go on and try to reach their own personal
professional goals and to maintain themselves and their families. They
gutted up ignore the symptoms and did not want to appear weak. Those
that spoke up or continued pushing faced huge odds against them. Many
were left in the dark totally and did not know to question and keep
seeking care and help. Most of all they wanted to live their lives and
not to be disabled and warrant a compensation. Many wanted to stay for
a full 20 years or more in military service to their country and hid
their concerns in order to struggle on and serve in the intervening
years and deployments into war time environments adding more exposures
to their weakened physiological bodies.
This whole situation starts with inadequate records, maintaining
military active records from in theater, inadequate maintaining of logs
from headquarters down to lowest level of units on location changes,
vaccinations given, preventive medicines recorded in individual
records, inadequate and erroneous measurement of exposures levels at
multiple locations throughout the theater. Then inadequate
documentation of medical concerns of the symptoms as they occurred both
while on active duty status and upon leaving the service. The majority
of troops were kept in the dark on information on exposures and what
symptoms they needed to report i.e. any changes they had in pre-
deployment, deployment, redeployment home, and later throughout post-
deployment for 26 years.
There was no SOPs to medical personnel to truly take complete
physical history details, documenting locations and specifics of duty
positions that may be factors to consider, no physical assessments were
done completely in evaluation of exposures documented or undocumented,
medical personnel were not educated on exposures potential or what
symptoms to assess and report in medical records, vaccine records went
missing, medical items were not documented, the standards and
regulations of maintaining all documents from every level of command
were neglected.
Non-documented verbal directives seem quite realistically to have
been given to turn a deaf and mute response to our concerns when we
returned. Some doctors at the VA even said they could not help or their
hands were tied. I know this lead to professional dissatisfaction to
many of these health care providers. But MUM was the Standard operating
procedure or else they were left totally uninformed due to the DOD
actions. A few VA physicians and civilians researchers stood up for us
since the beginning many were disciplined in many ways or found
themselves out of jobs for speaking up.
If they weren't told, or given written information, or given
documentation from the DOD that VA accepted, or educated -then that was
just it. WE as veterans would end up and continue to surmise the why.
Was it money, budget, cover, negligence, geopolitical, personal
reputations of our leaders, politics, just ignorance, or blind
obedience to orders not valuing the service members health and
wellbeing, or even our commanders in the field and supervisory ranks
also affected by the ill effects of exposures that their abilities and
common sense were affected and degraded their leadership and
responsibility to their troops.
Have no doubt they have suffered for 26 years now. They have been
treated with no honor, no care, no celebration of their service. They
have been treated as third class citizens not as valued service members
and war time veterans. Their service is forgotten in every national
veterans ceremony or memorial day ceremonies.
Another factor is inadequate education and knowledge to health care
providers both military, VA, and civilians in regards to each exposure
or multiple exposures with synergistic and overlaying physical damage.
( whether documented and acknowledged by DOD or not!) None of the
doctors and health care providers have ever had education in medical
schools, internships, residencies, continuing medical education, or
medical conferences, or in VA employment as mandatory training on our
exposures or the greater area of military toxic materials and the
effects thereof to physiological body systems. The majority of health
care providers are whole fully uneducated on even our presumptive
conditions of chronic fatigue syndrome, fibromyalgia, Irritable bowel
syndrome, or the mirage of our other health problems listed under ill
defined chronic multi-symptom or un-diagnosable conditions. WE still
get health care providers that get that look like a deer in the
headlights, or how fast can They turf this to mental health and
behavior medicine, or how can I avoid the veterans questions, or avoid
real concerns, or avoid the good patient doctor communications, or how
fast can I get them out the door. WE take in research articles and
reports to help give them the info and tools but they are too busy and
not required to receive and read and question. They do not even to seem
to know what information is available if they pull up VA gulf war
health, WRIISC, VA RAC GWIR, gulf war public health information on the
computer sitting in front of them. They just follow the template as
provided by VA on medical documentation for a health visit.
The battle on a term for diagnosis for us and definition has been
talked about for 26 years! Name it gulf war Illnesses or military
toxics conditions define it by symptoms and findings so far in research
and give it a code and use the code! Quit running around in circles and
in the process denying our physiologic changes and symptoms and denying
claims for whatever purpose or reasons. You disrespect the veterans
service totally and do not give the veterans any benefit of doubt that
was caused by all the factors I am covering in this testimony. You
Dishonor our service and sacrifices. You do not give due trust in the
honesty of each veteran. A result of that loss of trust it leads to
future generations of civilians questioning joining the military if
their health and lives are not protected and given full priority
attention and benefit of the doubt!
The first step was a Gulf War Registry that became a rushed
questionnaire and very brief physical with very little physical
assessment except yep breathing, pulse, Bp. No full physical, no
complete detail history taking, no documentation of what the job was
that the veteran did and what exposures needed to be documented i.e.
fuels, tanks, flight duties, sanitation practice, noise levels exposed
to, medicines, vaccines given in theater, where were they located from
entrance to exit from theater, what unit and type of unit, what did
they handle, did they handle dead bodies or injured EPWs or friendly
casualties, or casualties showing symptoms, what symptoms no mater how
slight occurred and when, what did they take note of in theater?, what
did they observe as strange, what has changed head to toe.
No neurological exam, no follow on consults re sleep study, no
referral to dermatology for skin samples are just a few examples. No
history taking on changes noted in memory, multitasking, comprehension,
executive management tasking, change of IQ, school or duty performance
impacts. They did not document exposures to oil fires smoke and follow
up with complete respiratory function test and challenge substance
respiratory functions. No EEGs, EMG, no assessments by specialties like
immunology, endocrinology, infectious diseases, otologist(hearing)
testing, no visual acuity testing were some of the items neglected.
If you are going to do a registry then a full, complete, through
history, complete physical, complete testing of blood hematological,
immune factor, neurological transmitters testing, virus, infectious
testing, viral testing, testing for endemic diseases, complete urine
testing for Depleted uranium, metals and known toxins like a forensic
toxicology screen must be done.
These tests are needed in relation to confirmed, suspected, or
unknown toxins.
The registry records were never maintained from the start and data
collection has been missing.
The early specialty centers set up for gulf war veterans by the VA,
the early CCEEP by the military, and the follow on VA WRIISC were more
complete in this aspect but the majority of veterans who had symptoms
were not able to obtain these services. These services would have
provided much more in depth evaluations and testing and medical reports
to assist in the later application for claims and compensation from the
start.
The health care within the VA for Gulf war illness and exposure
assessment and medical reports is totally lacking on the physical
symptoms and changes that occur after exposures to any military toxic
exposures. The difficulty experienced in getting the diagnoses of
Chronic Fatigue Syndrome, fibromyalgia, and irritable bowel syndrome
that are so prevalent much less the other complaints and symptoms
addressed in the regulations is another problem that has not been
solved. Again the Doctors and health care professionals in the
military, VA, and civilian health care areas do not receive education,
continuing medical education, and training in military toxins. I wonder
why when service members receive training in NBC why is the medical
profession so lacking in knowledge? This is not covered in curriculums
for medical schools, internships, or residencies.
The total emphasis on claims should be focused on Desert Storm
Veterans and gulf war illnesses because we happened prior to 911, OIF,
OEF, etc, or the world trade center exposures. WE have waited too long!
Where was the preparedness planning for medical professions? What if
this happened within the continental US with massive civilians exposed?
Would the medical professionals know what to do?
In the GAO reports they state 1.1 million claims and 40% with
claims. How many of those are Desert Storm Veterans? Many Desert Storm
veterans were also Vietnam Era and mistakenly listed under Agent
Orange, yes we have documented cases of that too! And why does the GAO
not include every VARO in their reviews why only a small number of
VAROs are reviewed to get a really complete review? Why not pick out
those with high rates of approvals and find out the best practices?
Without adequate Gulf War Registry Exams and with VA uneducated
health care providers providing our health care then adequate medical
records and medical progress notes and medical testing is interwown in
the failure of successful claims adjudications ! The proof is in the
medical records, progress notes, diagnoses lists, medications list,
laboratory studies. Without proper mandatory training, education , CME
and credentialing and Standard Procedures(SOP), standing orders it was
destined to fail us the veterans in our claims process. The
requirements of proof and documentation is the necessary steps for a
successful claim. WE can not meet the requirements needed when we deal
with VA Benefits/Claims.
Without the right credentialed specialists Drs it is next to
impossible to get the presumptive conditions diagnosed. Then the VA
thru the Choice or fee basis programs for Desert Storm Veterans to get
to experts in the civilian medical profession does not work. When the
Desert Storm Veterans do go on their own expense to civilian experts
i.e. Rheumatology, Immunology, Dermatology, Neurologist, Endocrinology
with definite expertise and credentialed by specialty boards then the C
and P examiners and VA adjudicators ignore these experts diagnoses,
history, medical testing, and DBQs. The doctors at the VA may diagnose
but out right refuse to fill out DBQs for the veterans to help aid in
the claims process.
The medical providers, C and P examiners, and VA adjudicators need
mandatory and credential training to handle Desert Storm/Gulf War
illness/ military toxins issues. We were told by VA headquarters
personnel that all the adjudicators and examiners would receive
mandatory training! They lied to several of us. The GAO study proves
that fact!
The WRIISC staff at Palo Alto has done some clinician training both
in person and by web training. How many no one seems to have a full
data collection on that aspect. This has been a very small number I am
sure. Again No mandatory education has been done! The scheduled session
by phone and computer web is not known about at all by medical
professionals at each VA hospital much less the clinics. The VA care
providers have no knowledge on what WRIISC is, what they provide, how
to make referrals, how to find all the basic educational materials and
brochures, pamphlets, newsletters, magazines that the WRIISC have
developed. These materials are seldom if ever seen in the VA Waiting
Rooms or Doctors offices! The veterans get educated by other veterans
of where to find these materials and they hand carry the info to their
doctors. Then if they are lucky and do get referred the doctors at
their home VA have problems with follow thru with the results and
suggested plan of care. Again the documentation by WRIISC can help
significantly in the success of claims being approved due to their
documentation.
The VA RAC GWIRP since the turn over of committee members started
under Secretary Shinseki, then McDonald has deteriorated that advisory
group. The Presentations are not 100% applicable to what the mission of
the RAC is. There are no short term and long term goals for each
presentation made to the VA RAC GWIR. The RAC went to San Francisco a
year ago but did not seek a presentation by Dr Golumb at UCSD and VA SD
who is a prior committee member and gulf war illness funded researcher!
When they went to Boston on their last meeting the funded DOD GWIRP
Researchers at BU and Mass General were not invited to present past and
current research findings on GWI.
Personally, I have communicated in writing and verbally at each
meeting and to their staff coordinator the shortfalls of the RAC as the
veterans see them. They do not provide full interactive video
conferencing of their sessions. The example role model would be the HHS
Civilian CFS/ME Research Advisory Committee which has excellent web
based audio visual interactive meetings. They do not provide printed
notebook materials for the attendees to reference even on a back table.
I have suggested and encourage the committee to consider and use VA
facilities auditoriums like at Minneapolis VA where we have had MEG
research studies done and hyper coagulation research and a treatment
trial occurring! I suggested using Miami VA or the medical universities
there to have DR Klimas and Roskamp Institute to review their funded
gulf war illness research that is finished and ongoing. But no to that
too. Then there is a Stanford University Researcher expert in civilian
CFS/ME research and now funded at University of Alabama Birmingham for
a gulf war treatment trial research. Then there is Salt Lake City VA
funded studies on treatment trials for IBS. Then there is the gulf war
illnesses researcher at Georgetown Medical University here in DC
another expert in civilian CFS/ME that I recruited who has had funded
GWIR studies on MRI DT, Spinal Proteomics who has not been invited to
present to VA RAC GWIR when in DC for their meeting.
Why are we not using VA hospital auditorium and the Medical
Universities that are directly involved with VA hospitals as facilities
for these RAC meetings. Certainly it would help cost wise much less
drawn in more experts in the Medical Universities and their students!
WE need the different locations throughout the country utilized so more
veterans, Drs, researchers, and medical universities can be involved to
further research and get answers and help to Desert Storm veterans. I
would give the VA RAC GWIR at D in grade. All of us that fought for the
introduction and passage of the law for the VA RAC GWIR and served as
members of the committee or as attendees to the meetings have been
distressed by its decline in productive goal and mission directed
fulfillment. WE need a new RAC on a different set up model and covering
military toxic exposures.
The VA is still looking at our gulf war illnesses as a
psychological and Behavior Problem or Mental health problem. They are
treating with anti-depression medications and psychological
medications. Many of these have side effects impacting further our
immune system of the body. They frequently are using multiple anti-
depressant drugs at a time for a patient. And to use these drugs as
pain control is not appropriate. Some of our Desert Storm veterans have
been diagnosed with bipolar disease but never evaluated by MRI DT or
MEG or other advanced neurological techniques. Is it possible that they
have been misdiagnosed?
Genomics is what is needed NOW. That is the direction we are headed
in many areas of medicine to include Gulf War illnesses. Dr Klimas,
Golumb, DR Baranuck(Georgetown) and the researchers at Minneapolis are
headed now in that direction! The VA MVP could recruit more Desert
Storm Veterans rapidly and make that a priority now on GWI. Then we can
rapidly move to individualized genomic treatment and in the process
have more definitive evidence for the claims proof.
Serotonin and neurotransmitters have not been tested on Desert
Storm veterans that would provide more definitive proof of
physiological damage and symptoms of gulf war illnesses. Again this
would provide more definitive proof for claims to be approved. Dr Terry
at the VA has mention the neurotransmitters as being key to Gulf War
illness but no testing or data is available because that has not been
done.
Again, areas that could provide proof of exposures and
physiological damage that could help with diagnose, proof for claims,
and treatment avenues has not been meeting the urgent need. The other
is that of biomarkers coming from the animal models and correlated with
biomarkers from a small sample size of ill Desert Storm veterans that
matched! Again proof from the desert storm veterans physical bodies
that show exposures and proof that could be used individually in claims
or by extending the benefit of the doubt rule. These developments in
biomarkers and genomics can lead to true treatment of Desert Storm
veterans.
There has been a lack of coalition forces' governments to interact
in solving the medical problems and compensation issues. WE had UK
veterans attend RAC meetings to take an active role by fellow Desert
Storm veterans to set an example for the RAC but so far no action taken
by the RAC to seek out known experts in coalition countries.
There needs to be an urgent priority by all entities in the US
government from legislative branch, to health care VA and Civilians, to
researchers, and to VA Adjudicates on the Gulf War illnesses. WE have
not learned from the past of WWI, Atomic Veterans, Agent Orange
Veterans, Gulf War Illnesses Veterans, the WTC contaminated responders,
Camp Lejune Environmental exposures, Pesticide exposed agriculture
workers, and other toxic environmentally contaminated military bases.
There has been no Standardized Operating Procedures, standing medical
orders, regulations, education, training, credentialing of all that
were needed to be involved. Failures in the areas of documentation,
tracking mechanisms, effective leadership and management at all levels
that have direct impact on the effectiveness of claims adjudication and
thus failure approval of claims at a higher percentage.
Who is hurt most? The Veterans! It has been evidence that 26 yrs of
effort has failed not only in health care documentation but equally
assuring the claims process is fair, rapid, and effective to serve tens
of thousand, even hundred of thousands of Desert Storm Veterans.
WE need Toxic Exposure centers in each region of the country
located close to VAROs. If doctors give a presumptive diagnosis there
is no excuse for denial of the claim!
It seems to all of us Desert Storm veterans that it is the saying:
Same ##### Different Day. What is need is SOPs, Leadership, Expertise,
Outstanding Management, Creative thinkers and researchers to truly be
effective and solve the problems for Desert Storm Veterans with Gulf
War Illnesses.
Enough delay has occurred!
WE hold all US Representatives, Senators, DOD officials, VA
officials from every VA area, VA Headquarters, VA administrators, each
VA hospital administrator, chief of medical staff, VARO director, and
VA claims adjudicators, each committee or entity that has been involved
as failing to provide for the health and well being in all ways to
those Desert Storm Veteran dealing with Gulf War illnesses both with
presumptive categories and yet to come the diagnosable illnesses/
diseases that are leading to early age based diseases death rates.
I say again it is all interconnected and interwoven failures that
have led to the extremely high denial of claims for Gulf War Illnesses
and to correct this problem all areas have to be reviewed and revamped
now. I hope my testimony offers you the overview of the interconnected
failures. One of the reasons I pushed to cover the overview is because
US Representatives and Senators change every election cycle and many
elected after 1991 do not have the institutional knowledge of the
problems and delays we have faced. New doctors and health professionals
enter the profession, the military, and the VA constantly and are not
aware. New VA claims adjudicators and new C and P examiners get hired
without adequate or mandatory training.
WE need new legislation and laws now. No more delays fix this
problem as the highest priority that it truly deserves.
Look at our past lessons in exposures in war and compare
presumptives by war and exposure similarities and really look to the
urgent need to add Brain Cancers, other cancers, myocardial
infarctions, pulmonary emboli , hyper coagulation resulting
connections, neurological diagnoses, immune-endocrine related
diagnoses, Parkinsons Disease, early appearing Althemizers Disease,,
and many other diagnosed conditions.
It is wrong to deny claims and leading to widows and widowers left
high and dry after living thru their veterans deterioration and deaths.
We veterans know each other and see those left with nothing due to
serving this nation and having one of those life altering diagnosed
illness in too early of an age group compared to like population of
civilians at different age ranges. Maybe review the 911 workers at the
World Trade center program and legislation as a model to follow.

Questions For The Record

HVAC to VA
1. An analysis of data in the GAO's report shows that the grant
rates for undiagnosed illness (UDX) claims are lower than for chronic
multi-symptom illness (CMI) in most regional offices.
a.Why is the grant rate for UDX claims below 10% at approximately
half of the regional offices?

VA Response: When comparing approval rate data between regional
offices (RO), which GAO used in their study, it is not feasible to draw
conclusions on the reasons for approval rates or any variations between
ROs. As mentioned in the testimony, VA has conducted special-focused
reviews of completed claims in the last 2 years, and the reviews showed
94 percent and 89 percent accuracy rates. Further, the lower
inventories of cases at certain offices also affect any comparative
analyses conducted.
When discussing approval rates, it is important to note, as the GAO
report revealed, that Gulf War Illness claims have about twice as many
medical issues per claim as other disability claims. Further, this
category of Veterans has six conditions on average for which service
connection has been awarded, which is more than any other era of
Veterans.

b.Does the grant rate at each regional office (RO) influence how
work is assigned from the National Work Queue?

VA Response: The grant rate at each RO does not influence how work
is assigned by the National Work Queue.
2. GAO's report showed that grant rates for Gulf War Illness (GWI)
related medical issues varied across regional offices, from 0 to 64
percent for medical unexplained chronic multi-symptom illness (MUCMI)
issues and from 0 to 49 percent for UDX issues. Please explain the
variation in grant rates among regional offices?

VA Response: Please see response to Question 1(a).
3. GAO's report noted that the grant rates of the oldest types of
GWI related medical issues, UDX and MUCMI, have declined from 2010 to
2015. Similarly, the 2015 grant rate for UDX is approximately 10%
according to GAO. Why are the grant rates for these types of GWI-
related medical issues declining?

VA Response: Based on VA's analysis of data, to include fiscal year
(FY) 2016 data (which was not included in GAO's analysis), there is not
a trending decline in grant rates for UDX and/or MUCMI claims. In fact,
as noted in our testimony, 4,594 out of 18,681 Veterans were awarded
service connection for one or more UDX or MUCMI conditions in FY 2016.
This equates to a 25 percent approval rate, which is an increase from
the 22 percent approval rate in FY 2015. When analyzing only UDX
claims, VA's approval rate in FY 2016 was 13 percent compared to 12
percent in FY 2015. For MUCMI's, the approval rate in FY 2016 was 31
percent versus 29 percent in FY 2015.
4. How much of the appeals backlog was the result of VA denials of
GWI claims during the period reviewed by GAO, 2010-2015?

------------------------------------------------------------------------
Fiscal Year GWI Appeals Established
------------------------------------------------------------------------
2010 162
------------------------------------------------------------------------
2011 160
------------------------------------------------------------------------
2012 151
------------------------------------------------------------------------
2013 125
------------------------------------------------------------------------
2014 205
------------------------------------------------------------------------
2015 356
------------------------------------------------------------------------

a. How many GWI-related medical issues are currently in the appeals
process?

VA Response:
Number of GWI issues on pending GWI appeals (as of 7/31/2017):

------------------------------------------------------------------------
Number of Appeals GWI Issue Count
------------------------------------------------------------------------
1,242 2,513
------------------------------------------------------------------------

5. What is the grant rate of appeals filed by Gulf War veterans
whose initial claim was denied?

VA Response:
Number of Grants (VBA and BVA), and Total Decisions (Grants,
Denials, Appellant Satisfied with Decision, Remands, Withdrawn,
Dismissed, Vacated)

------------------------------------------------------------------------
Fiscal Year Appeals Granted Total Decisions Grant Rate
------------------------------------------------------------------------
2010 118 348 33.9%
------------------------------------------------------------------------
2011 90 259 34.7%
------------------------------------------------------------------------
2012 86 259 33.2%
------------------------------------------------------------------------
2013 86 274 31.4%
------------------------------------------------------------------------
2014 66 258 25.6%
------------------------------------------------------------------------
2015 108 271 39.9%
------------------------------------------------------------------------
2010-2015 554 1,669 33.2%
------------------------------------------------------------------------

a. Does VBA track the number of appeals per veteran?

VA Response: Yes.
NODs Established (2010-2015):

------------------------------------------------------------------------
Appeals per Appellant Number of Appellants
------------------------------------------------------------------------
1 1,131
------------------------------------------------------------------------
2 14
------------------------------------------------------------------------

Appeals Pending (7/31/2017):

------------------------------------------------------------------------
Appeals per Appellant Number of Appellants
------------------------------------------------------------------------
1 1,196
------------------------------------------------------------------------
2 20
------------------------------------------------------------------------
3 2
------------------------------------------------------------------------

6. Given VA's research into a potential connection between brain
cancer and service in the Persian Gulf War, is VA considering adding
brain cancer as a presumptive condition for Gulf War Veterans?

VA Response: Based on current science, VA has no immediate plans to
pursue establishing presumptive service connection for brain cancer in
Gulf War Veterans. VA will continue to review and evaluate any new
science that might be sufficient to establish a presumption of service
connection.
a. If yes, what is the timeline and cost estimate?

VA Response: N/A
7. Given the complexity of Gulf War Illness-related claims and that
only 10% of medical examiners had completed voluntary, supplemental
training, what efforts are underway to make this training for medical
examiners mandatory?

VA Response: Currently, the Office of Disability and Medical
Assessment (DMA) in conjunction with the Employee Education System
(EES) has changed the status of the course to mandatory training for
all Veterans Health Administration (VHA) clinicians who conduct
compensation and pension (C&P) examinations.
a. Are there any current proposals to make training mandatory?

VA Response: All current VHA C&P examiners have been assigned a
date of October 1, 2017, for mandatory completion of the training. The
course is now a certification requirement for all new examiners before
they can conduct C&P examinations. All VHA C&P examiners, regardless of
what type of examinations they conduct, are now required to complete
the ``DMA Gulf War Exam'' training.
b. Is training mandatory for contract providers?

VA Response: VHA does not currently have any contract staff
performing C&P examinations. Historically, VHA contractors were
excluded from conducting Gulf War examinations, thus the mandatory Gulf
War training would not be applicable to them.
c. How does VA plan to enforce compliance with training
requirements?

VA Response: VHA is monitoring and tracking the mandatory
completion of the course through its C&P Certification Database; we are
also working in concert with the Veterans Integrated Service Networks
(VISN) and field facilities to ensure compliance with the established
mandate to complete the training by October 1, 2017. EES is also
providing assistance with compliance by requiring their Designated
Learning Officers to assign this mandatory training to C&P providers in
the field.
8. GAO noted that MUCMI issues are only identified as being related
to GWI if VBA employees identify them within a Veteran's claims file.
Is VBA concerned that employees may not always accurately identify UDX
and MUCMI claims, and what is being done to limit the effect of human
error?

VA Response: The Veterans Benefits Administration (VBA) has
instructed field employees to carefully review claims and all other
evidence of record to identify conditions for which service connection
may be granted. This also includes reviewing the evidence of record to
determine when and where a Veteran served, for example, because such
service may warrant service connection on a presumptive basis. VA
continues to improve its claims forms to solicit detailed information
from the Veteran regarding his or her claim. In fact, VA is currently
in the process of creating special environmental hazard form(s), which
would allow employees to better identify claims related to Gulf War
and/or other in-service hazards. VA Central Office will continue to
provide information to the regional offices on various environmental
hazards that may cause adverse health effects.
9. What accountability measures should VA implement to ensure that
claims from Gulf War Veterans are timely and accurately processed?

VA Response: VA is committed to delivering benefits and services in
a timely and accurate manner. This includes claims for disabilities
received from Gulf War Veterans. The mandated training from and special
reviews conducted by Central Office are examples of measures that will
promote accuracy of processing and accountability in the field. VBA
will continue these types of efforts, to include national and local
quality reviews, which will ensure Gulf War Veterans receive a higher
quality decision. In addition, VA Central Office will be mandating
training for VHA examiners in response to the GAO recommendation. This
measure will enhance the quality of examinations conducted for Gulf War
Veterans.
Additionally, in May 2016, VBA implemented the National Work Queue
(NWQ), which allows VBA to prioritize and distribute claim inventory
according to RO capacity to address each Veteran or claimant's claim
based on date of receipt. This new functionality improves processing
times by allowing VBA to assign the next right case for action by
matching claims to available capacity; reducing the overall amount of
time claimants wait to receive a decision on their claims.
10. GAO reported that from 1994 to 2015, VA spent more than $160
million dollars on research related to GWI, with two offices focused on
VA GWI research. Please explain the reason VA has not yet adopted a
single case definition for Gulf War Illness.

VA Response: In 2014, after a year-long review, the Institute of
Medicine (now National Academy of Medicine (NAM)) released a report on
a case definition and Chronic Multi-symptom Illness, but could not
decide on a single definition and recommended instead two research
based definitions known as the Centers for Disease Control and the
Kansas definitions. These definitions are difficult to use clinically
or for benefits determinations. During that same year, a VA-Department
of Defense (DoD) workgroup adopted a definition for their Clinical
Practice Guidelines, but this definition was not research based or
validated through research in clinical practice. Currently, VA is
engaged in efforts to design a case definition that is explained below.
a. Who is responsible for prioritizing VA's research program?

VA Response: There are many entities that decide on research
priorities.
VHA's Office of Research and Development (ORD) provides research
funds to investigators at VA medical centers, and the priorities for
Gulf War research projects in ORD are described in the Gulf War
Research Strategic Plan (https://www.research.va.gov/pubs/docs/
GWResearch-StrategicPlan.pdf). The strategic plan was developed by ORD
with input from external advisory committees and internal experts. The
highest priority is given to projects that deal with treatments and
laboratory tests that could be used for diagnosing the condition. Each
proposed research project is evaluated for scientific merit by a panel
of subject matter experts (physicians and scientists) before a funding
decision is made.
b. Explain if and when VA plans to create a consensus, evidence-
based case definition for Gulf War Illness.

VA Response: VA, in collaboration with DoD experts, is currently
engaged in a concerted effort to develop a plan for an evidence-based
consensus definition that could be used in the clinical setting, but
would be validated by research as well. The effort includes a thorough
search of the literature and expert deliberations using various subject
matter experts and VA and DoD collaborators, including the
Congressionally Directed Medical Research Programs and the Naval Health
Research Center. The workgroup is targeting this effort to be done by
March 31, 2018.
11. Based on testimony received in connection to the hearing, how
might VA's alleged lack of GWI-related research impact the current
generation of Iraq and Afghanistan Veterans?

VA Response: VA continues to perform and to fund GWI related
research. This research will provide benefit to Veterans of more recent
conflicts. As an example, VA is funding a special volume on Gulf War
and Health by NAM to review possible intergenerational effects of
various toxic exposures. Although the contract specifies this is
targeting the first Gulf War, VA has encouraged the Committee to think
broadly so that the findings might translate to the newer conflicts as
well. Also, VA has the three War Related Illness and Injury Study
Center sites (WRIISC-DC, CA, NJ) that fall under the Post Deployment
Health Service. These specialty sites are doing research on health
effects that translate across conflicts. Post Deployment Health
Services currently has five Gulf War related research studies in
progress.
12. VA's testimony stated that VBA works with VHA and the DOD in
joint work groups that address occupational and environmental hazards
related to military service.
a. When did these work groups begin?

VA Response: The joint DoD/VA Deployment Health Work Group (DHWG)
met for the first time in January 2003. DHWG reports directly to the
joint DoD/VA Health Executive Council.
b. How often do they meet?

VA Response: The Work Group meets monthly and is made up of
representatives from VBA/VHA/DOD Defense Health Headquarters and the
Uniformed Services.
c. What are some of the goals for these work groups?

VA Response: DoD/VA DHWG was established to ensure coordination and
collaboration to maintain, protect, and preserve the health of Armed
Forces personnel. In order to improve force health protection efforts,
DHWG focuses on the health of active-duty members, Veterans, and their
families during and after combat operations and other deployments.
Initially, the primary focus was on Service members returning from
Operations Iraqi Freedom and Enduring Freedom. In addition, DHWG
coordinates initiatives related to Veterans of all eras, going back to
the 1940s. DoD and VA share information and resources in the areas of
deployment health surveillance, assessment, follow-up medical care,
health risk communication, and research.
d. How do these groups and VA in general, track and record
environmental exposure for the current generation of service members?

VA Response: A millennium cohort study began in 2001 and will
continue until 2022. Launched in the summer of 2001, the Millennium
Cohort Study began enrolling a representative sample of US military
personnel, both active duty and Reserve/Guard members, who agreed to
participate in follow-up well past their time in service, for up to 21
years. All participants provide important information on exposures and
health through and beyond their time in service. Information is
maintained confidentially and securely. The Millennium Cohort Study was
designed to conclude in 2022.
13. How many registries does VA maintain related to deployment and
environmental exposure?

VA Response: VA has six Congressionally-mandated registries.
a. How are these records being used to improve the diagnosis and
treatment of deployment related conditions?

VA Response: VA and collaborators have built cohorts for research
using these registries. However, a more important aspect of these
registries is that they enable VA to provide clinical care, education
as to issues that may arise, and assessments to Veterans. Examples are
the Toxic Embedded Fragment Surveillance Center Program that does
thorough workups on affected Veterans, and the Gulf War and Agent
Orange Registries. Veterans benefit from a discussion of the results of
their exams, specialty clinical consultations, and examinations when
necessary. VA has a current multi-year, multimillion dollar effort to
improve the utility of the registries and improve the data utility.
Finally, VA has a concerted effort underway to train providers and
environmental health coordinators on various aspects of environmental
exposures and conducted several trainings and outreach. The newest
registry, the Airborne Hazards and Open Burn Pit Registry is providing
a service to both Veterans of the first Gulf War and also Veterans of
the more recent conflicts in that area.
Registries are self-reported ``opt-in'' lists, and these attributes
have significant limitations for research. The Individual Longitudinal
Exposure Record (ILER) may correct that concern. ILER is a VA/DoD
effort funded with Joint Incentive Funding to develop an automatic
recording of exposures from the time a person enters military service
until discharge or retirement. This would allow VA to place a person at
a specific place and time and know what exposures and at what levels
the Servicemember was exposed, rather than relying on best
recollection. VA has recognized the need and a pilot will be delivered
in summer 2018.
b. Please provide a list of registries

VA Response:

Agent Orange Registry
Airborne Hazards and Open Burn Pit Registry
Gulf War Registry
Ionizing Radiation Registry
Depleted Uranium Follow-Up Program
Toxic Embedded Fragment Surveillance Center

14. Much of the data that GAO used to conduct the review is easily
available within VA's Performance Analysis and Integrity unit, but it
is not reported publicly and reportedly not provided to Veterans'
Service Organizations (VSOs).
a. Will VA publicly report this data on a quarterly basis?

VA Response: VBA is not routinely reporting specific trend data
about GWI claims as there have been no significant changes in recent
years.
b. Is VA routinely tracking and publishing trend data about the
characteristics of GWI claims. If not, please explain why not.

VA Response: VBA is not routinely reporting specific trend data
about GWI claims as there have been no significant changes in recent
years. Two studies into the rating characteristics of GWI claims have
been conducted in the past few years. Copies are attached along with a
spreadsheet that correlates to the December 2015 report. In addition,
we have included a spreadsheet that shows the trends through July 2017
for UDX and CMI decisions.
15. The GAO report states: ``VBA Officials noted that it may be
more useful to compare Gulf War Illness rates to those of presumptive
disability claims, such as those for presumptive illnesses VA
associates with exposure to Agent Orange during the Vietnam War.
However, the data provided to us by VBA did not allow us to conduct
this analysis.''
Does this analysis exist in any VA internal or independent reports
or reviews? If so, please provide a copy of all such reports and
reviews. If not, please explain why not.

VA Response: VA is not aware of this analysis existing in any
internal or independent reports or reviews. VBA believes there may be
something to be gleaned from a comparison of grant rates for
presumptive diseases across different eras and such a study is planned
when competing requests of higher priority have been satisfied.
16. Please provide detailed information regarding the consistency
study completed in April on referrals for medical examinations. Such
information should include the following:
a. How the study was conducted.
b. The results of the study.
c. The results of the study specific to Gulf War Illness claims.
d. The steps VA has taken to correct any issues with referrals
revealed in the study.

VA Response: In April 2017, Compensation Service conducted two
computer-based consistency studies on the Southwest Asia exam
requirements. The Veterans Service Representative (VSR) pre-test was
comprised of three scenario-based questions assessing the following
objectives: determining when it is appropriate to request exams in
claims based on Southwest Asia service; determining the language
requirements for exam requests based on Southwest Asia service; and
recognizing which exam Disability Benefits Questionnaire (DBQ) is
required for Southwest Asia service conditions. The Rating VSR (RVSR)
pre-test was comprised of eight scenario-based questions assessing the
following objectives: determining when it is appropriate to request
exams in claims based on Southwest Asia service; recognizing which exam
DBQ is required for Southwest Asia service conditions; and determining
whether the exam is sufficient for rating purposes in cases based on
Southwest Asia service.
Compensation Service requires that any consistency study
participant who incorrectly answered one or more questions in the pre-
test take the computer based training along with the post-test
associated with the subject of the study. Participants must correctly
answer all questions on the post-test to complete the study and receive
credit.
All questions on both the April 2017 VSR and RVSR Consistency
Studies assessed the participants' competency with the Southwest Asia
Exam requirements. There were a total of 3,151 participants that
completed the VSR pre-test with an average score of 43.2 percent. Of
these participants, 10.2 percent of the participants answered all three
pre-test questions correctly and received credit without needing to
take the Southwest Asia Exam requirements computer based training or
post-test. Those participants who incorrectly answered one or more
questions on the pre-test were required to immediately take the
computer based training on the Southwest Asia Exam Requirements and the
post-test. Of the VSR study participants required to take the computer
based training and the post-test, 35 percent answered all the post-test
questions correctly on the first attempt.
There were a total of 3,484 participants that completed the RVSR
pre-test with an average score of 56.4 percent. Less than one percent
of the participants answered all eight pre-test questions correctly.
Those participants who incorrectly answered one or more questions on
the pre-test were required to immediately take the computer based
training on the Southwest Asia exam requirements and the post-test. Of
the RVSR study participants required to take the computer based
training and the post-test, 14 percent answered all the post-test
questions correctly on the first attempt.
Both studies had a training portion based on the questions from the
tests.
17. Please provide the number of appeals that were completed from
fiscal years 2010 to 2015, disaggregated by FY, that were related to
UDX or MUCMI claims.

VA Response:

------------------------------------------------------------------------
Fiscal Year Total Decisions
------------------------------------------------------------------------
2010 348
------------------------------------------------------------------------
2011 259
------------------------------------------------------------------------
2012 259
------------------------------------------------------------------------
2013 274
------------------------------------------------------------------------
2014 258
------------------------------------------------------------------------
2015 271
------------------------------------------------------------------------

18. For such appeals from fiscal years 2010 to 2015, please provide
the following information, disaggregated by each FY:
a. How many appeals were completed during that time period?
b. How many appeals were approved?
c. How many appeals were denied?
d. How many appeals were remanded?

VA Response:

----------------------------------------------------------------------------------------------------------------
Veteran
Fiscal Year Total Decisions Appeals Appeals Denied Appeals Satisfied with Other
Granted Remanded Decision* Decisions**
----------------------------------------------------------------------------------------------------------------
2010 348 118 30 117 59 24
----------------------------------------------------------------------------------------------------------------
2011 259 90 21 91 35 22
----------------------------------------------------------------------------------------------------------------
2012 259 86 22 84 42 25
----------------------------------------------------------------------------------------------------------------
2013 274 86 24 86 50 28
----------------------------------------------------------------------------------------------------------------
2014 258 66 24 74 66 28
----------------------------------------------------------------------------------------------------------------
2015 271 108 15 63 68 17
----------------------------------------------------------------------------------------------------------------

* Appellant Satisfied with the decision on the Statement of the
Case
** Includes appeals Withdrawn, Dismissed, or Vacated