New Approach Needed To Make Decisions About Awarding Veterans' Benefits On A Presumptive Basis, USA

Main Category: Veterans / Ex-Servicemen
Article Date: 13 Aug 2007 - 0:00 PDT

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The process for awarding benefits to veterans with health conditions presumed to be connected to military service should be improved, says a new report from the Institute of Medicine. The report proposes a revised approach to presumptive disability decision-making designed to assure veterans and the public that these decisions are being made appropriately, consistently, and in a transparent way.

The report recommends that Congress create a new standing advisory committee to guide the U.S. Department of Veterans Affairs (VA) on which health conditions and related exposures during military service merit a detailed scientific review to evaluate for presumptive disability benefits, and that Congress establish a permanent, independent science review board to assess whether the scientific evidence supports a causal connection between the exposures and the health conditions in question. Ultimately, VA's secretary would be responsible for establishing presumptions based on the evidence and guidance provided by the scientific review board.

"We envision a formalized, evidence-based, public process by which health problems in veterans and the factors that may have caused these problems can be evaluated to determine if a presumption of service connection should be made," said Jonathan Samet, professor and chair, department of epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, and chair of the committee that wrote the report. "Stakeholders would have appropriate input, the process would be fully transparent, and the outcomes of the evaluation made publicly available on a timely basis," he added.

The VA automatically awards veterans monthly compensation payments and health care for disabilities that, on the basis of scientific evidence, are presumed to be caused by military service. Presumptions relieve veterans of the burden of having to prove that their health problems are connected to their service. Such presumptions have been established for nearly 150 health conditions since 1921. Examples of health conditions covered under presumptive disability include type II diabetes and prostate cancer among Vietnam veterans, undiagnosed illness in Gulf War veterans, and anxiety disorders in former prisoners of war. Proposals of health conditions to consider for presumption have come from a range of sources, including veterans service organizations, veterans and their families, members of Congress, and the VA.

In many cases, however, the evidence base for presumption decisions is weak because potential exposures are often not measured or recorded in the field and health studies may be lacking. Therefore, decisions sometimes have been made on the basis of a limited scientific foundation. The committee could not determine the basis for some of Congress' and VA's past presumptive disability decisions, which points to the need for greater transparency. The committee called on the U.S. Department of Defense to strengthen its surveillance programs for tracking troops' health and their field exposures and recommended that DOD and VA work together to improve data collection and information sharing.

The advisory committee proposed by the report should include veterans or their representatives as well as recognized experts in relevant scientific disciplines. Its role would be to receive proposals for possible health conditions and related exposures for which presumption may be warranted and recommend to the VA secretary which merit a full scientific review.

The proposed science review board should comprise experts in the key disciplines needed to weigh the full body of scientific evidence, and it should conduct a two-step process as it considers possible presumptive conditions. The first step would be to determine if a specific exposure during military service could cause a particular health condition. There will be instances in which the evidence is not sufficient to show either a clear-cut causal connection or lack thereof. The committee called for decisions to favor veterans if the available evidence shows that it is at least as likely as not that the health condition in question is causally linked to service. By favoring veterans in such instances, the committee points to the root purpose of veterans disability programs, which is to recognize and compensate for veterans sacrifices on behalf of their nation.

In the second step of the process, the science review board would estimate what portion of veterans with a specific health condition experienced the condition because of their military service. Because most health conditions can be caused by several factors -- such as occupational and environmental exposures, diet, and genetics -- the science review board should, whenever possible, estimate to what extent military service is likely to be responsible for the health condition compared with other potential causes.

This two-step process would lead to more consistent and evidence-based presumptive decisions, the report says. The committee acknowledged that there are reasons besides scientific evidence that may factor into presumption decisions, but it added that a strong scientific framework sets a solid base for the overall process. Though the advisory committee and science review board would provide guidance and expert evaluations, neither would make recommendations about granting presumptions, the report adds. The decision to grant presumptions would rest with VA, as charged by Congress.

The study was sponsored by the Veterans' Disability Benefits Commission. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. A committee roster follows.

National Academy of Sciences

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