January 29, 2022

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VA Disability Benefits: Process for Identifying Conditions Presumed to be Service Connected and Challenges in Processing Complex Gulf War Illness Claims

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<div>GAO has reported on the Department of Veterans Affairs' (VA) use of research to identify and add new illnesses to its list of presumptive conditions for both Gulf War Illness and Agent Orange—a tactical herbicide used extensively during the Vietnam Era. VA entered into agreements with the National Academy of Sciences to assess the link between certain exposures and illnesses experienced by veterans, and uses the Academy's findings to inform its lists of presumptive conditions. GAO also reported in 2017 that VA did not have a single set of uniform criteria to define Gulf War Illness (a case definition) that could improve research, clinical diagnosis, and treatment of Gulf War veterans. GAO recommended that VA prepare and document a plan to develop a single case definition. In response, VA convened a group of subject matter experts from VA and the Department of Defense to create a multi-step plan to develop a case definition. According to VA, it is in the final stages of the plan and will bring together experts in 2021 to review new research and work toward delineating a definition. Further, according to VA, the department continues to support research on conditions related to Gulf War service as well as Agent Orange exposure and will use the findings to consider future presumptive conditions. In 2017, GAO reported on challenges that VA faced in processing complex, presumptive disability claims for veterans who served in the Gulf War—claims that were being denied at higher rates than other disability claims. At the time of GAO's review, VA officials stated that Gulf War Illness claims may be denied at a higher rate, in part, because they are not always well understood by VA staff, and veterans sometimes do not have medical records to adequately support their claims. The challenges we identified included: Inconsistent requests for disability medical exams. VA claims processors can request that a veteran undergo a disability medical exam to help determine whether the conditions in the claim exist and are linked to service. GAO found that claims processors were inconsistent in asking for an exam, in part, due to confusion about the guidance. VA issued training on the topic and in April 2017 completed a review of Gulf War claims to assess the effectiveness of the training and help ensure future consistency. Inconsistent disability medical exam reports. Veterans Health Administration disability medical examiners did not always complete medical exam reports properly and sometimes offered a medical opinion when one was not necessary. GAO recommended that VA require all examiners to complete Gulf War medical exam training before conducting these exams, and VA implemented this recommendation. Since our 2017 report, VA has allowed contracted medical examiners to complete these exams, and in 2018 GAO found VA was not monitoring whether all contractors completed required training. GAO recommended VA improve its oversight of training, but the department has not fully implemented this recommendation from GAO's 2018 report. VA provides disability compensation to millions of veterans with service-connected disabilities. Veterans are generally entitled to these benefits if they can prove their injuries or illnesses were incurred or aggravated by active military service. For certain claims, VA presumes a condition is due to a veteran's service. For example, VA can provide benefits to any veteran with certain symptoms, from respiratory disorders to gastrointestinal issues, who served in Southwest Asia from 1990 to the present, without the veteran needing to prove cause. GAO refers to these as Gulf War Illness claims. In 2017, GAO issued Gulf War Illness: Improvements Needed for VA to Better Understand, Process, and Communicate Decisions on Claims ( GAO-17-511 ), which identified needed improvements in VA's processing of Gulf War Illness claims. In 2018, GAO issued Agent Orange: Actions Needed to Improve Accuracy and Communication of Information on Testing and Storage Locations ( GAO-19-24 ). This statement summarizes information from these reports on how VA determined certain presumptive conditions and challenges VA faced with processing Gulf War Illness claims. In GAO's 2017 report, it recommended that VA develop a plan to establish a single case definition of Gulf War Illness and make Gulf War Illness training mandatory for medical examiners. VA implemented the recommendations. For more information, contact Elizabeth Curda at (202) 512-7215 or curdae@gao.gov.</div>

What GAO Found

GAO has reported on the Department of Veterans Affairs’ (VA) use of research to identify and add new illnesses to its list of presumptive conditions for both Gulf War Illness and Agent Orange—a tactical herbicide used extensively during the Vietnam Era. VA entered into agreements with the National Academy of Sciences to assess the link between certain exposures and illnesses experienced by veterans, and uses the Academy’s findings to inform its lists of presumptive conditions. GAO also reported in 2017 that VA did not have a single set of uniform criteria to define Gulf War Illness (a case definition) that could improve research, clinical diagnosis, and treatment of Gulf War veterans. GAO recommended that VA prepare and document a plan to develop a single case definition. In response, VA convened a group of subject matter experts from VA and the Department of Defense to create a multi-step plan to develop a case definition. According to VA, it is in the final stages of the plan and will bring together experts in 2021 to review new research and work toward delineating a definition. Further, according to VA, the department continues to support research on conditions related to Gulf War service as well as Agent Orange exposure and will use the findings to consider future presumptive conditions.

In 2017, GAO reported on challenges that VA faced in processing complex, presumptive disability claims for veterans who served in the Gulf War—claims that were being denied at higher rates than other disability claims. At the time of GAO’s review, VA officials stated that Gulf War Illness claims may be denied at a higher rate, in part, because they are not always well understood by VA staff, and veterans sometimes do not have medical records to adequately support their claims. The challenges we identified included:

Inconsistent requests for disability medical exams. VA claims processors can request that a veteran undergo a disability medical exam to help determine whether the conditions in the claim exist and are linked to service. GAO found that claims processors were inconsistent in asking for an exam, in part, due to confusion about the guidance. VA issued training on the topic and in April 2017 completed a review of Gulf War claims to assess the effectiveness of the training and help ensure future consistency.

Inconsistent disability medical exam reports. Veterans Health Administration disability medical examiners did not always complete medical exam reports properly and sometimes offered a medical opinion when one was not necessary. GAO recommended that VA require all examiners to complete Gulf War medical exam training before conducting these exams, and VA implemented this recommendation. Since our 2017 report, VA has allowed contracted medical examiners to complete these exams, and in 2018 GAO found VA was not monitoring whether all contractors completed required training. GAO recommended VA improve its oversight of training, but the department has not fully implemented this recommendation from GAO’s 2018 report.

Why GAO Did This Study

VA provides disability compensation to millions of veterans with service-connected disabilities. Veterans are generally entitled to these benefits if they can prove their injuries or illnesses were incurred or aggravated by active military service. For certain claims, VA presumes a condition is due to a veteran’s service. For example, VA can provide benefits to any veteran with certain symptoms, from respiratory disorders to gastrointestinal issues, who served in Southwest Asia from 1990 to the present, without the veteran needing to prove cause. GAO refers to these as Gulf War Illness claims.

In 2017, GAO issued Gulf War Illness: Improvements Needed for VA to Better Understand, Process, and Communicate Decisions on Claims ( GAO-17-511 ), which identified needed improvements in VA’s processing of Gulf War Illness claims. In 2018, GAO issued Agent Orange: Actions Needed to Improve Accuracy and Communication of Information on Testing and Storage Locations ( GAO-19-24 ). This statement summarizes information from these reports on how VA determined certain presumptive conditions and challenges VA faced with processing Gulf War Illness claims.

What GAO Recommends

In GAO’s 2017 report, it recommended that VA develop a plan to establish a single case definition of Gulf War Illness and make Gulf War Illness training mandatory for medical examiners. VA implemented the recommendations.

For more information, contact Elizabeth Curda at (202) 512-7215 or curdae@gao.gov.

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