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Reform Government for Today’s Veterans

A government still stuck in the 20th century is trying to meet the demands of today’s new generation of veterans. Despite enormous efforts over the last 10 years, too many veterans are still waiting too long for decisions on their disability claims; at the end of 2014, more than 242,000 veterans were stuck in the Department of Veterans Affairs (VA) backlog. Roughly 60 percent of new veterans are enrolled in VA care and those that are, often face long wait times for appointments. Others are simply lost in the cracks—between the the Department of Defense (DoD) and the VA, or between state, local, nonprofit and private services.

The numbers reported by the VA only tell part of the story and last year’s VA scandal casts a shadow on all its data. In 2013 and 2015, IAVA gave a voice to the stories of thousands of veterans stuck in the VA disability claims process through TheWaitWeCarry.org, a groundbreaking interactive website collecting and publicizing quantitative and qualitative data on the VA backlog. TheWaitWeCarry.org has collected almost 3,000 stories, putting the faces and critical details on the true cost of outdated government services: women and men who wore our nation’s uniform struggling with the financial and emotional stress of waiting for their benefits.

Of the veterans that reported their experiences:
• 74% reported filing disability claims was extremely or moderately stressful;
• 56% reported filing disability claims was extremely or moderately financially straining; and
• 48% reported the overall quality of their VA health care was “unacceptable” or “minimally acceptable.”

The VA has recognized the TheWaitWeCarry.org as a valuable vehicle to connect with veterans in need, and Secretary McDonald has applauded this groundbreaking tool in a blog on the VA website.

The system required to best serve today’s veterans—whether they served in Vietnam or Iraq and Afghanistan—will be very different from the current legacy system. Our newest veterans are returning home ready for full lives having survived complex injuries that would previously have been fatal or absolutely debilitating. Meanwhile, the veterans’ population in the United States is shrinking, with the number of veterans dropping from 28.5 million in 1980 to 21.2 million in 2013.  With less than one percent of the U.S. population having served in Iraq or Afghanistan, local support and public awareness of veterans’ issues are waning. These changing demographics and circumstances require a nimble, dynamic system of care that can anticipate the needs of veterans and respond quickly; yet, the DoD and the VA still do not effectively transfer a service members medical records when they leave the jurisdiction of one agency to another.

A bold approach will take the full coordination of the executive branch and Congress, along with stakeholder partners in state and local governments, and the private and nonprofit sectors. We need a system that leverages the use of new technologies to streamline processes and enables the VA to take a more dynamic approach to respond to the needs of today’s veterans. Even so, the best technology will not save a system if it is built upon outdated structures. The VA must connect its internal departments and work with the DoD to streamline services.

Veterans envision a system of care designed with the same entrepreneurial spirit required of them during their service. Standing on ceremony or hiding behind process cannot stand; success must be measured by results. Today, veterans too often feel like they are fighting the government for the services and benefits they have earned; a successful system of care will fight for them.

3.1: Finally End the VA Backlog
3.2: Seamlessly Transfer Care from the DoD to the VA
3.3: Improve Government Outreach to Veterans
3.4: Defend Troops Against Military Sexual Assault
3.5: Build on the Success of Local Veterans’ Courts

3.1: Finally End the VA Backlog

Despite significant progress in 2014, too many veterans remained stuck in the Department of Veterans Affairs (VA) disability backlog. The VA backlog decreased by 34 percent in 2014, but more than 242,000 were still waiting more than 125 days for decisions on their claims at the end of 2014. Moreover, at the end of 2014 there were more than 287,500 veterans waiting on their appeals of the initial decisions on their claims.  These men and women often face significant financial and emotional stress while waiting for the benefits and care that they’ve earned.

Under the leadership of the the new Secretary, Bob McDonald, the VA has implemented a massive transformation plan to improve the disability claims process. Yet, it remains unclear if these efforts are sufficient to keep pace with incoming claims and while the disability backlog is coming down, there is a growing number of pending appeals. The VA must give stakeholders the tools to help assess their progress and help solve their problems with outside-in solutions by establishing clear goals and metrics and expeditiously releasing complete data on their progress towards those goals.

But you can’t speed up a train running on broken rails and the VA still has to address the factors that created the VA disability claims backlog: the burdensome process and misaligned VA staff incentives. Veterans often struggle to understand the claims process and how they can help the VA more quickly adjudicate their claims. At the same time, the VA must reform the work credit system to hold VA employees accountable at every level and improve its ability to collect and use private medical evidence to substantiate a claim.

IAVA Recommendations:
I. 
Transform VBA’s adversarial culture, integrating best practices from industry and leveraging modern technology to deliver a system of customer satisfaction that rivals the best in the private sector.

II. Reform VA’s work credit and productivity evaluation system for claims processors. A new system should reward processors based on the accuracy and the amount of hours worked in productivity evaluations, not the quantity of claims they processed.


III. The VA’s “duty to assist” should provide the claimant a thorough explanation of the elements needed to substantiate a claim. The VA must publicize the criteria for claims based on the veteran’s case rather than a general claim.

IV. Adopt the “treating physician rule” for medical evaluations for compensation and pension, requiring the VA to treat private medical opinions with the same weight as an opinion of a VA medical specialist when determining disability rating or eligibility.

V. Require that appeals forms be sent along with the Notice of Decision letters to expedite the appeals process.

VI. Evaluate the Segmented Lanes work initiative to continually assess whether it is meeting the goals of fast tracking simpler claims and streamlining more complex claims through experienced staff.

VII. Fund independent data visualization and accountability programs like IAVA’s The Wait We Carry.

VIII. Report the intake of new compensation and pension claims on the Monday Morning Work Report, the weekly report on the performance of the VBA’s 56 regional offices’ processing of compensation, pension and education benefits.

IX. Report statistics on the intake and processing of supplemental and original claims separately in the Monday Morning Report to allow for better analysis of the challenges slowing each type of claim.

X. Build a predictive model to accurately project the workload and the resource required, including personnel, to meet the future disability claims demand.

XI. Make all disability benefits questionnaires available to private medical providers.

XII. Simplify notification letters to provide easily digestible, specific and clear information about the reasons for rating decisions.

XIII. Continue to engage veteran stakeholders in updating the VA Schedule for Rating Disabilities (VASRD). Information about the reasons for rating decisions.

XIV. Require the VA to accept a PTSD diagnosis from a qualified private medical provider.

XV. Allow the VA to incentivize private medical providers to furnish medical health records to the VA for processing.

XVI. Clarify and report accuracy ratings for each regional VA. Designate what percentage of errors are processing errors, such as improperly completed paperwork, and those that are inaccurate rating decisions.

XVII. Create a fully developed appeal option for veterans similar to the fully developed claims process to provide veterans more choice while saving time during the appeals process.

XVIII. Provide the Board of Veteran Appeals with full access to and integration with Veterans Benefits Management System (VBMS).

XIX. Revise title 38 U.S. Code § 7107 so that the VA may utilize video teleconference hearings more frequently and as the default option when scheduling hearings, and the appellant may request a video hearing in lieu of an onsight hearing.  

3.2: Seamlessly Transfer Care from the DoD to the VA 

Despite the commitments of past Presidents and Secretaries of the Departments of Veterans Affairs (VA) and Defense (DoD), there is still no sustainable system to share electronic health records. The DoD and the VA have established stopgap measures to lessen the negative impact of the two isolated systems, but it is still unclear how the departments will achieve this singularly important goal of fully sharing electronic health records.

The consequence of the failure to seamlessly share information is that too many veterans are falling through the cracks in the transition from the DoD to the VA. Despite initiatives to enroll more service members in eBenefits and reach more service members through the Transition Assistance Program, just 60 percent of all new veterans are registered for VA health care. National Guard members and reservists face particular difficulties in their transition between the DoD and the VA, since they are bounced between the VA, DoD and state care. Dealing with so many agencies, they often struggle to obtain their medical and service records, resulting in more delays in applying for VA benefits and services.

IAVA Recommendations:
I. 
Automatically enroll all troops leaving active duty service in VA health care with an option to opt out.

II. Fully implement the DoD plan to develop an automated system to transfer Service Treatment Records to the VA electronically.


III. Provide oversight by monitoring the progress and development of interoperable DoD and VA health records, including submitting regular DoD and VA progress reports to Congress.

IV. Fully implement the comprehensive exit physical before a service member separates from the military.

V. Improve the transition of National Guard medical and service records from state National Guard units to VA.

3.3: Improve Government Outreach to Veterans

Too many veterans don’t understand the benefits for which they are eligible. More than 10 percent of IAVA’s survey respondents who were not enrolled in Department of Veterans Affairs (VA) care indicated that this was because they were unsure of whether or not they qualified. Another 11 percent said they did not know how to apply. Just 60 percent of new veterans use VA health care. It is an untapped resource for many veterans of Iraq and Afghanistan, not because they made an informed decision to opt out, but because they don’t know enough about the benefits available to them.

Over the last year, the VA has taken steps to improve its outreach to veterans. As the VA works to streamline its website and develop new promotional materials, the VA will improve its ability to reachout to veterans of all generations.

VA’s outreach must achieve two goals: 1) VA outreach must clearly communicate to veterans what benefits are available to them, and 2) VA must provide a seamless flow of information when applying for and using these benefits. Without this dual approach, the VA will fail to effectively enroll and retain all veterans who want to take advantage of the benefits they earned.

IAVA Recommendations:
I. 
Prioritize VA outreach efforts by including a distinct line item in VA appropriations for marketing and outreach. Partner with Veteran Service Organizations and best-in-class communications, technology and public relations firms to reform how the VA communicates its benefits to veterans.

II. Establish a set of best practices for local resource directories, such as citywide 311 services, that provide local information geared specifically toward veterans.

III. Fund and partner with Veteran Service Organizations (VSOs), especially next generation VSOs, to expand reach and trust across the veteran community.

IV. Design and implement national guidelines and programs for VA to reach out to rural and underserved veterans. Contract with local community health care providers and veteran service organizations in areas where rural veterans do not have reasonable access to care.

V. Increase appropriations to the VA’s Office of Rural Health (ORH) annually by the same percentage increase approved for VA Medical Centers to ensure continued support to rural and remote area veterans

VI. Given the importance of the ORH in supporting rural and remote veterans, elevate its organizational position in the VA from its current position under the Deputy Undersecretary for Health for Policy and Services.

VII. Give authority to ORH to establish partnerships and grant funds to non-VA organizations that serve the rural and remote veteran community.

VIII. Fund private nonprofit support programs that expand housing, health care and technology access to rural and remote veterans.

3.4: Defend Troops Against Military Sexual Assault

If troops aren’t safe in our military, they can’t defend America against our enemies. The scourge of military sexual assault in the military is a national embarrassment and must be eliminated. While military sexual assault is often framed as a women’s issue, it impacts both men and women. And while the percentage (4.3 percent in FY 2014) of active duty women estimated to experience unwanted sexual contact is higher than the percentage of men (0.9 percent in FY 2014), in raw numbers more active duty men are estimated to have experienced unwanted sexual contact than women.

The FY 2012 annual report from the Department of Defense’s (DoD) Sexual Assault Prevention and Response Office (SAPR) was a wake-up call to the nation, revealing an estimated 26,000 cases of unwanted sexual contact in the military.  Both the DoD and Congress responded. Congress passed significant legislative reforms to protect survivors from retaliation, track and preserve evidence of sexual assault, prevent sexual assault, and begin reforming the military judicial system to better prosecute crimes of sexual assault. The DoD continues to assess sexual assault in the military through annual updates and address the findings in these reports.

In the FY 2014 update, the DoD reported some improvements, including an increase in the number of reports filed, indicating less stigma associated with reporting an assault, and an overall decrease in the number of estimated accounts of unwanted sexual contact (estimated at 18,900).  However, there is still much bad news. The report highlighted no significant change in the high number of retaliation for reporting. The report also revealed that while the number of women experiencing unwanted sexual contact decreased, the number of men didn’t significantly change. This highlights the need for additional action to create the circumstances where all survivors can come forward to report cases of sexual assault.

Survivors may not choose to formally report a sexual assault for fear of retaliation, whether professional or social. Continued efforts are needed to help survivors of sexual assault come forward so they can seek the care they need, bring the perpetrator to justice, and prevent future assaults by that perpetrator. This will require holding military leaders, throughout the chain of command, accountable for fostering an environment where retaliation against those reporting is unacceptable.

Congress must improve the military justice system by placing the disposition authority for all serious crimes in the hands of experienced and impartial military prosecutors, instead of the chain of command. While the chain of command would remain involved, the ultimate decision would rest with the prosecutor, ensuring that decisions of whether to prosecute is made on the facts of the case alone, giving both the survivor and the accused justice.

IAVA Recommendations:
I. 
Ensure full funding for the SAPR by including it in the DoD Program Objective Memorandum budgeting process to ensure that a separate line of funding is allocated to the services.

II. Provide a plan to prevent an increase in military sexual assault in newly integrated Military Occupation Specialties following the military’s decision to allow women to serve in combat arms units. 

III. Place the disposition authority for cases involving serious crimes in the hands of an experienced, independent military prosecutor.

IV. Determine additional support systems needed for male survivors of sexual assault.

V. Evaluate the discharge status of survivors of military sexual assault and upgrade the status of those who may have been a victim of retaliation for reporting.

3.5: Build on the Success of Local Veterans’ Courts

IAVA has long been a strong supporter of these effective, innovative courts. More than 40 states have established Veterans Courts to offer alternatives to traditional criminal sentences for veterans with legal trouble characteristic of a mental health injury rather than criminality. While the first Veteran Court was established just six years ago in Buffalo, New York, today it is estimated that more than 250 exist.  

Veterans Courts provide enormous benefits both to veterans and the community. Those convicted through a Veterans Court are put through a rehabilitative program that often includes mental health support, and they avoid criminal sentences if they meet the requirements of the program. This provides veterans with a second chance, but also lowers recidivism rates. As more is understood about these programs, state and local governments should now seek to adopt best practices and expand the use of Veterans Courts beyond the 40 states that currently have them.

Additionally, there is no clear sense of how many veterans are incarcerated and for which crimes. Some of these incarcerated veterans would certainly come under the jurisdiction of a Veterans Court, their crimes being characteristic of mental health injuries, but slipped through the cracks or they didn’t have a local Veterans Court available to them. Unfortunately, these incarcerated veterans don’t receive treatment from the Department of Veterans Affairs (VA) for injuries, though they could benefit from VA expertise on combat-related physical and mental health injuries.

IAVA Recommendations:
I. 
Employ the best practices from the more than 250 Veterans Courts operating nationwide to develop a set of guidelines for localities to successfully execute an alternative sentencing program for veterans whose crimes stem from service-related injuries.

II. Provide grants to states to establish Veterans Courts.

III. Assist local municipalities in establishing Veterans Courts by providing grants that include basic stipends to support the travel and expenses of veterans volunteering as peer support counselors.

IV. Repeal the standing VA prohibition against treating incarcerated veterans. The VA must coordinate with local municipalities to develop counseling, recovery and peer-support services for veterans in the criminal justice system.

V. Require the Department of Justice to compare quarterly data from the Universal Crime Report with the DoD to determine the number of, and reasons for, incarcerated veterans.

VI. Train probation officers in the benefits available to veterans to aid in helping formerly incarcerated veterans transition back into their communities.