Compensation for Veterans With Service Connected Disabilities: Current Findings and Future Implications

Increases in the Number of Veterans, the Combined Rating for Service Connected Conditions, and Expenditures for Compensation

Since 2000 there have been dramatic increases in the number of veterans receiving compensation as well as expenditures for the compensation program. Figure 1 shows the increases in the number of veterans receiving compensation and the number with a 70% or greater combined rating, as well as the increase in expenditures. The number of veterans receiving compensation increased 91% from 2.3 million in the year 2000 to 4.4 million in 2016 and expenditures increased 340% from $14.8 billion to $64.7 billion. There was also an increase in the combined rating such that in 2000 14% of recipients had a combined rating of 70% or greater, whereas in 2016, 36% had a 70% or greater combined rating. This increase in the combined rating, which is a function of the number of service connected conditions (on average veterans have 5 compensable conditions) (Maynard et al., 2017), as well as the severity of each condition, is one explanation for the large increase in expenditures.

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Figure 1.

Changes in expenditures, numbers of veterans, and numbers with ≥ 70% combined rating.Sources: VA (2016, 2018a).

Since 2016, the number of veterans receiving compensation increased 1.8% to 4.7 million in 2018 and expenditures increased 22% to $78 billion in 2018 (VBA, 2018a). The CBO (2014) has suggested strategies for reducing the effect of compensation on the federal budget. Briefly these include (a) instituting a time limit on initial applications, (b) requiring VA to expand its use of reexaminations, (c) changing the positive association standard for declaring presumptive conditions, (d) restricting individual unemployability benefits to veterans who are younger than the full retirement age for Social Security, (e) changing the cost of living adjustment, (f) changing concurrent receipt of compensation and receipt of military service retirement benefits, and (g) taxing compensation.

Changing the positive association standard refers to presumptive disability due to environmental exposures during military service. Agent Orange exposure affected many veterans serving in Vietnam and disability associated with specific medical conditions was presumed to be due to Agent Orange exposure (Maynard et al., 2017). Legislation for “blue water Navy” benefits is moving through the U.S. Congress (Kime, 2019). These individuals were exposed to chemicals, including Agent Orange, while serving on U.S. Navy ships during the Vietnam War. These sailors never set foot in the country of Vietnam, but nevertheless developed conditions associated with Agent Orange exposure.

As of October 2016, more than 1.3 million veterans 50 years old or younger (average age 38 years) received compensation (Maynard, 2018). Almost 60% had a combined rating of at least 50% and nearly 9% had a 100% rating (Maynard, 2018). If most achieve a normal life expectancy, there will be many years of benefits and health care provided to these individuals. While there have been dramatic increases in individuals receiving compensation in the recent past, it is difficult to predict the future. Whether the next 10 years will see the dramatic increases in the number of veterans receiving compensation as well as expenditures for the program remains to be seen. Part of the significant increase from 2000 to 2018 was due to conflicts in Iraq, Afghanistan, and other theaters. Future numbers of veterans with service connected disabilities will also depend on the involvement of United States military personnel in on-going and future conflicts. The CBO (2019) estimates that in the year 2028 there will be over 5.6 million veterans receiving compensation and that expenditures will exceed $129 billion. This represents a 19% increase in the number of veterans receiving compensation and a 65% increase in expenditures compared to 2018.

Women With Service Connected Conditions

In the last 25 to 30 years, there has been a significant increase in the number of women serving in the military (National Center for Veterans Analysis and Statistics, 2017b; VA, 2014b). Overall, there has been a decrease in the number of Veterans, but an increase in the number of women veterans. In 1995, of the 26.2 million living veterans, approximately 1.2 million (4.6%) were women (VA, 1995). In 2017, the number of living veterans decreased 25% to 19.6 million, while the number of women increased 58% to 1.9 million. In 2017, women comprised almost 10% of the veteran population (National Center for Veterans Analysis and Statistics, 2017a).

Consequently, the number of women with service connected conditions has also increased. The number of women receiving compensation increased 28% from 2011 to 2016, which was similar to the 31% increase for all veterans (VA, 2011). Of the 388,947 women receiving compensation for service connected disabilities in October 2016, almost 60% were 50 years of age or younger. Nearly 90% were enlisted personnel who served in the U.S. Army (48%), Air Force (22%), or Navy (21%). The most common service connected conditions were migraine headache (32%), post traumatic stress disorder (PTSD) (23%), tinnitus (22%), and major depression (15%). Nine percent of women 50 years or younger had a combined rating of 100% and 56% had a rating of 50% or greater. Among women with service connected migraine headache, 13% had a 100% combined rating and 25% and 17% had service connected PTSD and major depression, respectively (Maynard, Nelson, & Fihn, 2019). It is likely that for many women these conditions were acquired or aggravated during deployment in Iraq or Afghanistan.

Only 47% of young women with service connected conditions used VA health care in 2015 (Maynard et al., 2019). VA is and will be providing more obstetrical care as all young women and not just those with service connected disabilities leave the military and become mothers. In addition, VA (2014a) has established the Office of Women’s Health and now provides a variety of services having to do with safety, reproductive health, mental health, general health and wellness, substance use disorder treatment, and intimate partner violence prevention. These programs appear to be highly relevant to the needs of women whose disabilities stem from military service generally and deployment to combat zones, specifically.

Service Connected Mental Health Conditions

There are over 1 million veterans with serviced connected PTSD and nearly 80% have at least a 50% combined rating (Maynard et al., 2017). VHA provides a vast array of mental health services to these and other veterans with service connected conditions including those not related to mental health. The need and demand for these services have no end. The provision of these benefits and services is a critical mission for VA and would be difficult to accomplish in the civilian sector (Maynard et al., 2017).

VA (2014a, 2018c) provides outpatient, inpatient, supported work settings, and residential services for veterans with mental health conditions, including PTSD, major depression, anxiety, schizophrenia, military sexual trauma, and substance use disorders. Among these many innovative services is the integration of primary care and mental health services in which mental health providers are part of the primary care team. Depression, anxiety, and substance use disorders are the conditions most often addressed in this setting. These services are available to all veterans with service connected conditions and are particularly relevant for those with service connected mental health conditions.

In a survey of Iraq and Afghanistan veterans, it appeared that veterans with the greatest need used VA mental health services (Elbogen et al., 2013). The authors concluded that treatment could be improved by increasing awareness of gender differences in diagnosis and treatment of mental health conditions, integrating mental health and pastoral counseling services, and recognizing that treatment of alcohol use disorders can reduce utilization of mental health services. They also reported that veterans who did and did not use services had different views of treatment, indicating that barriers to accessing care may be distinct from barriers to engaging in care (Elbogen et al., 2013). Engaging in care may be especially relevant for veterans with service connected mental health conditions in that most all of them are eligible for care at little or no cost.

VA Health Care and Service Connected Conditions

Which veterans with service connected disabilities use VA health care varies by numerous factors, including military rank and type of service connected condition (Maynard et al., 2017). Among those with service connected PTSD, roughly 30% don’t use VA health care, even though they are entitled to care at little or no cost. Should VA reach out to those who have a combined rating 50% or greater and do not use VA health care? A first step in considering this question is to understand why those who are eligible for VA care don’t use it. It may be that individuals receive their health care from other providers. It may also be that these individuals require assistance in accessing care, even though they have high priority for VA health care. It would also be helpful to understand if perceptions of VA health care differ by basic demographic and military service characteristics, as well as type and extent of service connected disability.

Premature Death in Veterans With Service Connected Conditions

Individuals who die prematurely are more likely to die of external as opposed to natural causes. These external causes include both intentional (suicide) and accidental deaths. Deaths due to external causes appear to be more prevalent in veterans with service connected conditions, especially young women (Maynard, Trivedi, Nelson, & Fihn, 2018). For deceased women veterans who were born after 1957, 8.7% of deaths were due to suicide and 17.2% were due to accidents. For deceased men born after 1957, 11.2% of deaths were due to suicide and 19.9% were caused by accidents.

VA (2017, 2018c) provides extensive suicide prevention services, but preventing so called accidental deaths is also part of the program to reduce unnecessary deaths. Through innovative screening and assessment programs such as Recovery Engagement and Coordination for Health Veterans Enhanced Treatment (REACH-VA), VA (2017) identifies veterans who are at risk for suicide and may benefit from enhanced care such as follow-ups to missed appointments, safety planning, and care plans that directly assess suicide risk. One part of the program involves predictive modeling to identify individuals at elevated risk of suicide or accidental death. What is particularly challenging is reaching veterans who are at elevated risk of suicide or accidental death, but do not use VA health care. Some of these individuals have service connected conditions, including PTSD, anxiety, or depression. VA provides numerous outreach services for all veterans, including those who have service connected disabilities and do not use VA health care. These outreach services include Vet Centers, Vet Center call centers, and a national suicide call center. The Vet Centers aid with the transition from military to civilian life as well as provide broad support and direction regarding services available to veterans.

Veterans With a Combined 100% Rating

Veterans with a combined 100% rating, who comprise about 13% of all veterans with service connected disabilities, use more VA health care and have a higher 1-year mortality rate than other veterans with service connected conditions (Maynard, Nelson, & Fihn, 2018). Significantly, almost half of veterans with a 100% rating have service connected PTSD. Veterans with a 100% rating are eligible for certain benefits not available to others with service connected conditions. These include increased compensation, certain types of health care, and increased income and educational support for spouses and children. Since it is highly unlikely that these veterans will ever achieve gainful employment, it is important that these individuals and their families are adequately supported not only during the veteran’s life, but after his or her death as well.

Conclusion

Compensation for service connected conditions provides critical income support to individuals whose earning capacity has been reduced by events that occurred during their military service. In the last 20 years, there have been significant increases in the number of veterans with service connected conditions, the combined rating for these conditions, and expenditures for the program. Significant support of this program will be required for many years to come given the large numbers of young veterans, including increasing numbers of women, with service connected conditions. Virtually all veterans with service connected conditions are eligible for health care provided by VA at little or no cost. Mental health services are particularly needed given the many women and men who have service connected PTSD, major depression, or anxiety. About 30% of veterans who have service connected mental health conditions don’t use VA health care. This is a concern, since these individuals are more likely to die prematurely from suicide or accidental causes. VA provides extensive outreach services to veterans but identifying individuals who are at elevated risk of premature death due to external causes is very challenging. Last, there should be continued focus on individuals with a 100% rating, as these veterans have virtually no ability to follow a substantially gainful occupation. We hope that individuals who value the integrated array of benefits offered to veterans with service connected conditions will consider these important issues.