The downtown Washington offices of Disabled American Veterans hummed with activity on a recent weekday as four staff counselors helped ex-servicemembers navigate the bureaucracy of the Department of Veterans Affairs.

James Mack, a stern-looking veteran of the first Gulf War, welcomed recent returnees from the conflicts in Iraq and Afghanistan by handing them copies of VA Form 21-526 — a two-sided, 13-page application for benefits — then tearing out the first four pages of fine-print instructions.

“For folks who just want to know what they’re entitled to, that’s a little bit too much information,” said Mack, who patiently guided some veterans through questions about service-related injuries and the care they received, and signed others up for a biweekly class on veterans’ benefits that he teaches Monday nights. It is fully subscribed until July.

Elsewhere in the office, workers tracked the progress of hundreds of appeals filed by veterans in response to VA denials, stepping around piles of inch-thick files detailing the particulars of each case that threatened to inundate their cubicles. Phones constantly rang with big and small requests. One frantic ex-servicemember could not find the room in VA headquarters where he was supposed to participate in a teleconference about his appeal. By the time Mack sorted out the matter and provided directions, the hearing had been postponed. Mack then spent an hour rescheduling the hearing and briefing the veteran on what to expect.

Disabled veterans of the Iraq War already have braved insurgent attacks and the threat of improvised explosive devices. But few are prepared for the nerve-wracking experience of dealing with the VA system. The government is trying to hack away at a backlog of more than 405,500 disability claims while marshaling more injured soldiers through its bureaucracy. It now takes an average of 177 days for a disabled soldier to get a VA claim processed — nearly double the 89.5-day wait civilians face in a private health-insurance system widely acknowledged to be underperforming. And with recent revelations about neglect of care at the Army’s flagship Walter Reed Medical Center, the political pressure is mounting for the government to improve its performance.

But there aren’t many signs that the crush is dissipating at critical junctures like the Disabled American Veterans office and similar facilities run by nearly a dozen veterans’ service groups. Academic experts and veterans’ advocates say the VA is facing unprecedented stresses due to the conflicts in Iraq and Afghanistan and is ill-equipped to handle an influx of returning soldiers that would come from any troop withdrawal in Iraq.

Beyond the paperwork hassles and delays, there are serious gaps in medical care, especially for treating traumatic brain injuries and psychological problems that have arisen from extended deployments and stressful ground warfare, according to health professionals and veterans’ groups.

“We have not paid careful enough attention, or devoted sufficient resources, to planning for how to take care of these men and women who have served the nation,” said Linda Bilmes, a lecturer in public policy at Harvard University’s John F. Kennedy School of Government who has studied the long-term costs of caring for veterans.

Congress, rattled by the problems at Walter Reed and public concern over returning servicemembers, is pledging to spend considerably more on veterans’ programs. The House’s 2008 budget resolution would increase the budget for VA health care and claims processing by $6.6 billion over 2007 levels. Congress in February included $3.6 billion for veterans’ programs in a budget package to fund much of the government for the remainder of the fiscal year. A supplemental spending bill cleared April 26 would give the department $1.8 billion more.

But experts such as Bilmes warn that the extra money will do little good unless Congress and the VA fix deep-rooted problems in the way the government processes disability claims, screens veterans for health problems and handles appeals for denied benefits. These problems will loom over Congress for the rest of the session as the House and Senate debate the direction of the war and how to provide for what a bipartisan majority have come to call “wounded warriors.”

“All of the things we’re seeing — the problems at Walter Reed, people getting lost in the process — can all relate back to the fact that the VA and the Department of Defense did not plan for a long war and the impacts of that,” said Democratic Sen. Patty Murray of Washington, a member of the chamber’s Veterans’ Affairs Committee and the Appropriations subcommittee that oversees the VA. “If I was sitting in the VA, I’d be in the president’s face all the time, saying we have to deal with these huge issues and I want resources to educate people.”

The Bush administration says it is addressing the most serious concerns. An interagency task force headed by VA Secretary Jim Nicholson released recommendations April 24 that include adding case managers to help guide troops and their families through the system and improving the process for handing off medical records when an active-duty soldier is discharged and enters the VA’s network.

“The federal government must be responsive and efficient in delivering our benefits and services to these heroes,” Nicholson said in announcing the recommendations. “They should not have to fight bureaucratic red tape for benefits earned by their courageous service.”

Some of the problems are due to the unique nature of the Iraq and Afghanistan conflicts. Better battlefield care has allowed more servicemembers to survive roadside bombs, suicide attacks, rocket-propelled grenades and other incidents that probably would have killed soldiers in past conflicts. But many are returning home with complicated, sometimes catastrophic wounds that require much more elaborate treatment and rehabilitation.

The government has not prepared itself for such demands. Harvard’s Bilmes notes that while the VA has steadfastly maintained that it can cope, the agency ran out of money to provide health care for the past two years and had to submit emergency budget requests to Congress for $2 billion in fiscal 2006 and $1 billion in 2005. A Government Accountability Office analysis of the shortfalls concluded that the VA was basing its cost projections on 2002 data that was generated before the war in Iraq began.

Flawed Claims Process

The concern about the VA goes beyond just how it calculates costs to how efficiently it provides veterans with their benefits. Experts are particularly worried about the claims process that returning soldiers must confront to qualify for disability payments — a system that has been widely criticized for delays and excessive bureaucracy.

Servicemembers file claims in one of 57 regional offices belonging to the Veterans Benefits Administration, a branch of the VA that assesses service-related injuries on a sliding scale from 0 percent to 100 percent in 10 percent increments. Veterans must submit to medical evaluations for each condition they are claiming. If a claim is rejected, the veteran can appeal to a VA board that renders a decision or sends the case back to the regional office.

Government audits have uncovered fundamental flaws in the process. The GAO last March reported that even though medical problems that veterans report are becoming more complex — including those based on environmental risks, infectious diseases and brain injuries — the VA’s criteria for disability decisions continue to be based on estimates made in 1945 about how service-connected impairments could affect the average individual’s ability to perform manual labor.

The GAO also found that the Veterans Benefits Administration has to wait a year or longer to obtain military records to verify some claims of post-traumatic stress disorder. Auditors suggested that the VA try using an electronic library of medical records instead of submitting requests to the Army and Joint Services Records Research Center. The VA responded that it would study the matter.

Piecemeal efforts to streamline claims processing in the regional offices have left big disparities in service, with significant delays in some cities. The advocacy group Amvets found that 63 percent of claims filed at the VA’s Washington, D.C., office took six months or longer to resolve. By contrast, 7 percent or fewer claims filed in offices in Providence, R.I., Fargo, N.D. and Boise, Idaho, took that long.

The VA’s reliance on medical checkups to verify claims is adding to the bureaucratic headaches by lengthening waiting times at VA medical centers around the country and delaying some patients from getting access to specialists. “People are just clamoring to get VA medical treatment in order to be able to get into the VA disability benefits ladder,” Bilmes said.

She expects the situation to worsen, projecting that the VA will receive roughly 400,000 new claims from servicemembers returning from Iraq and Afghanistan over the next two years. Many will be submitted after the veterans exhaust the two free years of medical care the VA provides upon discharge. “The main stress is yet to come,” Bilmes said. “There will be a huge increase in the number of claims.”

The claims process also does not treat every returning servicemember equally. Active-duty soldiers have a better chance of getting claims evaluated promptly and approved than reservists and members of the National Guard. That is because active-duty soldiers often have the option of having their condition reviewed earlier by the VA before they are discharged from service. Reservists and guardsmen typically cannot get a ruling because they are discharged much faster. The result is that some ex-servicemembers start collecting their disability payments later.

“They typically don’t remain in place long enough for us to go ahead and make the arrangements for the necessary medical exams and the other steps needed . . . to give them the same types of service we give the active-duty members,” said Ron Aument, the VA’s deputy undersecretary for benefits.

Data the VA released in February confirmed that active-duty servicemembers are nearly twice as likely as reservists to have claims approved.

“The result is devastating and scandalous,” said Paul Sullivan, executive director of Veterans for Common Sense and a former project manager at the Veterans Benefits Administration. “The VA should immediately and aggressively investigate this problem and then correct it.”

Congress tried to address claim denials last year by including language in a VA authorization bill allowing claimants to retain attorneys to represent them at some stages of the appeals process. But VA officials and veterans’ groups have said the addition of attorneys has made the claims process more adversarial, encouraging claimants to file more, and more complicated, appeals. Veterans’ groups predict additional delays as the system gets increasingly clogged.

“You have an entire system that’s been designed around the notion of being a non-adversarial process,” Aument said. “You are now bringing attorneys into the process whose very training is to be a zealous advocate and actually conduct themselves in many cases in an adversarial manner on behalf of their clients.”

Nicholson, in announcing improvements April 24, attributed some of the backlog in the system to the VA’s improved outreach to the veterans’ community, which made some ex-servicemembers aware of benefits and, in turn, encouraged more claims.

“We’re challenged really because we’re . . . a victim, maybe is the best way to say it, of our own success,” Nicholson said. “The result of that is that while we are working diligently, the time it’s taking is too long.”

The VA and Congress propose solving many of the problems by hiring more claims processors. The agency, in its fiscal 2008 budget request, requested 450 processors to help cut through red tape. Congress will probably authorize money in this year’s supplemental spending measure, and again in 2008 spending bills. VA officials say the additional staff will help the agency reach a goal of shortening the time it takes veterans to get a ruling on initial claims to 125 days, although Aument said that this may not be realized until fiscal 2009 at earliest.

However, some veterans’ groups predict that extra staff at claims centers could increase waiting times even more. That is because it takes two to three years for senior staff to train claims processors. Meanwhile, some longtime processors are expected to retire, with the net effect being a shortage of experienced personnel available to process the veterans’ paperwork.

“They’re going to have to pull some of their best people off to train” the new hires, said Dennis Cullinan, legislative director of the Veterans of Foreign Wars. “Things are going to get worse for a while rather than better.”

Shifting the Burden

Some in Congress, such as House Veterans’ Affairs Chairman Bob Filner of California, have embraced a new approach proposed by Bilmes in which the government would assume that all claims are valid, then audit a fraction at some later date. That would effectively shift the burden of proving a claim was valid from the veteran to the government.

“I do favor the principle of shifting the burden,” Filner said in an interview, adding that the VA “had enough time to deal with this, and they have refused.”

VA officials have stated publicly that they are concerned that the extra auditing of claims will sap the agency’s resources. The department this spring announced its opposition to a bill by Indiana Democratic Rep. Joe Donnelly, a member of the Veterans’ Affairs panel, that would essentially implement the system Bilmes proposes, citing projections that the change would cost an extra $173 billion over 10 years.

Groups such as Disabled American Veterans, which for decades have guided returning servicemembers through the claims process, also believe the change would unwisely divert VA funding for the sake of shaking up the present system. Carl Blake, legislative director of the Paralyzed Veterans of America, even suggests that blanket approval of all claims would encourage fraud and abuse.

“We believe if Congress lowers this threshold . . . the results would be an overwhelming number of claims filed for compensation,” Blake said.

But opinion within the VA could be shifting on the issue. While Aument testified against Donnelly’s legislation and said in an interview that such a proposal probably would cause “serious unintended consequences,” VA Secretary Nicholson has made statements to the contrary. In an interview April 24, he said he is considering the possibility of creating a pilot program modeled on Bilmes’ proposal, and has discussed the matter with the White House Office of Management and Budget.

Bilmes said that during a recent meeting with her, Nicholson “definitely was intrigued at the concept of changing the presumption.”

But even if the VA gets behind such a change, the prospect of offering blanket approval of claims would face tough scrutiny in the Senate.

“There are serious procedural questions, but far more importantly, the cost implications suggest this has little chance of enactment,” said a Senate Democratic aide.

Another change proposed by Bilmes would streamline the VA’s 10-point disability rating system and create four classifications: none, low, medium and high. Bilmes believes the change would cut down on the number of appeals in the system.

Some lawmakers, such as New York Democratic Rep. John Hall, who also serves on the House Veterans’ Affairs Committee, would provide financial assistance to veterans whose claims were languishing by providing a $500 monthly benefit to those whose appeals were not taken up within 180 days.

The Claims Crush: Click here for the chart
 
But such proposals face stiff opposition in the Senate, where lawmakers from both parties are worried about the extra costs and inclined to wait for the recommendations of a congressionally mandated 13-member commission convened to study the VA’s disability benefits programs.

Sen. Larry E. Craig of Idaho, the ranking Republican on the Senate Veterans’ Affairs Committee, says he hopes the commission “will provide the foundation for the types of fundamental changes that may be needed to ensure lasting improvement to the disability compensation system” and possibly lead to a bipartisan reform package. “The system as currently structured cannot provide veterans with timely, accurate and consistent decisions on their claims,” Craig said.

Gaps in Medical Care

In contrast to the troubled claims process, the VA’s medical system has received widespread praise from politicians and veterans’ groups for the way it treats more than 5 million veterans annually. The network’s well-regarded rehabilitation services have become vital for many of the recent returnees from Iraq, who suffer from head trauma, spinal injuries, amputations, blindness or deafness.

But experts contend that the system is ill-equipped to cope with increased caseloads because the VA has regularly underestimated the cost of care, workloads and the length of waiting lists. Harvard’s Bilmes noted that the VA’s fiscal 2006 request for emergency funding included $677 million to cover an unexpected 2 percent increase in the number of patients, another $600 million to correct inaccurate estimates of long-term care costs and $400 million more for an unexpected 1.2 percent increase in per-patient costs.

Some professional organizations and veterans’ groups are particularly concerned about the VA’s ability to treat mental health and brain disorders — including traumatic brain injuries and behavioral problems such as post-traumatic stress disorder, depression and substance abuse — that are fast becoming the war’s signature medical issues.

Frances M. Murphy, the VA’s deputy undersecretary for health policy coordination, stoked fears last year when she told a presidential commission on mental health that some VA clinics do not provide mental health or substance abuse care, and that in other locations, “waiting lists render that care virtually inaccessible.” The remarks triggered a huge flap in which Murray and other congressional Democrats questioned whether Nicholson was giving returning veterans the services they need.

The American Psychological Association reported in February that the armed forces and veterans’ systems both suffer a shortage of qualified specialists, noting that the VA employs 1,839 psychologists to serve some 24.3 million veterans. Veterans’ groups contend that the shortage has meant some returning servicemembers — especially National Guard members and reservists — are subjected to perfunctory screenings lasting only several minutes that are geared toward treating easily apparent physical disabilities.

“Funding for the VA was based more on hope than projectable data,” said Paul Rieckhoff, executive director of the advocacy group Iraq and Afghanistan Veterans of America. “They hoped people wouldn’t have casualties, wouldn’t have brain injuries. The reality is those things happened. There was an absurd lack of planning.”

The VA has disputed the psychological association’s study, saying the findings were flawed because the group did not contact the department for information about VA programs, staffing data and other information.

However, veterans’ groups and experts contend that staffing shortages within the military medical establishment hinder the ability to diagnose mental health problems in the field, before servicemembers return home. The American Psychological Association says the number of active-duty psychologists has been slipping in recent years because of heavy caseloads, job stress and declining morale. And only 10 to 20 percent have been trained to counsel soldiers suffering from post-traumatic stress disorder.

Harvard’s Bilmes says the cumulative effect of these gaps in care is that veterans are at higher risk of unemployment, homelessness, family violence, crime, alcoholism and drug abuse — problems that will impose societal and financial burdens on states and localities.

VA officials say they are addressing shortcomings in their system by beginning to screen discharged servicemembers for traumatic brain injuries as soon as they are admitted into the veterans system. The department also will hire 100 new patient advocates to travel to medical facilities and help wounded servicemembers and their families cut through bureaucratic red tape and obtain information about disability compensation and options for rehabilitation. And the department is asking Congress for money to expand a network of 21 “polytrauma” centers across the country so that veterans who live in outlying areas can have better access to facilities that can simultaneously treat injuries to more than one body part.

The task force recommendations that Nicholson issued April 24 call for making VA and military medical records systems interoperable sometime between mid-2008 and January 2009.

“VA has worked hard to improve the transition process for our deserving servicemen and women. Yet we are not satisfied that we have achieved all that is possible,” VA Undersecretary for Benefits Daniel Cooper told a joint hearing of the Senate Armed Services and Veterans’ Affairs committees April 12.

Helping ‘Wounded Warriors’

While Congress has always supported the principle of improving veterans’ health care, the disclosure of problems at Walter Reed Army Medical Center has inspired more detailed proposals that address kinks in the system.

After the Walter Reed disclosure, the House in late March overwhelmingly passed a plan to improve the coordination of VA and military health services by adding caseworkers and counselors to the military’s medical system. The plan also required the Pentagon and VA to better coordinate the transfer of servicemembers between the two bureaucracies. The changes would cost at least $300 million over the next five years, according to the Congressional Budget Office.

There is no identical companion legislation in the Senate yet. An effort by Democrats Barack Obama of Illinois and Claire McCaskill of Missouri to add caseworkers and mental health counselors to military hospitals and provide money for the military to develop a system allowing soldiers to submit medical paperwork over the Internet was defeated by Republicans during a debate on a war spending bill in late March. The Bush administration says it prefers that Congress wait until a presidentially appointed commission studying problems in the military’s medical system issues a report, due by July 31. The commission is headed by former Republican Sen. Bob Dole and Donna Shalala, former secretary of Health and Human Services in the Clinton administration.

House members and senators also are trying to confront the problems by earmarking more money in spending bills. The 2007 supplemental spending bill, for example, designated $100 million for mental health services, another $30 million for a new polytrauma center and $20 million to improve services at “Vet Centers” — a network of more than 200 storefront centers the VA operates around the country where veterans and their families can receive counseling.

Beyond such narrow remedies, VA officials and medical researchers are trying to gain a better understanding of the new types of injuries veterans are bringing home. With as many as one in five soldiers projected to suffer mild traumatic brain injuries, researchers at the W.G. Hefner Medical Center in North Carolina are collaborating with scientists at the Massachusetts Institute of Technology to establish how the force of an explosion affects brain cells and their ability to communicate with one another. The answers could yield clues about whether veterans with brain injuries are more susceptible to the effects of alcohol or certain medicines, and help VA screeners differentiate between physical brain injuries and stress-related disorders.

Murray, a leading Democratic voice on veterans’ issues, gives the administration some credit for recognizing the scope of the problems and taking constructive steps. But she says the VA needs to be a much more vocal advocate for veterans’ needs, especially in the area of health care.

She predicts that unless there is more initiative, the Democratic Congress will impose more oversight when it draws up fiscal 2008 spending bills and takes up a defense authorization bill later this year.