```

[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]

 
TWENTY	FIVE YEARS AFTER THE PERSIAN GULF WAR: AN ASSESSMENT OF VETERANS 
   AFFAIRS' DISABILITY CLAIM PROCESS WITH RESPECT TO GULF WAR ILLNESS

=======================================================================

                             JOINT HEARING

                               before the

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                               joint with

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        TUESDAY, MARCH 15, 2016

                               __________

                           Serial No. 114-59

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
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         Available via the World Wide Web: http://www.fdsys.gov
         
         
         
         
         
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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION

                    MIKE COFFMAN, Colorado, Chairman

DOUG LAMBORN, Colorado               ANN M. KUSTER, New Hampshire, 
DAVID P. ROE, Tennessee                  Ranking Member
DAN BENISHEK, Michigan               BETO O'ROURKE, Texas
TIM HUELSKAMP, Kansas                KATHLEEN RICE, New York
JACKIE WALORSKI, Indiana             TIMOTHY J. WALZ, Minnesota

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                   RALPH ABRAHAM, Louisiana, Chairman

DOUG LAMBORN, Colorado               DINA TITUS, Nevada, Ranking Member
LEE ZELDIN, New York                 JULIA BROWNLEY, California
RYAN COSTELLO, Pennsylvania          RAUL RUIZ, California
MIKE BOST, Illinois

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                              ----------                              

                        Tuesday, March 15, 2016

                                                                   Page

Twenty-Five Years After The Persian Gulf War: An Assessment of 
  Veterans Affairs' Disability Claim Process with Respect to Gulf 
  War Illness....................................................     1

                           OPENING STATEMENTS

Honorable Mike Coffman, Chairman.................................     1
    Prepared Statement...........................................    32
Honorable Ann Kuster, Ranking Member.............................     2

                               WITNESSES

Mr. David R. McLenachen, Deputy Under Secretary for Disability 
  Assistance.....................................................     4
    Prepared Statement...........................................    32

        Accompanied by:

    Mr. Bradley Flohr, Senior Advisor, Compensation Service, 
        Veterans Benefits Administration, U.S. Department of 
        Veterans Affairs

Mr. Zachary Hearn, Deputy Director for Claims, Veterans Affairs 
  and Rehabilitation Divison, The American Legion................     5
    Prepared Statement...........................................    35

Mr. Aleksandr Morosky, Deputy Director, National Legislative 
  Service, Veterans of Foreign Wars..............................     7
    Prepared Statement...........................................    38

Mr. Rick Weidman, Executive Director for Policy and Government 
  Affairs, Vietnam Veterans of America...........................     9
    Prepared Statement...........................................    40

Mr. Richard V. Spataro, Director of Training and Publications, 
  National Veterans Legal Services Program.......................    10
    Prepared Statement...........................................    43

                             FOR THE RECORD

Anthony Hardie, Gulf War Veteran and Director, Veterans For 
  Common Sense...................................................    47
Ronald E. Brown, Gulf War Veteran and President, National Gulf 
  War Resource Center............................................    53

TWENTY-FIVE YEARS AFTER THE PERSIAN GULF WAR: AN ASSESSMENT OF VETERANS 
   AFFAIRS' DISABILITY CLAIM PROCESS WITH RESPECT TO GULF WAR ILLNESS

                              ----------                              

                        Tuesday, March 15, 2016

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                  Subcommittee on Oversight
                                        and Investigations,
                                                   Washington, D.C.
    The Committee and Subcommittees met, pursuant to notice, at 
10:30 a.m., in Room 334, Cannon House Office Building, Hon. 
Mike Coffman [Chairman of the Committee] presiding.
    Present: Representatives Coffman, Lamborn, Roe, Benishek, 
Huelskamp, Walorski, Kuster, O'Rourke, Walz, Abraham, Zeldin, 
Costello, Bost, and Ruiz.

             OPENING STATEMENT OF CHAIRMAN COFFMAN

    The Chairman. Good afternoon. This hearing will come to 
order. I want to welcome everyone, especially our good friends 
from the Subcommittee on Disability and Memorial Affairs, to 
today's hearing regarding VA's handling of disability claims 
for Persian Gulf War veterans.
    As a preliminary matter, I would like to ask unanimous 
consent that statements from three Gulf War veterans, and 
advocates for the issues we will discuss today, be entered into 
the record. The statements are found in each Members' packet. 
Hearing no objection, so ordered.
    This hearing is the second part of the Committee's two-part 
series on the 25th Anniversary of the Persian Gulf War, a war 
in which I served. Today, we will examine VA's own data that 
reveals a 16 percent approval rate and an 84 percent denial 
rate for claims of Gulf War veterans for undiagnosed illnesses 
and chronic multi-symptom illnesses, both presumptive 
conditions under current law.
    VA often seems to deny these claims because it demands to 
know the specific cause for the illness. Yet, under the law, 
presumptive conditions do not require causality because they 
are presumed to have been caused by service in the Gulf War. 
The critical point to understand is that veterans cannot 
receive VA care for symptoms of Gulf War illness when a 
majority of those claims are denied by VA.
    We will also discuss former Under Secretary Allison 
Hickey's email citing her, ``concern that changing the name 
from chronic multi-symptom illness to Gulf War illness might 
simply imply a causal link for veterans who served in the 
Gulf.''
    Ms. Hickey's official email exposed VA's efforts to block 
not only the use of the term recommended by the Institute of 
Medicine for Gulf War illness, but also VA's practice of 
requiring causality for GWI claims, even though, again, 
presumptive conditions do not require causality. We also know--
we also want to know more about an internal VA email, which has 
been provided to today's panel, that reveals claims evidence 
that has been lost, even though VA's system told veterans that 
such evidence was received. This is not particular to Gulf War 
veterans, but important regarding claims processing in general.
    I want to also mention that last Friday, March 11th, VA 
held a community of practice call to discuss issues related to 
our Subcommittee's hearing held on February 23rd. The call 
included more than 50 participants, and it discussed how to 
improve care for veterans suffering from Gulf War illness. 
Unfortunately, the majority of the attention was given to a 
presentation by Dr. David Kearney regarding chronic pain with 
what seemed to be an emphasis on PTSD, and the use of 
mindfulness as a method of treatment for Gulf War illness.
    The call, coordinated by Dr. Stephen Hunt, shows that VA 
still clings to its often criticized efforts, and it 
contradicts his testimony from February 23rd, leading me to 
believe veterans suffering from Gulf War illness will never 
receive appropriate care while Dr. Hunt is at all connected to 
the issue.
    While the conversation during Dr. Hunt's call warrants 
additional comments, I will save that for a later time. Before 
I turn my--to my friend Ranking Member Kuster, I want to 
highlight that the invitation for this hearing specifically 
cited our interest in discussing, ``veterans who served in the 
Persian Gulf War,'' and yet VA's testimony has lumped 
information from 1990 with the current OIF, OEF veterans in an 
apparent effort to reflect better statistics than those 
specific to our issue today.
    With that, I now yield to Ranking Member Kuster for any 
opening remarks she may have.

    [The prepared statement of Chairman Coffman appears in the 
Appendix]

        OPENING STATEMENT OF ANN KUSTER, RANKING MEMBER

    Ms. Kuster. Thank you very much, Chairman Coffman, and 
Chairman Abraham, and Ranking Member Titus, who will be with us 
shortly, for holding this hearing on Gulf War veterans.
    As I have said during our hearing on Gulf War illness last 
month, in the 25 years since the end of the Gulf War, many 
veterans have suffered from symptoms that are not readily 
identifiable or well understood, and still struggle to receive 
compensation for their illness.
    During our hearing--the previous hearing, we heard from 
medical experts, researchers, and Under Secretary Clancy, and 
they all agreed that the symptoms of Gulf War illness vary and 
that research must continue so that we can better understand 
and treat our veterans suffering from unexplained medical 
conditions associated with their Gulf War deployment.
    In 1998, Congress passed the Persian Gulf War Veterans Act, 
which granted veterans who served in the Persian Gulf during 
the first Gulf War a presumption of service-connection for 
their illnesses associated with their service. This gave our 
Gulf War veterans compensation for their illness and access to 
VA medical care to treat their symptoms.
    This change reflects our belief that veterans should not be 
denied disability compensation or access to VA health care 
because their symptoms may vary, or because it is not fully 
understood what caused Gulf War illness, or other unexplained 
symptoms. But 18 years later, we continue to receive reports 
that veterans suffering from Gulf War illness and other 
unexplained medical conditions are improperly denied VA 
compensation for not being able to establish a service-
connection when they were deployed to the Persian Gulf. Each 
time this happens, another veteran is being denied the 
compensation and health care that this Nation owes to them. And 
this is simply unacceptable.
    We have also received reports that as a cohort, Gulf War 
veterans have a higher disability claim denial rate, higher 
than her OEF and OIF veterans. This is why I am concerned about 
the end of the Gulf War presumption of services connection this 
year. I am concerned that veterans who may have been improperly 
denied compensation and health care by the VA will not have a 
chance to submit a claim after this point. I am also concerned 
that veterans who became sick later in life due to their 
deployment will be unable to receive compensation or VA health 
care.
    The VA has extended this presumption period once, but now 
it is up to Congress to decide if another extension is 
necessary. I look forward to hearing from our witnesses today 
about whether another extension is warranted and necessary. And 
I also want to know what needs to be done to improve the 
disability claims process for Gulf War veterans.
    I want to know if Veterans Benefits Administration 
employees are properly trained to rate Gulf War veterans 
claims, and how can we improve the quality of the claims rated 
so that veterans are not forced to appeal their claim every 
time. And with that, Chairman Coffman, I yield back.
    Mr. Chairman. Thank you, Ranking Member Kuster. I ask that 
all Members waive their opening remarks as per this Committee's 
custom. Additionally, Chairman Abraham and Ranking Member Titus 
will provide their statements at the conclusion of the hearing.
    With that, I invite the first and only panel to the witness 
table. Thank you. On the panel, for the Department of Veterans 
Affairs we have Mr. David McLenachen, Deputy Under Secretary 
for Disability Assistance. He's accompanied by Mr. Bradley 
Flohr, Senior Advisor for the Compensation Service of the 
Veterans Benefits Administration.
    Also on the panel we have Dr. Zachary Hearn, Deputy 
Director for Claims of the Veterans Affairs and Rehabilitation 
Division of the American Legion. Mr. Alexandra Morosky, Deputy 
Director for the National Legislative Service of the Veterans 
of Foreign Wars. Did I pronounce that right?
    Mr. Morosky. It's Aleksandr, sir.
    Mr. Chairman [continued]. Aleksandr. Okay, I'm sorry. Mr. 
Rick Weidman, Executive Director for Policy and Government 
Affairs for the Vietnam Veterans of America, and Mr. Richard V. 
Spataro, Director of Training and Publications for the National 
Veterans Legal Services Program.
    I ask for witnesses to please stand and raise your right 
hand.
    [Witnesses sworn.]
    Mr. Chairman. Please be seated. And let the record reflect 
that all witnesses have answered in the affirmative.
    Mr. McLenachen, you are now recognized for five minutes.

                 STATEMENT OF DAVID MCLENACHEN

    Mr. McLenachen. Chairman Coffman, Chairman Abraham, Ranking 
Member Kuster, and Members of the Subcommittees, thank you for 
the opportunity to discuss VA's processing of claims for 
disability benefits from veterans who served and, in some 
cases, continue to serve in the Persian Gulf war.
    I am accompanied today by Mr. Bradley Flohr, Senior Advisor 
in our Compensation Service. We will discuss our efforts to 
ensure that Gulf War veterans receive the benefits they have 
earned, VA--VA's processing of these claims, its training and 
quality assurance efforts, presumptive service-connection, the 
statutory authority for establishing presumptions, and the 
science and rationale behind such presumptions.
    This year marks the 25th anniversary of the start of the 
Gulf War. The initial conflict lasted from August 1990 until 
February 1991. However, neither the President nor the Congress 
has declared an end to the Gulf War. So men and women who serve 
in the Southwest Asia theater of operations to this day remain 
entitled to presumptions of service-connection based upon their 
service.
    As of the end of fiscal year 2015, almost 7.2 million 
veterans served during the Gulf War era and over 1.8 million of 
these veterans were in receipt of disability compensation, 
which is the highest percentage of veterans in receipt of 
compensation from any era, war time or peacetime. Gulf War 
veterans who have received VA compensation average greater than 
six service-connected disabilities. Again, more than any other 
era. And Gulf War veterans now make up the majority of claims 
that VA receives.
    VA continues to improve the efficient, timely, and accurate 
processing of Gulf War veterans' claims. It has reduced its 
overall backlog of pending claims by approximately 86 percent 
from its peak in March 2013 to the end of February 2016. VA has 
also reduced the average days for waiting for a decision to 93 
days, which is a 189-day reduction from its peak in March 2013.
    The Veterans Benefits Administration is constantly looking 
for ways to improve the service it provides to this cohort of 
veterans. We closely review Gulf War issues with the Veterans 
Health Administration, the Department of Defense, the Institute 
of Medicine, and the National Gulf War Resource Center.
    VBA has a national quality review staff as well as quality 
reviewers in its local regional offices to ensure that 
employees correctly process and decide claims for Gulf War 
illness. Last year, VA conducted a special focused review of 
decisions on claims for Gulf War-related illness which showed a 
94 percent accuracy rate.
    Although the science and medical aspects of undiagnosed 
illnesses and multi-symptom illnesses are not yet fully 
understood, VA continues to review scientific and medical 
literature to gain a better understanding of the impact of 
these illnesses on Gulf War veterans.
    Presumptive service-connection fills a critical gap when 
exposure to toxic substances or certain disabilities resulting 
therefrom are not specifically documented in a Gulf War 
veteran's service records. Service-connection for an 
undiagnosed illness or multi-symptom illness requires service 
in the Persian Gulf after August 2, 1990, and a qualifying 
chronic disability that rises to a compensable level of 
severity before December 31, 2016.
    Service-connection is also warranted for veterans who 
contract certain infectious diseases such as malaria, Q fever, 
and West Nile virus after Gulf War service, and that includes 
Afghanistan. The Secretary of Veterans Affairs has broad 
authority under Section 501 of Title 38, United States Code to 
establish presumptions.
    To determine which diseases are associated with such 
service, the Secretary takes into account reports from the 
National Academy of Sciences, and all other sound medical and 
scientific information that's available. Public Law 105-368 
charges VA with the responsibility for notifying Congress of 
NAS findings that might impact presumptions of service-
connection for diseases associated with service in the 
Southwest Asia theater of operations during the Gulf War due to 
exposure to biological, chemical, or other toxic agents, 
environmental or wartime hazards, or preventive medicine, or 
vaccines.
    That concludes my opening statement, we are happy to answer 
any questions that you might have. Thank you.

    [The prepared statement of David R, McLenachen appears in 
the Appendix]

    Mr. Chairman. Mr. Hearn, you are now recognized for five 
minutes.

                   STATEMENT OF ZACHARY HEARN

    Mr. Hearn. Thank you. 9,358 days. 9,358 days have lapsed 
since our Nation deployed nearly 700,000 brave men and women of 
an all volunteer military to soundly defeat an aggressor and 
secure the peace. Today, many of these veterans need our help, 
and sadly, they have not been able to receive the benefits 
associated with their service in Southwest Asia.
    Chairman Coffman, Abraham, Ranking Members Kuster, Titus, 
and distinguished Members of the Subcommittees on Oversight and 
Investigation and Disability Assistance and Memorial Affairs, 
on behalf of National Commander Dale Barnett, and the over 2 
million members of the American Legion, we welcome the 
opportunity to discuss the struggles that veterans with service 
in Southwest Asia have faced in receiving disability benefits 
associated with their Persian Gulf service.
    According to VA's March 2014 update for Gulf War veterans, 
37 percent of veterans that served during Operation Desert 
Storm suffer from symptoms associated with Gulf War service. 
Yet, in over 9,100 days since the final shots of Operation 
Desert Storm were fired, approximately 80 percent of all claims 
associated with Persian Gulf service were denied according to a 
separate VA report.
    The concept of the Department of Veterans Affairs 
presumptively service-connecting conditions associated with 
environmental exposures is not new to this generation of 
veterans. Veterans that participated in nuclear testing have 
conditions presumptively related to radiation exposure, and 
veterans with exposure to herbicides such as Agent Orange have 
a host of conditions that are presumptively related to their 
military service.
    So what separates the Gulf War generation from previous 
generations of veterans? For veterans with service in Vietnam, 
if they were diagnosed with conditions such as diabetes, 
ischemic heart disease, or a variety of cancers, outside of 
rare circumstances, they are presumptively service-connected 
for these conditions. It is simply a process of receiving a 
diagnosis and then determining the severity of the condition 
affecting the veteran.
    For veterans with service in Southwest Asia from August 
2nd, 1990, to the present, gaining service-connection for 
presumptive conditions is not as easily accomplished. Many of 
these--many of these conditions or symptoms associated with 
what VA has labeled as undiagnosed illness. The term is 
inherently gray and confusing. Veterans must endure years of 
medical testing and may even have multiple diagnoses associated 
with their symptoms.
    But here's the catch. The moment that the veteran is 
diagnosed, it is virtually impossible to receive service-
connection on a presumptive basis because the condition is no 
longer undiagnosed.
    The American Legion has over 3,000 accredited 
representatives located throughout the Nation. To ensure we 
provide effective advocacy for veterans, we bi-annually hold 
department service officer's school. During last month's 
training, we specifically discussed concerns surrounding Gulf 
War veterans and presumptive service-connection. Often, these 
representatives state that via medical professionals will 
assign symptoms to aging or, sadly, even malingering.
    For those that ultimately gain service-connection, it only 
comes after years of testing to exhaust the possibilities of 
other diagnoses. This process often causes significant stress 
for veterans and their families.
    Beyond concerns surrounding VA, many veterans of our 
National Guard and reserve components have an uphill fight 
regarding their medical records. While Operation Desert Storm 
serves as a first major conflict in the American Century with 
an all volunteer military, it also served as the impetus for 
frequent use of our guard and reserve forces.
    Unfortunately for guard and reserve veterans, treatment 
records become scattered between their duty station, mobility 
center, and foreign hospitals. As a result, these veterans have 
conditions that could be attributed to their military service, 
but due to unavailable records, are never able to receive the 
required positive nexus statement.
    To help correct problems facing Gulf War veterans, the 
American Legion believes that all of VA's disability benefits 
questionnaire should include asking if, a) the veteran served 
in Southwest Asia; and b) has the medical professional 
considered the relationship between the sought symptoms and 
conditions in Gulf War service.
    Additionally, we continue to call for a full implementation 
of the Virtual Lifetime Electronic Record. While VA has shown 
progress, concerns surrounding obtaining records from the 
Department of Defense continue to linger. Finally, there needs 
to be an increase in education for medical professionals 
regarding Gulf War veterans to decrease the delay in benefits 
and an increase in outreach to veterans to improve their 
knowledge regarding presumptive conditions associated with Gulf 
War service.
    Again, on behalf of National Commander Dale Barnett and the 
millions of dedicated veterans that comprise the Nation's 
largest veterans service organization, we thank you for having 
the opportunity to speak today. I'll be happy to answer any 
question--any of the Committee's questions. Thank you.

    [The prepared statement of Zachary Hearn appears in the 
Appendix]

    Mr. Chairman. Thank you, Mr. Hearn. Mr. Morosky, you are 
now recognized for five minutes.

                 STATEMENT OF ALEKSANDR MOROSKY

    Mr. Morosky. Chairman Coffman and Abraham, Ranking Members 
Kuster and Titus, and Members of the Subcommittee, on behalf of 
the men and women of the Veterans of Foreign Wars of the United 
States, I'd like to thank you for the opportunity to testify on 
VA's disability claims process with respect to Gulf War 
Illness.
    Today's hearing is extraordinarily timely, as this year our 
Nation recognizes the 25th anniversary of the Persian Gulf war. 
While symbolic recognition is important, the VFW strongly 
believes that the most meaningful way to honor the service of 
Persian Gulf veterans is to ensure they have access to the 
benefits they need and deserve.
    All too often we find that this does not happen. This is 
largely due to the fact that the signature condition associated 
with the Persian Gulf war, commonly known as Gulf War Illness, 
presents itself in a way that's not conducive to the 
traditional VA disability claims process. Consequently, our VFW 
service officers and appeal staff report that VA denies Gulf 
War Illness claims at a consistently higher rate than other 
types of claims.
    Part of the challenge is that Gulf War Illness is an 
inherently difficult condition to diagnose and treat. This is 
because it presents itself as a host of possible symptoms 
rather than a single condition that is clearly identifiable and 
unmistakable.
    What is certain is that more than 200,000 Persian Gulf war 
veterans suffer from symptoms that cannot be explained such as 
chronic widespread pain, cognitive difficulties, unexplained 
fatigue, and gastrointestinal problems, just to name a few. 
Instead of Gulf War Illness, VA uses the term medically 
unexplained chronic multi-symptom illness, or simply 
undiagnosed illness, to describe those symptoms. Although 
undiagnosed illness is considered a presumptive condition for 
Persian Gulf veterans, there are certain factors that prevent 
them from receiving favorable decisions when claiming that 
condition.
    When claiming undiagnosed illness, the veteran lists the 
symptoms he or she is experiencing. These symptoms are often 
seemingly unrelated to one another, affecting multiple body 
symptoms. As a result, VA assigns separate disability benefit 
questionnaires, or DBQ's, for each symptom and separate exams 
are scheduled.
    The current Gulf War DBQ asks the physician whether there's 
a condition of each body system present, and then asks them to 
complete the relevant DBQs. Only after that are questions about 
undiagnosed illnesses asked. We find that this practice of 
assigning separate DBQs for each symptom being claimed in 
connection with undiagnosed illness has the effect of promoting 
diagnoses even when those diagnoses are minimally supported.
    Once a symptom receives a diagnosis, it's no longer 
considered connected with undiagnosed illness, which, as its 
name implies, requires that the illness be unexplained. Since 
undiagnosed illness is ruled out for that condition, the 
veteran no longer has the opportunity to be granted on a 
presumptive basis. Often lacking any evidence of the condition 
in the service treatment record, a nexus cannot be established, 
and the claim is denied.
    VFW staff at the Board of Veterans Appeals notes that 
remands become numerous in these cases, and veterans often 
receive several different diagnoses for the same symptom from 
different doctors as a result. They believe that this is due to 
minimal support for those diagnoses in the first place. It is 
apparent to them that VA seems to go to great lengths to find 
diagnoses for each symptom simply so that undiagnosed illness 
can be ruled out.
    The practice of parsing out symptoms has the additional 
effect of preventing a holistic evaluation for undiagnosed 
illness. When the claim is for an undiagnosed illness, the VFW 
believes the physician should be asked more questions about the 
cluster of symptoms, which could be one illness leading to 
symptoms in multiple body symptoms rather than separate 
conditions related to each symptom. Only if they're confirmed 
diagnoses should separate DBQs be completed.
    To improve the current system, the Gulf War DBQ should be 
analyzed by a team of physicians, including those from a war-
related illness and injury study center. Additionally, VA 
should grant veterans reasonable doubt when deciding whether or 
not a veteran's symptoms should be considered undiagnosed 
illness.
    Mr. Chairman, we see this as the most significant barrier 
for veterans seeking service-connection for Gulf War Illness. 
As noted in my written statement, the VFW has several other 
recommendations, including analyzing whether it would be better 
to process Gulf War illness claims at a centralized location; 
better tracking for Gulf War related BDD claims; enabling 
contract physicians to conduct Gulf War Illness exams; and 
training for claims adjudicators.
    Mr. Chairman, this concludes my testimony. I'm happy to 
answer any questions you may have. Thank you.

    [The prepared statement of Aleksandr Morosky appears in the 
Appendix]

    Mr. Chairman. Thank you, Mr. Morosky. Mr. Weidman, you are 
now recognized for five minutes.

                   STATEMENT OF RICK WEIDMAN

    Mr. Weidman. Thank you, Mr. Chairman. No doubt each of you 
are asking yourselves the obvious question is, given that we're 
a single generation organization, why are we here today? And 
the answer is, we are committed. Our founding principle is, 
never again shall one generation of American veterans abandon 
another, number one. But secondly, what is happening to the 
Gulf War veterans is all too reminiscent of the way in which we 
were bounced around on Agent Orange where they denied, denied, 
and most Vietnam veterans who've been through this, it's almost 
a truism that delay, deny until they die. And they're doing the 
same thing to those who fought in the Persian Gulf War.
    It is the sophistry involved in trying to break out the 
symptoms in multi-symptom Gulf War illness, is--and then 
forcing you to prove that what that is connected to is--the 
reason why I say it's sophistry, is VA well knows that you 
cannot pin down exact cause when you have a multi-toxin 
environment, which is exactly what you had during the Gulf War.
    And given that together, it is--it is something that what 
we should be doing is doing epidemiological studies intensively 
of this population compared with their peers in the military 
and the same MOS who did not deploy to the Gulf, and their 
civilian peers because it may be something about military life 
in general.
    So it is--having--having attended the IOM meeting recently, 
I, for the first time really, understand the emotional impact 
that they keep saying that there's nothing physically wrong 
with you. I mean they'll beat around the bush on that, but 
basically, that's what they're saying. And they keep running 
in--that panel, as an example, was half neuropsychologists and 
psychiatrists and half hard science.
    So that they're--and the chair was a psychologist, so it's 
little wonder that that panel recommended no more hard science 
because that's too hard to figure out what has caused all of 
this in order to, a) begin to come up with treatments that are 
effective, and b) protect our troops in the future by not 
exposing them in the same way to the same conditions.
    So--and in regard to those who are applying now, they play 
the game of divide and conquer on all this, and you're chasing 
a rabbit hole about what one particular symptom, what is the 
etiology of it, knowing full well that you can never pin that 
down. And that's the game that they put individual veterans in 
when they apply for benefits and file their claim for 
compensation, and that's not just for compensation because you 
have to be service-connected unless you are almost indigent in 
order to have health care. So it is a denial of all of the 
rights of these folks.
    I was particularly shocked when I stumbled across this 
little puppy, and it's called VA DoD Clinical Practice 
Guideline, and it's from 2014. And in this, the whole--all of 
this is--the only thing missing in this bit of sophistry is a 
snake oil to wash it down, because it says nothing, produced 
at, no doubt, at great expense by VA and DoD, but doesn't do a 
darn thing to enlighten the individual clinician who is trying 
to help that particular veteran. I could perhaps say that more 
elegantly, but that's where it is.
    We worked very hard with Chairman Benishek and with 
Chairman Miller in bringing along the toxic research--Toxic 
Exposure Research Act. And one of the reasons why we're so 
committed to that bill is not just for children, but also 
understanding that any one of these toxic bills has to be 
multi-generational, that we've got to rationalize this process 
if, in fact, we're going to get beyond the sturm und drung for 
every generation.
    The--we've already--we are going through it now on burn 
pits, there was a major article that came out today that VA and 
DoD are stopping any further research into the burn pits, and 
they are blaming the Congress for not appropriating more monies 
and vice a versa.
    Whatever the upshot is this, we need more research that is 
systematically, that is for real, into both toxicology, and 
even more importantly, the epidemiology of how these toxins 
manifest in the veterans' population.
    I thank you for the opportunity, Mr. Chairman. I'd be happy 
to answer any questions.

    [The prepared statement of Rick Weidman appears in the 
Appendix]

    Mr. Chairman. Thank you, Mr. Weidman. Mr. Spataro, you are 
now recognized for five minutes.

                  STATEMENT OF RICHARD SPATARO

    Mr. Spataro. Thank you, Mr. Chairman, Mr. Chairman, Members 
of the Subcommittees. I am pleased to have the opportunity to 
testify on behalf of the National Veterans Legal Services 
Program. There are two topics I'll be discussing today: VA's 
handling of claims related to Gulf War illness, and the 
extension of the end date for the period during which a 
qualifying chronic disability must manifest in order to qualify 
for presumptive service-connection.
    NVLSP has vast experience with veterans claims for VA 
disability compensation under 38 U.S.C. Section 1117, which 
requires the VA to pay compensation to Persian Gulf War 
veterans for 1) undiagnosed illnesses, 2) medically unexplained 
chronic multi-symptom illnesses, and 3) diagnosed illnesses 
that the Secretary determines warrant a presumption of service-
connection.
    It has been over two decades since Section 1117 was added 
to Title 38 of the U.S. Code, yet VA adjudicators still have 
difficulty adjudicating claims for the first type of chronic 
disability in particular: undiagnosed illnesses. In our 
experience, there are four common types of errors that the VA 
commits when adjudicating these claims.
    The first type of error is VA failing to consider the 
favorable rules for presumptive service-connection for an 
undiagnosed illness when the veteran does not explicitly claim 
benefits under that theory of service-connection. This type of 
error typically occurs when the veteran claims entitlement to 
service-connection for a particular diagnosis the veteran 
thinks he or she has, but does not refer to Gulf War illness.
    And the--if the evidence ultimately shows that the 
veteran's chronic complaints cannot be attributed to a 
diagnosis, the VA adjudicator sometimes denies the claim due to 
the lack of a diagnosed disability, which is a requirement for 
establishing service-connection under all other theories of 
entitlement.
    Although VA adjudicators have an affirmative duty to 
consider all reasonably raised theories of service-connection, 
they often fail to consider the theory of service-connection 
for an undiagnosed illness when that theory of entitlement is 
reasonably raised by the evidence.
    The second type of error is VA erroneously attributing 
symptoms that have not been associated with a diagnosed 
condition to a diagnosed condition unrelated to military 
service. VA then denies the claim on the basis that the veteran 
does not have an undiagnosed illness.
    We have seen several cases like this in which a careful 
review of the medical evidence shows that contrary to the VA's 
finding, not all of the symptoms identified by the veteran are 
linked to a specific diagnosis.
    The third type of error is VA denying the claim due to the 
lack of medical nexus evidence. Under Section 1117, a Persian 
Gulf War veteran is entitled to the presumption of service-
connection for a chronic undiagnosed illness if certain 
requirements are met. In 2004, in Gutierrez v. Principi, one of 
NVLSP's cases, the CAVC emphasized that the medical evidence 
linking the disability to military service, or the Persian Gulf 
War, is not one of those requirements.
    The VA, however, continues to erroneously deny some claims 
for service-connection for undiagnosed illnesses on the basis 
that no medical expert has linked the veterans' symptoms to 
Gulf War illness.
    The fourth type of error is VA denying the claim due to the 
absence of objective indications of a chronic disability 
without considering non-medical indicators capable of 
independent verification. One requirement for establishing 
service-connection is that a veteran exhibit objective 
indications of a chronic disability.
    Objective indications include both signs in the medical 
sense of objective evidence perceptible to an examining 
physician, and other non-medical indicators that are capable of 
independent verification. And that last part is the critical 
part. We have seen cases in which the VA erroneously denied the 
claim solely due to the lack of objective evidence perceptible 
to a VA physician without considering other non-medical 
indicators that are capable of independent verification.
    Now I'll move on to the second topic. Under Section 
1117(b), the Secretary must establish the period during which a 
qualifying chronic disability must manifest following service 
in Southwest Asia in order to qualify for presumptive service-
connection.
    After initially establishing a two-year presumptive period, 
VA has repeatedly extended the end date. Most recently, in 
2011, VA extended the end date to December 31, 2016, due to 
scientific uncertainty regarding the time period in which 
Persian Gulf War veterans had an increased risk of suffering 
from chronic illnesses, as well as the fact that National 
Academy of Sciences reviews were still ongoing.
    Little has changed with respect to the level of scientific 
certainty regarding Gulf War illness. Due to this continued 
state of uncertainty, VA should again extend the date of 
presumptive service-connection during which symptoms of a 
qualifying chronic disability must first manifest to at least 
December 31st, 2021, if not indefinitely.
    I'd be pleased to answer any questions you may have. Thank 
you.

    [The prepared statement of Richard V. Spataro appears in 
the Appendix]

    Mr. Chairman. Thank you, Mr. Spataro. The written 
statements of those who have just provided oral testimony will 
be entered into the hearing record and we will now proceed to 
questioning.
    Mr. McLenachen, based on testimony from many today, it is 
apparent that VA is not doing justice to presumptive claims-
related to undiagnosed illnesses and chronic multi-symptoms, 
and chronic multi-symptom illnesses. What good are your quality 
reviews when, across the board, VA isn't correctly applying the 
law?
    Mr. McLenachen. I thank you for that question, Mr. 
Chairman. I am not ever going to come to these Committees and 
say that we are perfect in the work that we are doing, so I am 
not going to tell you that. I will say that we have taken a lot 
of steps to improve how we process these claims to include some 
of the suggestions that you have heard today, such as improved 
training, which we did just within this last fiscal year.
    Training is now a part of our challenge training that we 
provide to new adjudicators. All adjudicators were required to 
take revamped Gulf War training beginning in October 2015, 
which is mandatory. I have heard the message about the DBQs. I 
intend to go back and look and see whether that is something we 
can improve on based on the suggestions that you have heard 
here today.
    But we have extensive quality review programs, both locally 
and nationally, where we do look at these claims, to include 
something that we did in addition to those two programs, which 
is to do the focused review that is discussed in my testimony. 
So we do have a very robust quality review program where we 
look at processing of these claims. Having said that, I intend 
to look carefully at the testimony of the other witnesses, and 
carefully consider their suggestions.
    Mr. Chairman. In 2015, the Board of Veterans' Appeals 
remanded about a fourth of these claims, nearly a fourth were 
granted, only 6 percent were denied, and roughly half remained 
unresolved. These same percentages are similar to 2016, so far. 
This indicates a problem in the handling of these claims. We 
want to know what you are going to do to immediately fix these 
problems.
    Mr. McLenachen. Mr. Chairman, I just want to challenge the 
idea that a remand means that VA did something wrong. In fact, 
due to the appeal process that we have, it is often because of 
the passage of time. Again, having said that, the goal is 
always to resolve the claim at the earliest point possible. And 
we have had some discussions recently about how we can do that 
better with the service organizations. If the Board points out 
errors that make it back to the regional office, we try to 
incorporate that in our training to the best that we can.
    Mr. Chairman. Yeah. Well, Mr. McLenachen, will VA extend 
the presumptive claims deadline?
    Mr. McLenachen. We have a rule-making in progress that 
addresses that. Before I can provide you a definitive answer, 
we have to go through the rule-making process, but I can tell 
you we got a new IOM report just recently, which the Veterans 
Health Administration is looking at very carefully.
    Mr. Chairman. Okay.
    Mr. McLenachen. I agree with what was said here today that 
the science has not really changed recently.
    Mr. Chairman. Mr. McLenachen, according to Ron Brown, 
president of the National Gulf War Resource Center, on August 
17, 2015, VA stated it would ``do a statistically significant 
review of completed Gulf War claims to determine if there is a 
problem'' in processing such claims. What is the result of that 
review?
    Mr. McLenachen. I will let Mr. Flohr address that.
    Mr. Chairman. Mr. Flohr.
    Mr. Flohr. Thank you, Mr. Chairman. We did do that review. 
It was approximately 360 claims, it was a statistically 
significant number. We found that we had two claims which 
actually were improperly denied. We have taken action to fix 
those. And there were another 6, or a little more than 12 or 
so, where we either had an examination that was not sufficient, 
or an improper examination was done by VHA, and we are 
returning those to have those corrected. So our rate there was 
94 percent accuracy.
    Mr. Chairman. Mr. Flohr, can you provide that information 
to this Committee immediately upon completion of this hearing?
    Mr. Flohr. Yes. We can do that, sir.
    Mr. Chairman. Very well.
    Ranking Member Kuster, you are now recognized for five 
minutes.
    Ms. Kuster. Thank you, Mr. Chairman. Well, it appears to me 
that this is deja vu all over again. We are revisiting where we 
were with the Vietnam veterans. And it was shortly after I came 
to Congress that Secretary Shinseki worked on this presumption 
about Agent Orange and I think it, hopefully, has made a 
significant difference in the lives, certainly for veterans in 
my district in New Hampshire, and I really believe in following 
the science where it leads us, but sometimes we don't have it 
in a timely way.
    And so I appreciate you being with us, Mr. Weidman, and I 
want to focus in on that, because it seems like we have a 
couple of different catch-22s that I am trying to catch up with 
and follow here.
    One is that I am impressed by the data, and thank you for 
providing it for my district, about the reduction in the 
backlog on disability claims, the reduction in time that it 
takes for an average claim, and the improvement in accuracy of 
claims, but I am trying to reconcile that with this data that 
the VA denies 80 percent of claims filed by Gulf War veterans 
for conditions related to the war.
    I mean, I meet veterans all the time that are trying to 
cope with this constellation of symptoms and it is very 
challenging, and so I am trying to determine if we believe in 
this, if Congress passed this presumption, why are we having 
such a hard time addressing, and is the 80 percent denial, is 
that these are somehow malingerers that are coming forward? I 
don't meet those people.
    Mr. McLenachen. So Mr. Flohr has some of that more specific 
data that we can provide to the Committee as far as actual 
grants and denials, specifically for subsets of the Persian 
Gulf war period. I just want to point out, however, that to 
some extent I assume that the 80 percent figure that we are 
talking about relates specifically to those Gulf War illness 
presumptions. In many cases, the veteran is service-connected 
for other disabilities that are diagnosed, and for that reason, 
there may be a denial on the basis of the Gulf War presumption.
    Ms. Kuster. I don't follow. I mean, if they are service-
connected for something else, why would you deny this?
    Mr. McLenchen. Well, the condition may be diagnosable, is 
what I am trying to say, rather than undiagnosed. And for that 
reason--
    Ms. Kuster. So I guess that is kind of the catch-22 that 
keeps coming up in the testimony of our witnesses, is we have 
defined this illness around chronic undiagnosed illness, but as 
soon as they get a diagnosis, then they don't qualify. That 
seems like really counterproductive to our goal, which is 
servicing these veterans who so bravely and courageously fought 
for us.
    So I guess--let me cut to the chase. Do you need something 
different from Congress? And this leads to this extension 
because I am confused, you are talking about the VA, this is in 
statute. I mean, we need to introduce a bill, right? You need a 
statutory change to keep this going?
    Mr. McLenachen. No, we don't. We have authority to 
establish a delimiting date for the presumption. The current 
delimiting date is that December 31st, 2016.
    Ms. Kuster. Which is going to be coming up on us pretty 
quickly. And what we learned from the situation with the 
schematic--is that what it is--heart disease. Ischemic, excuse 
me. That we didn't even know that, right? So I am concerned 
there may be something that we don't even know. And 
particularly with toxins, I have a big problem. And this isn't 
on you, this is on us as Congress and on the DoD, about these 
burn pits and the toxins that are--and I think one of our 
witnesses said it best, I want to protect future troops. I want 
to know what is happening.
    So the science hasn't caught up with us. I am very 
concerned about a fixed date of December 31st, 2016. And I just 
want to make sure that if you don't get it done that we get it 
done here because we don't even know the constellation of 
illnesses that are out there and we want to serve our vets.
    Mr. McLenachen. We will have the regulation done. The last 
time that we extended the delimiting date, we did it by an 
interim final rulemaking, which allowed us to put it out as a 
final rule and then--
    Ms. Kuster. In a timely way?
    Mr. McLenachen. Yes.
    Ms. Kuster. So that people aren't stressing out over it.
    Mr. McLenachen. And we intend to do the same thing in this 
case.
    Ms. Kuster. And I do want to acknowledge the improvement 
that is being made, and, you know, we want to work with you to 
make sure that we are serving our veterans. So, thank you for 
your testimony and thank you for the rest of you.
    I yield back.
    Mr. Abraham. Thank you very much, Representative Kuster. I 
will now question the panel.
    Mr. Morosky, in your written testimony, you note that part 
of the challenge with these claims is that the Gulf War Illness 
is an inherently difficult condition to diagnose and treat, 
because it presents itself as a host of possible symptoms 
common to many veterans that served in the Persian Gulf Region. 
As a doctor, I can understand that VA examiners are more 
familiar with evaluating a single condition that is clearly 
identifiable and unmistakable, but that being said, how do you 
suggest that the VA improve the quality of the examinations of 
veterans who served in the Gulf War?
    Mr. Morosky. Thank you, Mr. Chairman.
    So, as it has been pointed out, it is a bit of a catch-22 
for veterans who are claiming the undiagnosed illness because 
it could be a host of symptoms that they are claiming. It could 
be chronic pain, chronic fatigue, or gastrointestinal problems, 
and these are all known symptoms that could be considered under 
the chronic multi-symptom, undiagnosed illness. However, when 
VA looks at the claim, instead of giving one disability 
questionnaire to one physician to look at and consider whether 
or not those symptoms are Gulf War Illnesses, they are parsed 
out and one DBQ goes to a physician to look at the 
gastrointestinal problem. Another physician gets the 
questionnaire to look at the fatigue. Another physician gets 
the questionnaire to look at the chronic pain.
    And then, of course, when looking at them in a vacuum and 
not looking at it globally, what doctors do, as you point out, 
is to diagnose. So if the veteran comes back with diagnosis of 
Crohn's disease, fibromyalgia, and depression for those, they 
are no longer considered an undiagnosed disorder, and, 
therefore, they can't be considered undiagnosed illness, so 
they are not able to be adjudicated on a presumptive basis; 
whereas, if they were considered undiagnosed, they would have 
been adjudicated on an presumptive basis. So, since they are 
not, the claims adjudicators look into the service record and 
they don't see these there, and so they are denied.
    Mr. Abraham. So, how do you suggest fixing it, a different 
DBQ?
    Mr. Morosky. Yeah. Sir, we would suggest a DBQ where, when 
symptoms are claimed by a Persian Gulf War veteran that are 
consistent when taken together with Gulf War Illness, that a 
single Gulf War Illness DBQ be given to a single physician who 
is trained to look for those symptoms and look at those 
globally; look at them holistically, so that the physician can 
then say, yes, this is consistent with Gulf War Illness. This 
veteran has an event which is serviced during the Persian Gulf 
War and then be able to grant on a presumptive basis in that 
way. So, a holistic view versus parsing out the symptoms and 
not looking at them individually.
    Mr. Abraham. I understand.
    Any other VSOs wish to comment? Mr. Hearn? Mr. Weidman? Any 
suggestions as to how these examinations could be more 
productive?
    Mr. Weidman. Trying to parse it apart, when, in fact, you 
cannot separate the multi-toxic environment in which they were 
initially--had the problem originate is, you are never going to 
pin down what that silver bullet is. It just doesn't exist in 
environmental health science.
    And VA knows that and that is why it is pulling it apart in 
order to come up with the wrong answer. The real question is, 
why haven't they done the epidemiological work on this 
population in a serious way that would give us some of the 
answers as comparing those who served in the Gulf versus those 
with the same MOS who served elsewhere during that timeframe, 
and they haven't done that in any kind of serious way. And once 
they do that, a lot of this will become clearer.
    Let me just add that this--VA has the authority to have a 
shut-off date. They did the same thing with lung cancer having 
to do with Agent Orange and we finally took them to court and 
they had to lift that delimiting date, because they had zero 
scientific evidence--
    Mr. Abraham. And let me interrupt you. I apologize. I want 
your statement, but I want to ask one more question to Mr. 
Flohr.
    Given what you have just heard, Mr. Flohr, how is VBA 
ensuring that the quality controls are sufficient to ensure the 
raters are held accountable if they rely on inadequate 
examination results for Gulf War veterans?
    Mr. Flohr. Yes, thank you for your question.
    As recently as the end of 2014, we actually revised our 
training materials for our claims processors, with respect to 
Gulf War Illness. We put into our training system, every one of 
our claims processors, including not only rating specialists, 
but the other--the initial people who review claims. We were 
required to complete that by last September and they did so.
    So we have updated it. We are always looking for ways to 
update our training to make it better where we find that there 
are problems with it.
    By the same token, Veterans Health Administration revised 
their training for examiners who do Gulf War Illness claims.
    Mr. Abraham. And what about quality for purposes of STAR 
for a rating review, what is going on there?
    Mr. Flohr. Quality where? I am sorry, where?
    Mr. Abraham. STAR review.
    Mr. Flohr. STAR review?
    Mr. Abraham. Yes.
    Mr. Flohr. Do we know about our STAR review quality? It 
is--our overall quality is like 92 percent.
    Mr. Abraham. Okay. And I am out of time. I will ask some 
follow-ups in a written questionnaire.
    As a follow-up, what about the 90-to-91 group; what is 
going on?
    Mr. Flohr. I don't think we have that quality by group. 
That is our overall quality rate.
    Mr. Abraham. We would appreciate it for the record, please.
    Mr. Flohr. Okay. Thank you.
    Mr. Abraham. Mr. O'Rourke, you are recognized, sir.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    I wanted to ask Mr. McLenachen to respond to Mr. Morosky's 
suggestion that you have one DBQ handled by a single physician 
to be able to look at this comprehensively, instead of breaking 
it out into separately diagnosed symptoms.
    Mr. McLenachen. It may have been before you joined us, I am 
not sure, but I committed to going back and taking a look at 
what we are using as far as a DBQ, to see if there are those 
types of changes that we need to make, so I will go back and 
take a look at that.
    Mr. O'Rourke. Okay. So your commitment is to review it; you 
are not necessarily committing to that process, which seems to 
make a lot of common sense to me. If we are concerned about 
what the Ranking Member referred to as a catch-22, that is, you 
begin to diagnose these individual symptoms, you are no 
longer--you no longer have an undiagnosed illness. That seems 
to be the answer to me, so I am not sure--why don't you tell us 
the factors that you will look at, as you consider the 
proposal; in other words, I am wondering why you can't just 
commit to adopting that as the way forward.
    Mr. McLenachen. Well, I would like to show up here for a 
hearing and have all the information I need to answer that type 
of question, but I don't have all that information with me 
right now. The best I can offer you is that I will go back and 
look at that specific issue and the recommendation and see 
whether that is something that we can and we should implement, 
and that is my commitment to you.
    Mr. O'Rourke. What is the argument against it?
    Mr. McLenachen. Well, based on what I am hearing, first, we 
have to confirm that that is the--that that is a real problem 
that veterans are experiencing, and if it is, then it is 
something that we need to fix. So, then, I would not disagree 
that it's something we need to fix.
    Mr. O'Rourke. Okay. And I am sorry to pursue you on this 
one, but it seems as long as we have everyone here, we might as 
well get to as close to the bottom of it as we can. You said 
you want to substantiate that veterans are really having this 
problem of these separate diagnoses. It seems like every single 
person up here has confirmed that that is the case. I don't 
think that you doubt their credibility on this.
    Mr. McLenachen. Not at all.
    Mr. O'Rourke. We don't, as the representatives of Gulf War 
veterans, doubt the stories we are told by our constituents, so 
that factor seems to have been eliminated.
    I am very open to a counter-argument to the one proposed by 
Mr. Morosky, but unless there is one, I think we have to move 
forward. We can't, 25 years later, continue to extend deadlines 
or talk about this at another hearing. I have only been here a 
little over three years and it does not seem like we are making 
a lot of progress on it.
    Not because of any lack of commitment, necessarily, on your 
part, but I do think we need to have a conclusion and a 
solution to this. And this doesn't solve everything, but I 
think gets to the catch-22 issue that so many of us have asked 
about and so many of the VSO representatives have highlighted.
    So, all speed possible on your decision and I, for one, am 
sure, joined by the other Members of the Committee, would like 
to hear your response to that and would like to share it with 
the VSOs as soon as you have one. How long do you think it will 
take for you to get an answer on that?
    Mr. McLenachen. I will start looking into it today when I 
get back.
    Mr. O'Rourke. Okay. And when do you think we can hear back 
from you?
    Mr. McLenachen. I can't tell you exactly, but we are going 
to owe some information after this hearing, as far as what we 
have taken for the record. I think we can make it part of that.
    Mr. O'Rourke. Mr. Hearn, a question on a separate topic. Do 
you happen to know what the average age of a servicemember 
during the Gulf War was, 20, 21, 22?
    Mr. Hearn. In 1990 and 1991, I don't know that number off 
the top of my head, but--
    Mr. O'Rourke. Early 20s?
    Mr. Hearn. I am sorry?
    Mr. O'Rourke. Early 20s?
    Mr. Hearn. Yeah, I would certainly say early 20s, but let's 
think about it like this, if you do the math on it, a person 
that was towards the tail end of their career could have served 
in Vietnam. The son or daughter served in Iraq or during Desert 
Storm or Desert Shield. And then the children of those people 
from the Gulf War. So we are talking about three generations 
now--three generations--of Americans.
    And I saw this--there was an article that came out in 
Fortune just this week--they said 25 percent of recruits that 
had served in the military. So it is very possible that this 
type of situation occurred. We are talking about three 
generations of the same family could be impacted from serving 
in the same area.
    Mr. O'Rourke. Well, I wanted to ask you about a point Mr. 
Weidman brought up, which is how long it took for Vietnam-era 
veterans to have that presumptive condition awarded or 
recognized. And I wonder if someone who, let's say, was 20 
years old in 1991 is 45 today, or if they were at the tail end 
of their career and they are in their mid-60s, if we are seeing 
different symptoms--in other words, cancers--as they get older. 
As this cohort ages, are we seeing more critical urgent issues 
that need to be attended to, that the urgency that I think was 
part of eventually recognizing the presumptive condition for 
Vietnam-era veterans?
    I am going to, unfortunately, have to take your answer for 
the record, because I am out of time, but I am very interested 
in how we can add additional urgency as this cohort ages, based 
on the conditions that we are seeing.
    Mr. Hearn. We will be happy to look into it and send it to 
you then.
    Mr. O'Rourke. Thank you.
    I will turn it back to the Chair.
    Mr. Abraham. Thank you, Mr. O'Rourke.
    Dr. Benishek, you are recognized.
    Mr. Benishek. Oh, thank you, Mr. Chairman.
    Welcome. Actually, I want to do a little more follow-up on 
what Mr. Weidman had to say. I think all of us here would like 
to know what is going on with this Gulf War Syndrome a lot 
better and, you know a physician doesn't like a vague 
diagnosis. I mean you want to be able to do a blood test and 
then a yes or no, right? We don't have that here.
    And I think the point that he made is that more research 
needs to be done is the critical one here. And do you all, or 
are any of you are aware of what is going on in that 
department? Mr. Weidman, you mentioned, physically, the 
epidemiology studies that, you say, haven't been done. What is 
going on in the research of this Gulf War Syndrome?
    Mr. Weidman. The most useful research that is going on 
today is the CDRMP, the Congressionally Directed Medical 
Research Program, and the reason for that is that research and 
development at VA simply wasn't concentrating on research that 
would lead anywhere, if, in fact, they committed monies at all. 
You know, it is real--if you decide you want to find nothing 
and you work really hard at it, the likelihood is, you are 
going to find nothing, and that is exactly what VA has done 
here and in regard to other generations both, those who served 
in the recent wars as well as Vietnam.
    What the Institute of Medicine has repeatedly, time and 
time and time again, has urged VA and DoD to start to mine the 
mountain ranges of data they have on all of us and they don't 
do it. And that is how you can really start to make a 
difference.
    Let me just give you one example from Vietnam vets. Some of 
the most useful research that has been done was not directed 
from Washington, was not funded by Washington; it was 
individual clinicians in the field who were able to hustle some 
graduate students and did epidemiological work of Vietnam 
veterans who had served in Vietnam or Vietnam veterans who had 
not served in Vietnam and who was more likely to have prostate 
cancer, as an example. That is how we found out that prostate 
cancer among those who served in-country was almost three times 
that of the era vets.
    That kind of work is simply not being done by VA for any 
generation as a systematic thing.
    Mr. Benishek. I appreciate your answer, but I just want to 
get to a couple more items. Is there currently a registry for 
people who complain of Gulf War Syndrome symptoms?
    Mr. McLenachen. Yes, there currently is a registry program.
    Mr. Benishek. I don't understand, though. Do you object, 
personally, to extending the dates of eligibility for this, in 
view of the fact that there is a lot of vagueness to the 
diagnosis here, and that more time needs to be--I think more 
research needs to be done, than to have this cutoff date be an 
issue for people when there is so much uncertainty as to what 
the real etiology is. I mean it could be that there is some 
bacteria like TB or something that has just not been found that 
could be really the answer here.
    I don't know what it is, but there is a lot of uncertainty.
    Mr. McLenachen. I have no personal objection. We have to go 
through the rule-making process, but the reason why we did the 
five-year delimiting dates was because of that uncertainty in 
the medicine and the science. So, that still exists today, so 
if that reassures you--
    Mr. Benishek. Are there cutoff dates to other--is this a 
common thing that VA does, to cut off dates for application for 
eligibility?
    Mr. McLenachen. No. The statute that we are dealing with 
here gives the secretary authority to establish this particular 
cutoff date.
    Mr. Benishek. Does anyone else from the VSOs want to 
comment on what is going on? Mr. Morosky?
    Mr. Morosky. Sir, we absolutely agree that more research is 
warranted here. Right now, the only presumptive disorders for 
Gulf War Illness are either certain infectious diseases or you 
have this chronic multi-symptom unexplained medical illness.
    Under that, there are a lot of diagnoses, as I explained 
earlier, that come out of those symptoms. We would like to see 
research as to whether or not those diagnoses that are commonly 
given for those symptoms ought to be presumptive conditions in 
and of themselves. So if the gastrointestinal problems are 
being diagnosed as IBS, maybe IBS should also be a presumptive 
condition, which would lead to fewer denials, but that is what 
research would be for.
    Mr. Benishek. Mr. McLenachen seemed to indicate that a lot 
of the people were denied the undiagnosed disability, but were 
given a diagnosed disability. Is that the case? Or maybe I 
better take that for the record, because I am obviously running 
over time, but if you could give me the percentage of those 
numbers for the record, I would like to know that.
    Mr. Flohr. With respect to that, when the first Gulf War 
veterans returned from the Gulf and started complaining of 
multiple symptoms, for which a diagnosis could not be 
established, VA had no way to compensate them because our 
statutory authority is to provide compensation for disability 
resulting from injury or disease. So we worked with Congress, 
the Congressional staff, and that worked in the 1994 
legislation that created Gulf War presumptions and the whole 
Gulf War process.
    Mr. Abraham. Mr. Flohr, we are going to interrupt you. The 
time is out, but if you'll put that in for the written record, 
we would appreciate that.
    Mr. Flohr. Okay.
    Mr. Abraham. Mr. Walz?
    Mr. Walz. Thank you, Mr. Chairman, and thank you for all 
being here.
    I am going to go off this issue on the research and the 
cutoff dates. I think a little history is warranted here. Last 
summer when the Agent Orange Act was coming to expire, 53 of us 
co-sponsored that and it ended with a whimper without even a 
floor vote. And the argument we made was, is that the research 
wasn't in yet and we needed a little more time.
    That piece of legislation required the National Academy of 
Sciences to do a meta-analysis of all the research that was 
being done out there and compile that. I asked last summer, at 
least extend it to March until that study came out. Well, it 
came out last Thursday, again, with a whimper, and in that 
study, it showed a connection to bladder cancer and thyroid 
problems with Agent Orange.
    My question is, now, because that expired and because there 
is no authority of that piece of legislation, do you have, 
under Title 38, to do presumptions now for bladder cancer?
    Mr. McLenachen. Yes, the secretary has very broad authority 
under Section 501 of Title 38.
    Mr. Walz. Is it naive of me to think that after 25 years of 
that and the biennial reviews by the National Academy of 
Sciences, a meta-analysis of all the research that was out 
there, did we just do a wonderful job of picking the last two 
things they are going to find on the very last report that they 
will do? Would it have not made sense to extend it on for five 
more years to continue it--and I am going to segway into this 
that he has that broad authority; that broad authority, then, 
exists for Gulf War Illness.
    Mr. McLenachen. So, for Gulf War Illness, there is actually 
a public law, Public Law 105-368 that was enacted in 1998 that 
requires both NAS and the secretary to report to the Congress 
on scientific study results that would impact presumptions for 
Gulf War veterans. That law still exists and the secretary 
still considers that information in creating presumptions.
    Mr. Walz. And I don't want you to speak for the secretary 
on this, sir. I know your issue is where you are at and giving 
us the answers.
    What will it take now for Vietnam-era veterans, with 
exposure to Agent Orange, to get bladder cancer and thyroid 
issues, which are going to be multi-symptom, which aren't going 
to be difficult, what will it take now for them to get that 
covering that presumption done? What are the next steps 
involved here?
    Mr. McLenachen. So, the secretary is required to consider 
all medical science to include the National Academy's 
information that they provide, and based on the information 
that he considers, there is a workgroup that is established in 
the Department of Veterans Affairs whenever these presumptions 
are considered; it includes VHA experts, legal experts, our 
benefits experts. And they get together and prepare a 
recommendation for the secretary.
    Mr. Walz. And that is what happened with Parkinson's. We 
did--that same process went through for Parkinson's and then 
the Nehmer claims, they came following that.
    Mr. McLenachen. Yes. Whenever a presumption is created, it 
goes through this process and if the science is there to 
support it, then the secretary will create a presumption as 
to--
    Mr. Walz. Am I hearing you right, that it is different for 
the Gulf War, then, that it is for Agent Orange?
    Mr. McLenachen. Well, you had a concern about the 
expiration of the law that required us to go to NAS and then do 
a rulemaking within a specific period of time. Now, that law 
expired for the Agent Orange presumptions.
    My message to you is, that the expired authority has no 
real impact for us, because the secretary has separate 
authority to do it on his own, as far as Gulf War veterans, we 
are still required by law to receive those reports from NAS and 
consider them. So that gap does not exist for Gulf War 
veterans.
    Mr. Walz. But I would suggest to my colleagues here, why 
were we so willing to give up to the executive branch the 
authority to make these decisions, and why we gave away our 
power with the expiration of the Agent Orange Act. Now it makes 
it very difficult for us to go back and make the case here so 
that we can have a say, so that witnesses can have their input 
into this in a more direct channel.
    And this is no condemnation on you; you are following the 
rules as they are written for you. This is a soliloquy maybe to 
us that I think we need to take more of the lead on this. I 
think we need to make sure, because I think as science moves 
along, the research possibilities are still out there, and I 
think we are shutting doors and around here, once a door is 
shut, it is dang hard to get it back open again, and I think 
that is a mistake that we have laid the groundwork for. And 
this may give us the opportunity, through the Toxic Wounds Act, 
Mr. Benishek and others, maybe is an opening to that.
    So, I understand and I know you will do what is directed 
and you want to care for the veterans. I think we need to give 
you the tools to do that. I think the broad tools the secretary 
has are wonderful and I cannot say enough when then-Secretary 
Shinseki made the ischemic heart, the Parkinson's, it was the 
right thing to do, but that was a long fight.
    And now I feel like if you have bladder cancer and you are 
listening to this and you have thyroid issues where you were 
told it wasn't connected, as of Thursday, I am going to say it 
was. And my suggestion is that I wish we, as a Congress, could 
say it was. So, more of a clarification.
    I thank the Chairman for your time.
    Mr. Abraham. Thank you, Mr. Walz.
    Mrs. Walorski?
    Mrs. Walorski. Thank you, Mr. Chairman.
    Mr. Spataro, I want to direct this question to you, but I 
want to tell you a quick story about a veteran in my district. 
She joined the Army in 1990 and was first deployed to the Gulf 
as a part of Desert Storm and eventually was deployed to Desert 
Storm. She eventually left the Army in 1993, but after leaving 
the service, she began to have stomach pain, severe headaches, 
muscle pain, irritable bowl syndrome, and trouble sleeping.
    In order to cope with these issues, she took over-the-
counter meds, not thinking those conditions were a result of 
her military service. Years passed before she realized that all 
her medical issues were caused from her time serving in the 
Army.
    In 2011, she applied for benefits at the VA for Gulf War 
Syndrome, but was denied about a year later. In 2014, two years 
after her initial denial and appeals letters to the VA, she 
finally got an exam for Gulf War Syndrome. After three years of 
battling VA, she received partial benefits for her migraines 
and irritable bowl syndrome, but not for the rest of her 
medical issues.
    Her issues have been so debilitating that she had to quit 
her job. In her letter, she says, ``Finally, on February 25th, 
2015, I walked away from my job, my source of income, and the 
only source of reality that brought meaning to my life and 
amidst of pain and hurt, besides my family.'' And this is--I am 
going to quote her. Here's actually what she said to me in her 
letter, ``I was more disappointed than surprised, after all, to 
the VA, we, as veterans, are nothing but a money business. We 
are numbers on a piece of paper with no face. The VA denies 
claims or takes forever to answer them, hoping that we veterans 
will die before they come up with an answer. A VA 
representative advised me to write a letter to the VA telling 
them of myself, hoping they would think of me as a person, 
instead of a gold digger--and gold digger came from the person 
at the VA.''
    Our veterans should not feel like gold diggers when they 
seek the help for the benefits they deserve. They shouldn't be 
treated just like another number on a piece of paper. And I 
wanted to tell you this story because it is what I hear from 
veterans almost every day.
    So, my question to you, Mr. Spataro is, in a case of this 
veteran from my district, many of her debilitating issues were 
denied by VA. Do you have an example of a case in which VA 
erroneously attributed symptoms of an undiagnosed illness to a 
diagnosed disability? And you kind of alluded to this before, 
but can you kind of share a little bit more in reference to 
this case?
    Mr. Spataro. Yes, Congresswoman. It does seem like a fairly 
common problem that we see. An example where VA has attributed 
a symptom--an undiagnosed symptom to an illness, a case I had, 
for example, the VA--the veteran had liver problems. Testing 
showed--blood testing showed issues with his liver and the VA 
actually found that the veteran had Hepatitis C and we were 
flabbergasted.
    The veteran told me, "I don't have Hepatitis C. Why was I 
diagnosed--why is the VA saying I have Hepatitis C?" We 
reviewed the record in the veteran's case, and we noticed that 
there was another veteran with the veteran's same name who had 
Hepatitis C. His records had been erroneously associated with 
that veteran's claims file, and just carefully looking at it, 
you would have seen that the medical record numbers, the Social 
Security numbers were different, but that is the kind of error 
where there might be incorrect medical records associated with 
a claims file.
    Other times, it just seems that the VA adjudicators are 
very quick to overbroadly interpret medical records and medical 
evidence without very carefully looking at and separating each 
symptom and seeing if there is--that a doctor has specifically 
attributed a diagnosis to each symptom.
    Mrs. Walorski. Yeah, I appreciate it.
    And Mr. McLenachen, did you recognize this issue? When you 
came to this hearing today, did you expect this hearing to be 
what you are hearing from Members of Congress, and even in my 
case, a specific issue of veterans that we deal with every day, 
or did you think it was going to be about something else? Were 
you aware of the fact that this was going to be specifically 
about all of these ``undiagnosed diseases'' and this Gulf War 
Syndrome?
    Mr. McLenachen. Yes, that was the subject of the hearing.
    Mrs. Walorski. So, what do you do when you leave here? And 
you hear all this information and testimony, we have questions, 
we have numbers, we have all kinds of unanswered questions. 
Many of us are I think left with this issue of how quickly can 
you correct this?
    Is there something that is correctable or is this something 
that is going to take another action of Congress to fix?
    Mr. McLenachen. Well, as I committed to Mr. O'Rourke, what 
I do is, when I am here and I hear these issues, I go back and 
I look into it. The DBQ is a good example. I wish--if that is 
the problem, I wish we could fix it overnight, but it requires 
coordination with VHA. We have to do the public notice that is 
required through the Paperwork Reduction Act.
    Mrs. Walorski. Do you think that it is something that can 
be fixed, though, inside the VA without additional action from 
Congress?
    Mr. McLenachen. Yes.
    Mrs. Walorski. Okay. I appreciate it.
    Thank you, Mr. Chairman. I yield back.
    Mr. Abraham. Thank you, Mrs. Walorski.
    Dr. Roe?
    Mr. Roe. I wish Mr. O'Rourke were still here. I went to Dr. 
Google and found out that during the Persian Gulf, it was the 
oldest Army that we have had since the Civil War, age 27, and 
six years older than average Vietnam, because a lot of 
reservists, I think, were called up as opposed to when I was in 
the service, it was mostly drafted individuals.
    I will start out by saying, you cannot have too much 
information; it is impossible to have too much information. I 
think you just extend the date, at least five years, or maybe 
indefinitely to study this issue.
    I would disagree with Mr. Weidman on one thing, though. 
Environmentally, you can specifically find--we may never in 
this case and probably won't--but you can find an environmental 
substance that is the cause of certain problems. There is no 
question. I have seen that over and over again.
    The problem with this condition--and you have three doctors 
up here--is headache, fatigue, chronic pain, and GI issues. I 
mean we make our living seeing that and people never got near 
the Persian Gulf.
    And it is really hard--and I think, Mr. Weidman, you hit 
the nail on the head when you say we have to look--there may be 
a cohort of people in Iraq that you could study. There 
certainly are a cohort of people who never deployed, who were 
military age, who never deployed. And why we would stop 
investigating that is beyond me, when we don't have a clear 
ideology of what this is.
    So, I am really going to strongly encourage the secretary, 
if they have the discretion to do that, to do that, to extend 
this date to get more information, because we want to get it 
right. I think everybody said up here, look, you served the 
country and if something in your service caused you a 
disability, we need to compensate that disability. It is that 
simple. If it didn't, we don't.
    Right now we don't have the information to say one way or 
the other, and to play semantics with words bothers me. Whether 
you call it Gulf War or whether you call it whatever, you are 
still talking about the same thing and to presume somebody--I 
mean, to make a presumption based on how the verbiage is, may 
be silly. I think it doesn't make sense to me.
    I want to encourage us to do that. It is a very, very 
difficult thing to pinpoint when you--and I am sure Dr. Abraham 
and Dr. Benishek, too, will attest to this--two things that 
made me the--that frustrated me the most in practice was if we 
didn't know what was wrong with you, we just said you were 
nervous or you had a virus, when we didn't know what the 
problem was. And that is sort of what has happened with these 
veterans, I think.
    I think we need to study it, make the presumption open-
ended. I don't think we need to stop at the end of this year. 
It makes no sense to me to do that.
    So, until we get more information, that is really all I 
wanted, and I am open to any comment from any of the panel 
Members. You have been a great panel. Thank you for being here.
    I mean, you are welcome to comment or I will yield back my 
time.
    Mr. Morosky. Thank you, Congressman.
    You know, as you pointed out, there are a group of 
disorders which can be common in the general public, as well. I 
think the way we look at it is, when it is taken together and 
put together with this event in service, which was service in 
the Persian Gulf war, and you start to see it over and over 
again as a cluster of symptoms, which is what we look at when 
we talk about Gulf War Illness, as opposed to just parsing them 
out.
    And if you would use an example of say, TBI, we see a lot 
of veterans--that is a signature of the current era war. You 
might have a veteran who comes in and says, you know, I am 
experiencing some dizziness, I have some memory loss and I have 
some sleep problems. If you looked at those individually, you 
might say, oh, you have vertigo or, you know, you have some 
sort of a cognitive disorder. But when you look at them as a 
cluster and then you look back in the record and say, oh, you 
have blast exposure--
    Mr. Roe. That is a little different, though--
    Mr. Morosky. --then that makes sense.
    Mr. Roe. --you can specifically point to an etiology there, 
where the veteran was within 50 meters of a blast or wherever. 
That is a lot easier than this one, than Gulf War Illness--
Syndrome. It is much easier, I think.
    Mr. Morosky. I agree, but I just--the comparison is there, 
if you were to look at service in the Persian Gulf War, if we 
are going to assume, because there is already a presumptive 
basis for chronic multi-symptom disorder, if you were to look 
at that as an event in and of itself, but I agree with you that 
it is not a perfect comparison.
    Mr. Roe. Here is where Mr. Weidman is absolutely correct. 
Here's a blast. That is definitive. We know it happened and 
document it, no problem. There may be people who have those 
symptoms that you--look, I probably have had all of those 
symptoms at one time or another in my life and probably 
everybody at the dais out there has also had most of those 
symptoms. You could have those symptoms and be in Iraq and not 
have Gulf War Syndrome. I mean that is the problem that you get 
into, is that these are so common that it makes it--it is 
extremely difficult of all the--even more so than Agent Orange, 
this much more difficult to nail down, I think, than Agent 
Orange is. Agent Orange, basically, I think we have the 
science, as Mr. Weidman clearly pointed and Tim pointed out a 
minute ago--Mr. Walz did. Here, we don't have that and that is 
why it is foolish to stop studying this.
    With that, I will yield back.
    Mr. Abraham. Thank you, Dr. Roe.
    And I am going to start a second round of questioning, 
because I have a question and I want it answered. I will start.
    Mr. McLenachen, you stated that one of the challenges faced 
by the VA is making the call as to whether a diagnosis is 
appropriate before granting an undiagnosed illness; however, 
under Joyner v McDonald, it is inappropriate for VA to engage 
in this type of process of elimination. So why is the VA 
insisting that a diagnosis first be ruled out? I am a little 
confused there.
    Mr. McLenachen. Well, I guess the problem is we are talking 
about different types of claims. I mean if VA gets a claim and 
an individual doesn't specifically claim that these Gulf War 
presumptions apply and we are looking at the totality of the 
claim to grant what we can, it may be that that is what takes 
us down that direction of granting something that is diagnosed.
    Brad, do you have anything that you want to add?
    Mr. Abraham. So, why does a veteran have to specify Gulf 
War specifically? Again, I am somewhat in the gray there.
    Mr. Flohr. If I may say, the problem with undiagnosed 
illness is that--
    Mr. Abraham. Well, all three areas of entitlement have to 
be considered. You understand that, right?
    Mr. Flohr. Of course.
    Mr. Abraham. Okay.
    Mr. Flohr. Yeah. But when we schedule someone for an 
examination who claims various symptoms which have not been 
diagnosed, the first thing doctors do, right, is try to figure 
out what the diagnosis is, because if they can't, they don't 
know how to treat it appropriately.
    So, when they cannot come up with a diagnosis, then what we 
are looking for is a VHA or a contract examiner to say the 
veteran has an undiagnosed illness of the respiratory system, 
of the cardiovascular system, whatever it may be. But if they 
diagnose something, sinusitis, bronchial asthma, that becomes a 
disability and then the standard rules of service-connection 
apply. It has to be a current disability. It has to be 
something that happened in service. And it has to have a 
relationship between service and the current disability.
    Mr. Abraham. When you start the exam, is that veteran 
flagged as a Gulf War veteran or no? Yes?
    Mr. Flohr. Oh, no. When they file their claim, we get their 
service records. We have their DD214. We know they are a Gulf 
War veteran.
    Mr. Abraham. But does the examiner know that?
    Mr. Flohr. They should, because they--I think so. On the--
when we schedule the exams, they have that information, yes.
    Mr. Abraham. Okay. So why wouldn't the examiner consider an 
undiagnosed illness in that case?
    Mr. Flohr. If the veteran is only complaining of 
constellation or several symptoms, rather than the veteran 
claiming a specific disease--
    Mr. Abraham. By my definition, that is an undiagnosed 
illness if he has a myriad of symptoms, but you can't put a 
diagnosis on it. Well, by definition, to me, that is an 
undiagnosed illness.
    Mr. Flohr. Correct. See, our claims processors are not 
physicians. They are not scientists. They can't make that 
diagnosis of an undiagnosed illness themselves. They need a 
physician to tell them that. They need a physician to say, this 
veteran has an undiagnosed illness. We can't do that ourselves.
    Mr. Abraham. So, claims processors are just really not 
quite sure how to handle the undiagnosed illness; is that what 
you are saying?
    Mr. Flohr. I am not saying we don't know how to handle it. 
It is a problem because, generally, they end up being diagnosed 
with a disability, rather than an undiagnosed illness.
    Mr. Abraham. Is that appropriate in all cases?
    Mr. Flohr. Not in all cases, but quite often, that is what 
happens.
    We used to get--under--former Under Secretary Hickey used 
to get emails, 10, 15, 20 a day from Gulf War vets saying, I 
don't know why I have been denied for my presumptive conditions 
and they say I have got sinusitis, I have bronchial asthma.
    Those are not undiagnosed illness. Those are diagnosed 
illness and then they have to be associated somehow with their 
service, rather than being a presumptive.
    Mr. Abraham. Mr. Hearn, What is your take on that answer?
    Mr. Hearn. Well, it is a little bit like the insurance 
commercials when there is Tarzan and Jane and they say, well, 
you know, swinging around the jungles that is what they do. It 
is the same way with doctors to a certain extent, because it is 
in your DNA, right; make a diagnosis. That is what you do. 
Nobody wants to take their car to the mechanic and have the 
mechanic come back and say, I don't know what it is. It is the 
same way there.
    But the other problem is, is that what we have seen time 
and time again in doing our quality review checks is that there 
really ought to be a culture of when the rater looks at it, 
when the doctor looks at it, what can we do to get the benefit 
to the veteran, not what does a veteran have? Those are two 
different thought processes.
    And a lot of times--there is nothing on the DBQ right now 
that says, is this veteran a Gulf War veteran? They go to the 
VBMS and it says that they would have to go all the way down--
assuming that the VBMS isn't mislabeled--and look for the 214 
to show that the veteran has, you know, the Iraqi Campaign 
Medal, the Kuwait Liberation Medal, the Expeditionary Medal. 
So, there are all these parts that are going into this and it 
is inherently gray, and that is what the problem is.
    You know, I understand when they say that--and I guess I am 
a little bit confused because VA has said that a lot of those 
remands, that was time-constricted or that was because of the 
lapsing of time. But remember that we are trying to get 
something service-connected here, so I don't know where the 
time lapse is going to cause the problem where you are going to 
end up getting remanded.
    Now, if it is an issue where we are trying to get an 
increased rating, then, yeah, you have dated exams and you have 
other things that are going into play.
    So I think you have kind of got, you know, a mountain of 
things that are happening here. One is that we need to train 
the doctors. It is not right that veterans are being told by 
doctors that they are malingering; that is not fair. And you 
have to get them to get out of that DNA of diagnosing people, 
you know. And I think from there, if we can start tackling that 
issue, maybe we can start moving forward.
    Mr. Abraham. Thank you, Mr. Hearn.
    Ms. Kuster?
    Ms. Kuster. I am just wondering--just to continue this 
conversation--would it help if we changed the underlying 
presumption? Like, we have created this catch-22. As a matter 
of public policy, it sounds like it is an unintended 
consequence of what my colleagues, before I got here, were 
trying to do. We were trying to help Gulf War veterans who had 
a constellation of symptoms and we didn't have the science and 
the words to catch up with what that should be called.
    And we have created--and we are putting the VA between a 
rock and a hard place. We have asked them--we have defined it 
as undiagnosed and then, I agree, when you have sinusitis or 
something else, and you go to get the benefits based upon that, 
that is no longer undiagnosed.
    But the rest of the constellation, we still don't know the 
where or why or how. We know the wherefore; something to do 
with what was going on during that service. So, I guess it 
seems to me the short-term solution is--and we have been 
talking up here about a bipartisan letter urgency the secretary 
to move toward this single DBQ, but we may need to also unravel 
the catch-22 that we have created in our attempt to help Gulf 
War veterans. Because I agree with Mr. Hearn, our goal is to 
help them, but we have created these boxes where you start 
checking and it creates a problem.
    I want to get at, if we could, with either of our witnesses 
from the VA, that the science behind this and what is helpful 
to you. Who do you rely on and is the National Academy of 
Sciences or anyone else starting to look into what Mr. Weidman 
raised, which is, you know, my concern is going forward. We are 
exposing our troops to toxic chemicals and waste that we do not 
understand the significance of.
    I have had a respiratory illness myself based upon a trip 
to Alaska during a volcano, okay, and my doctor has had a hard 
time analyzing that and determining that. But I knew I got on a 
plane. I was in a volcano. I was in the--you know, I ingested 
the ash, which is crushed glass. It got in my lungs and I was 
sick; now, I am better.
    So, who are we looking to? What is the state of the 
science? And what could we be doing to encourage more science 
to determine the causation on this?
    Mr. McLenachen. Unfortunately, I think we are generally 
going to have to defer to the Veterans Health Administration. I 
know you had Dr. Clancy here a couple weeks ago and she 
provided some testimony on that specific issue, so we will 
defer to her on that.
    However, Brad does have a close relationship with the 
National Gulf War Resource Center. He meets with them every two 
weeks or so, I believe, so he may be able to add some 
additional information.
    Ms. Kuster. Sure. Yeah, it would be helpful to know what 
they are doing at this point.
    Mr. Flohr. Yes, we do work with them. Frankly, we have bi-
weekly calls and meet with Ron Brown and Jim Bunker in person 
quite often.
    VA also has a--this is statutory, I believe--a Gulf War 
Research Advisory Committee that meets regularly. They 
recommend research and VHA has an Office of Research and 
Development. They look at the recommendations. If they have 
funding to do the research that is being requested, they do 
that research.
    So it is not a matter that we are sitting around not doing 
anything.
    Ms. Kuster. I am concerned about this decision of IOM to 
recommend not researching it and it sounds as though the panel 
might have been skewed toward, this is all in your head, which 
is not where we are coming from.
    Mr. Flohr. I know there was a lot of concern about that 
among the Gulf War Community--
    Ms. Kuster. I think it may be something that we can look 
into in a bi-partisan way of whatever needs to be done to keep 
this research moving forward, because, again, deja vu all over 
again, what we went through with Agent Orange, there were 
symptoms and parts of illnesses and new illnesses that we 
didn't even know at the time. And I would have to believe that 
there is something like that going on here, as well.
    So, I will yield back, but I would love to work with my 
colleagues on the Committee on that. Thank you.
    Mr. Abraham. Agreed. Thank you, Ranking Member Kuster.
    Chairman Coffman?
    Mr. Coffman. Thank you, Mr. Chairman.
    Mr. Weidman, as a Vietnam veteran, you are probably 
familiar with the way Agent Orange claims were handled by VA. 
As I recall, presumptive conditions were frequently denied 
until VA was forced to resolve them under a Nehmer lawsuit; is 
that about right?
    Mr. Weidman. That is correct, sir.
    Mr. Coffman. Mr. McLenachen, does VA need to be sued in 
order for the department to properly address presumptive claims 
pertaining to the 25-year-old Persian Gulf War?
    Mr. McLenachen. I would not encourage that. No, I don't 
think it is necessary.
    I think we are dealing with something--I think the point 
was made earlier that we are dealing with something a little 
different here. Agent Orange presumptive conditions are 
specific conditions and, yes, we have been operating under the 
consent degree from the Nehmer Court for a long, long time, but 
here, as I think we have all recognized in this hearing, we are 
dealing with something that is much more difficult, which is 
the undiagnosed illness issue.
    Can we do better? I believe we always can, so we will try 
to do that.
    Mr. Coffman. Now, Mr. McLenachen, it seems to me that the 
2004 Gutierrez case underscored this very issue, citing VA's 
``clearly erroneous standard of review'' and that the veteran 
was not required to produce evidence ``specifically linking his 
disability to the presumptive condition in his claim.''
    Are you familiar with this case?
    Mr. McLenachen. I don't recall that case specifically.
    Mr. Coffman. I am. So you are telling me that, as a former 
general counsel, and the guy who is in charge of this entire 
issue, you are not familiar with this court decision? If that 
is the case, perhaps you are the wrong person for the job.
    Are you really not familiar with this Court decision that 
is foundational to this issue?
    Mr. McLenachen. I assure you I will go back and refresh my 
recollection.
    Mr. Coffman. Okay.
    Mr. McLenachen. Yes, I am the right person for the job.
    Mr. Coffman. Well, Mr. Chairman, I just want to thank you 
for and thank the staff for holding this joint Committee, and I 
just want to say that as a Gulf War veteran, I am just really 
disappointed that the law was passed that--by the Congress of 
the United States, that a specific set of conditions was 
supposed to be presumptive and yet the VA does not seem to be 
following along.
    I am disappointed, as well, as the fact that I don't think 
the VA has made best efforts in terms of research on this 
issue.
    Mr. Chairman, I yield back.
    Mr. Abraham. Thank you very much, Mr. Coffman.
    Well, ladies and gentlemen, on behalf of the Oversight and 
Investigations and Disability Assistance & Memorial Affairs 
Subcommittees, I thank you for your testimony. I appreciate all 
the witnesses coming here today to discuss what has turned out 
to be a very, very important issue.
    Unfortunately, the medical evidence indicates that some 
Gulf War veterans are developing serious illnesses such as 
brain cancer, multiple sclerosis, amyotrophic lateral 
sclerosis, and Parkinson's disease at relatively young ages. 
Moreover, the testimony we have heard today raises serious 
concerns about whether VA is accurately processing claims for 
veterans, who are suffering from Gulf War Illness, particularly 
those veterans who served during the first Gulf War.
    It is especially hard to understand why VA denies at least 
80 percent of claims for undiagnosed illness and chronic multi-
symptom illness conditions, even though there is a presumption 
of service-connection for those veterans who served in the 
Southwest Asia theater of operations.
    I intend to continue to work with the department, my 
colleagues on both of these Subcommittees, and the stakeholders 
who took their time to present these concerns today, to ensure 
that veterans who are suffering from these serious diseases 
receive the benefits that they have earned.
    So, again, thanks to everyone for being here with us today. 
As initially noted, the complete written statements of today's 
witnesses will be entered into the hearing record. I ask 
unanimous consent that all Members have five legislative days 
to revise and extend their remarks and include extraneous 
material. Hearing no objection, so ordered.
    I thank the Members and the witnesses for their attendance 
and participation today. This hearing is now adjourned.

    [Whereupon, at 12:04 p.m., the Committee was adjourned.]

                            A P P E N D I X

                              ----------                              

                 Prepared Statement of Chairman Coffman
    Good afternoon. This hearing will come to order.
    I want to welcome everyone - especially our good friends from the 
Subcommittee on Disability and Memorial Affairs - to today's joint 
hearing regarding VA's handling of disability claims for Persian Gulf 
War veterans. As a preliminary matter, I would like to ask unanimous 
consent that a statement from Mr. Ronald Brown, Gulf War veteran & 
President of the National Gulf War Resource Center be entered into the 
record. Hearing no objection, so ordered.
    This hearing is the second part of the committee's two part series 
on the 25th Anniversary of the Persian Gulf War, a war in which I 
served. Today we will examine VA's own data that reveals a 16% approval 
rate and an 84% denial rate for claims of Gulf War veterans for 
undiagnosed illnesses and chronic multi-symptom illnesses - both 
presumptive conditions under current law. VA often seems to deny these 
claims because it demands to know the specific cause for the illness, 
yet under the law, presumptive conditions do not require causality 
because they are presumed to have been caused by service in the Gulf 
War. The critical point to understand is that veterans cannot receive 
VA care for symptoms of Gulf War Illness when the majority of those 
claims are denied by VA.
    We will also discuss former Under Secretary Allison Hickey's email 
citing her "concern that changing the name from [chronic multi-symptom 
illness] to [Gulf War Illness] might imply a causal link.for veterans 
who served in the Gulf." Ms. Hickey's official email exposed VA's 
efforts to block not only the use of the term recommended by the 
Institute of Medicine for Gulf War Illness, but also VA's practice of 
requiring causality for GWI claims, even though, again, presumptive 
conditions do not require causality.
    We also want to know more about an internal VA email - which has 
been provided to today's panel - that reveals claims evidence has been 
lost even though VA's system told veterans that such evidence was 
received. This is not particular to Gulf War veterans, but important 
regarding claims processing in general.
    I want to also mention that last Friday, March 11th, VA held a 
Community of Practice call to discuss issues related to our 
subcommittee's hearing held on February 23rd. The call included more 
than fifty participants, and it discussed how to improve care for 
veterans suffering from Gulf War Illness. Unfortunately, the majority 
of the attention was given to a presentation by Dr. David Kearney 
regarding chronic pain, with what seemed to be an emphasis on PTSD - 
and the use of mindfulness as a method of treatment for Gulf War 
Illness. The call, coordinated by Dr. Stephen Hunt, shows that VA still 
clings to its often criticized efforts, and it contradicts his 
testimony from February 23rd, leading me to believe veterans suffering 
from Gulf War Illness will never receive appropriate care while Dr. 
Hunt is at all connected to the issue. While the conversation during 
Dr. Hunt's call warrants additional comments, I'll save that for a 
later time.
    Before I turn to my friend, Ranking Member Kuster, I want to 
highlight that the invitation for this hearing specifically cited our 
interest in discussing "veterans who served in the Persian Gulf War" 
and yet, VA's testimony has lumped information from 1990 with the 
current OIF/OEF veterans in an apparent effort to reflect better 
statistics than those specific to our issue today.
    With that, I now yield to Ranking Member Kuster for any opening 
remarks she may have.

                                 
                 Prepared Statement of David McLenachen
    March 15, 2016

Opening Remarks

    Chairman Coffman, Chairman Abraham, ranking members Kuster and 
Titus, and Members of the Committee, thank you for the opportunity to 
discuss how the Department of Veterans Affairs (VA) processes Gulf War 
Veterans' compensation claims. My testimony will provide an overview of 
VA's processing of these claims, its training and quality assurance 
efforts, presumptive service connection, the statutory authority for 
establishing presumptions of service connection, and the science and 
rationale behind such presumptions.

Gulf War Claims Processing

    This year marks the 25th anniversary of the start of the Gulf War. 
The initial conflict lasted from August 1990 until February 1991. 
However, neither the President nor the Congress has declared an end to 
the Gulf War, so men and women, who serve in the Southwest Asia theater 
of operations, to this day remain entitled to presumptions of service 
connection based upon their service.
    As of the end of fiscal year (FY) 2015, almost 7.2 million Veterans 
served during the Gulf War period. Through FY 2015, over 1.8 million 
Gulf War Era Veterans were in receipt of disability compensation 
(approximately 26 percent of Gulf War era Veterans receiving the 
benefit), the highest percentage of Veterans in receipt of compensation 
from any era, wartime or peacetime. Each Gulf War Era Veteran averages 
greater than six service-connected disabilities, again, more than any 
other era, wartime or peacetime. The most prevalent disabilities for 
Gulf War Era Veterans include tinnitus, knee conditions, back 
conditions, post-traumatic stress disorder (PTSD), migraines, and sleep 
apnea. Claims from Gulf War Era Veterans now make up the majority of 
claims received by VA.
    VA has made considerable progress in its claims processing 
performance, including claims from Gulf War Veterans. It has reduced 
its backlog of pending claims by approximately 86 percent, from its 
peak of 611,000 in March 2013 to 83,226 as of the end of February 2016. 
VA has also reduced the average days waiting for a decision to 93 days, 
which is a 189-day reduction from a 282-day peak in March 2013.

Training and Quality Assurance

    The Veterans Benefits Administration (VBA) is constantly looking 
for ways to improve the service it provides to this cohort of Veterans. 
We work with the Veterans Health Administration (VHA) in reviewing the 
research done by its Offices of Public Health and Research and 
Development, as well as the Institute of Medicine's biennial update on 
Gulf War issues. We also work with VHA and the Department of Defense in 
joint workgroups that research occupational and environmental hazards 
coincident with military service. We collaborate with VHA to update 
training for its medical examiners, as well as VBA's contract medical 
examiners. Finally, VA continues to collaborate with the National Gulf 
War Resource Center (NGWRC) in bimonthly meetings.
    VBA has a national quality review staff, as well as quality 
reviewers in its local regional offices, to ensure that the employees 
correctly process and decide claims for Gulf War illness. As agreed 
with NGWRC, VA conducted a special-focused review of decisions on 
claims for Gulf War-related illnesses for fiscal year 2015. This review 
showed a 94-percent accuracy rate. In the last year, VBA updated 
training for claims processors on Gulf War illness, including such 
topics as medical examinations, evaluating disabilities, assigning 
effective dates, and awarding special monthly compensation. Beginning 
in October 2015, we required all decision makers and quality assurance 
staff to complete these training modules.
    VA has implemented a number of other initiatives to improve Gulf 
War claims processing. VA has developed special tracking to 
specifically account for Gulf War claims. VA has also amended its Gulf 
War General Medical Examination template to include information for 
examiners on undiagnosed and chronic multi-symptom illnesses, as well 
as information on environmental exposures in the Gulf War.

Gulf War Illnesses

    Service connection for undiagnosed illnesses or multi-symptom 
illnesses requires service in the Persian Gulf after August 2, 1990, 
and a qualifying chronic disability that rises to a compensable level 
of severity before December 31, 2016.
    A medically unexplained chronic multi-symptom illness means a 
diagnosed illness without conclusive pathophysiology or etiology. The 
objective signs and symptoms of these disabilities, as well as 
undiagnosed illnesses, include fatigue, skin conditions, headaches, 
muscle pain, joint pain, sleep disturbances, and cardiovascular 
symptoms, among others. The term "medically unexplained chronic multi-
symptom illness" also covers diagnosed illness defined by a cluster of 
signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and 
functional gastrointestinal disorders (excluding structural 
gastrointestinal diseases).
    Service connection is also warranted for Veterans who contract 
certain infectious diseases, such as malaria, Q fever, and West Nile 
virus. In addition to Gulf War service, service in Afghanistan may 
qualify a Veteran for a presumption of service connection under this 
provision.
    Processing these types of claims requires a careful review of 
service treatment records, military personnel records, and post-service 
treatment records. Claims processors must carefully review the claimed 
disabilities and symptoms to determine if a presumption will 
potentially apply. Medical examinations are generally required where VA 
identifies these disability patterns to determine whether there is a 
medical explanation of the disabilities.
    Should VA determine that a Gulf War Veteran does not have a 
presumptive disease/disability, he or she may establish direct service 
connection by showing the three elements described below.

Overview of Presumptive Service Connection

    Direct service connection requires three elements: (1) evidence of 
a current disability; (2) an injury, disease, or event during active 
duty military service; and (3) medical or, in certain cases, lay 
evidence establishing a link or nexus between the two. A presumption 
relieves Veterans of the burden of producing evidence that directly 
establishes at least one of the elements they need to substantiate 
their claims. A presumption regarding exposure may establish the 
occurrence of an event in the military based on service in specific 
locations. The law may also presume a medical nexus or relationship of 
a disease to a presumed exposure.
    A presumption, whether based on location of service or medical 
relationship, provides a legal basis for establishing service 
connection for disabilities where a factual basis may not exist in the 
Veteran's individual service and/or medical record.
    For example, presumptions regarding location of service provide a 
legal basis for establishing an in-service event, such as a toxic 
exposure, where factual documentation of the actual exposure event does 
not exist. Under the provisions of section 1118 of title 38, United 
States Code, and section 3.317 of title 38, Code of Federal 
Regulations, VA presumes any Veteran who served in Southwest Asia since 
August 2, 1990, and who develops a disease associated with certain 
environmental hazards was exposed to those environmental hazards in 
service (in the absence of conclusive evidence otherwise).
    VA may also establish presumptions for the purpose of establishing 
relationships between certain events in service and certain diseases 
and conditions, even where specific factual documentation may not 
exist. For example, 38 C.F.R. Sec.  3.317 establishes malaria as a 
presumptive condition for Veterans who served in the Gulf War. In the 
absence of affirmative evidence of a cause outside of military service, 
including willful misconduct, VA presumes a Veteran's malaria resulted 
from this military service and provides compensation for that 
disability if it manifests to a compensable level of severity within a 
certain time.

Authority

    The Secretary of Veterans Affairs has broad authority under section 
501 of title 38, United States Code, to establish presumptions. To 
determine which diseases are associated with such service, the 
Secretary takes into account reports from the National Academy of 
Sciences (NAS) and all other sound medical and scientific information 
available. If the Secretary determines a presumption of service 
connection is warranted, he may issue proposed regulations setting 
forth his determination. VA issues a proposed regulation for public 
notice and comment outlining the presumption to be established. In 
proposing the regulation, VA outlines the scientific and/or medical 
basis for the presumption as well as the eligibility criteria for the 
presumption. VA then drafts a final regulation taking into account the 
public comments it received.

Scientific Bases

    Public Law 105-368 charges the Secretary of Veterans Affairs with 
the responsibility for notifying Congress of findings of NAS that might 
impact presumptions of service connection for diseases associated with 
service in the Southwest Asia theater of operations during the Gulf War 
due to exposure to biological, chemical, or other toxic agents, 
environmental or wartime hazards, or preventive medicine or vaccines.
    In preparing its reports for Gulf War health issues, NAS committees 
conduct comprehensive searches of all medical and scientific studies on 
the health effects of the environmental exposure being reviewed. In the 
course of this literature search and review, it is not uncommon for 
these committees to cover thousands of abstracts of scientific and 
medical articles, eventually narrowing their review to the hundreds of 
the most relevant and informative peer-reviewed journal articles. NAS 
then scores the strength of the total medical and scientific evidence 
available by utilizing broad categories of association such as 
"inadequate or insufficient evidence of an association," "limited or 
suggestive evidence of an association," or "sufficient evidence of an 
association." NAS does not directly recommend new presumptions.
    Upon receipt of the finished NAS reports, VA establishes work 
groups comprised of experts in medicine, disability compensation, 
health care, occupational and environmental health, toxicology, 
epidemiology, and law. These work groups, along with senior VA leaders, 
review in detail the NAS reports and all available scientific and 
medical information before recommending to the Secretary any 
presumptions. These recommendations to the Secretary are based in the 
strength and preponderance of the medical and scientific evidence.

Closing Remarks

    VA continues to improve the efficient, timely, and accurate 
processing of claims involving service in the Gulf War. Presumptive 
service connection fills a critical gap when exposure to toxic 
substances or certain disabilities resulting therefrom are not 
specifically documented in a Gulf War Veteran's service records. 
Although the science and medical aspects of undiagnosed illnesses and 
multi-symptom illnesses are not yet fully understood, VA continues to 
review scientific and medical literature to gain a better understanding 
of the impact of these illnesses on our Gulf War Veterans.
    This concludes my testimony. I am pleased to address any questions 
you or other Members of the Committee may have.

                                 
                  Prepared Statement of Zachary Hearn
    MARCH 15, 2016

    In the summer of 2014, long held suspicions of The American Legion 
were confirmed by figures indicating an alarming trend in denial of 
Gulf War Illness related claims at the Department of Veterans Affairs 
(VA) - about 80 percent of those claims , 4 out of 5 veterans filing 
for service connection for the unexplained aftereffects of their 
service overseas in the Persian Gulf, were being denied service 
connection. \1\ This figure stands out, because it is out of step with 
the overall denial rates for veterans overall in the VA system. Why is 
the system letting down these veterans, who answered the call and 
served, defeating an aggressor and liberating a nation within 100 hours 
of the use of ground forces?
---------------------------------------------------------------------------
    \1\ "VA denies 4 in 5 Gulf War illness claims, new data show," - 
Patricia Kime, Military Times (June 5, 2014)
---------------------------------------------------------------------------
    The reasons are as varied as the symptoms faced by the veterans who 
suffer from Gulf War Illness. Medical professionals are unsure how to 
address undiagnosed illness, some Veterans Benefits Administration 
(VBA) employees may not understand the rules regarding the treatment of 
such claims in the VA disability benefits process, and the massive 
reliance on National Guard and Reserve component service members to 
fight and win the Gulf War still contributes to problems with 
transmittal of military records to VA. These are challenges that must 
be met and overcome, with the same aggression and determination shown 
by the men and women who fought and served halfway around the world 
from their homes a quarter century ago.
    Chairmen Coffman, Abraham, Ranking Members Kuster, Titus, and 
distinguished members of the Subcommittees on Oversight and 
Investigations (O&I) and Disability and Memorial Affairs (DAMA), on 
behalf of National Commander Dale Barnett and The American Legion; the 
country's largest patriotic wartime service organization for veterans, 
comprising over 2 million members and serving every man and woman who 
has worn the uniform for this country; we thank you for the opportunity 
to testify regarding The American Legion's position on "Twenty Five 
Years After the Persian Gulf War: An Assessment of VA's Disability 
Claim Process with Respect War Illness".Background
    The American Legion has long been at the forefront of advocacy for 
veterans exposed to environmental hazards. Whether the hazard is Agent 
Orange, radiation, chemicals used during Project Shipboard Hazard and 
Defense, Gulf War Illness or conditions related to burn-pit exposure in 
Iraq and Afghanistan, The American Legion's position has been to:

      Treat the affected veterans.
      Study effects to improve treatment and protect future 
generations.
      Fully fund research and publicly disclose all instances 
of contact so affected veterans can seek treatment.

    VA currently identifies dozens of medical conditions that are 
presumptively related to Gulf War service. Assigning medical conditions 
due to environmental exposures is not a new concept for VA. Conditions 
such as diabetes, ischemic heart disease, and a variety of cancers are 
presumptively related to herbicide exposure in Vietnam. Additionally, 
veterans of the era of atomic weapons and radiation testing have had 
multiple conditions presumptively ascribed to radiation exposure in 
service.
    For Persian Gulf veterans, they face a unique set of challenges in 
their quest to gain benefits derived from their military service. 
Unlike herbicide and radiation exposed veterans, many Persian Gulf 
veterans must prove they suffer from symptoms or clusters of symptoms 
and endure years of medical tests to indicate that they suffer from an 
undiagnosed illness.
    "Undiagnosed illness" is a frustrating explanation to a complicated 
medical situation. Numerous medical studies have revealed that veterans 
returned from Persian Gulf service to face serious health concerns 
following their deployments. However, a generation removed from 
Operation Desert Storm, and the medical community still is uncertain of 
how to properly diagnose or treat these veterans.
    According to a February 2011 report published by the Department of 
Veterans Affairs (VA), over 1.12 million servicemembers deployed to the 
Persian Gulf between August 2, 1990 and September 10, 2001 \2\; over 17 
percent of those serving during these 11 years experienced a deployment 
to the Persian Gulf. A 2013 RAND Corporation report indicates 74 
percent of the Army's active components had been deployed to either 
Iraq or Afghanistan through 2011 \3\.
---------------------------------------------------------------------------
    \2\ Gulf War Era Veterans Report: Pre-9/11(August 2, 1990 to 
September 10, 2001)
    \3\  http://www.rand.org/content/dam/rand/pubs/research--reports/
RR100/RR145/RAND--RR145.pdf
---------------------------------------------------------------------------
    It is easy to get blinded by statistics associated with veterans 
suffering from conditions associated with their service in the Persian 
Gulf. However, as the nation's largest veterans' service organization, 
The American Legion, we regularly hear the painful stories of veterans 
negatively impacted by clusters of symptoms that is believed to have 
manifested due to their Persian Gulf service.
    One veteran contacted The American Legion and discussed how he 
entered the United States Marine Corps as a "poster recruit". He was 
healthy, physically and mentally sharp. Upon returning from his 
deployment to the Persian Gulf in support of Operation Desert Storm, he 
began suffering weakness and malaise. No longer was he able to 
withstand standing in formation, and a once easy three-mile run became 
an impossible task. Headaches and gastrointestinal issues manifested. 
Sadly, the veteran's rapidly declining health limited his academic 
pursuits. Throughout this process, VA medical professionals failed to 
properly treat this veteran, suggesting he was malingering.
    This is not the way veterans should be treated by the disability 
claims process.
                     Problems With Gulf War Claims
    The American Legion has over 3,000 accredited representatives 
located throughout the nation. Through their dedicated efforts, The 
American Legion was able to represent over 775,000 veterans in Fiscal 
Year 2015. During our bi-annual training conducted in February 2016, 
over 130 accredited representatives were asked to discuss issues facing 
Gulf War veterans when seeking benefits. The problems highlighted by 
the experienced service officers could be grouped into three main 
clusters:

      Problems with diagnoses
      Problems with medical records for Guard and Reserve 
service members
      Problems in the VA system

Diagnoses:

    By far the largest complicating factor for Gulf War Illness is that 
in dealing with "undiagnosed illness" medical professionals and claims 
adjudicators are operating outside the normal parameters they are used 
to working with. American Legion service officers note that it is quite 
common for medical professionals to hesitate to connect conditions to 
Persian Gulf service because they cannot identify a clear condition. 
Other obstacles include attributing symptoms to aging, suggesting the 
veteran is malingering as the veterans is "too young to be experiencing 
these symptoms," or to send the veteran for multiple tests to different 
doctors, only to receive many different diagnoses, further confusing 
the veteran's medical file.
    Medical professionals, doctors and examiners, by their nature are 
used to providing clear, defined diagnoses. Gulf War Illness defies 
this trend and creates as much confusion for the doctors as it does for 
the veteran who is experiencing the symptoms. Due to the complexity of 
Gulf War Illness, a veteran's diagnosis may have changed multiple times 
during the course of their claim. VA raters are not medical 
specialists; often, they are unaware that the rapidly changing 
diagnoses are all essentially descriptions of the same condition. 
Moreover, the situation is further complicated by the fact that a 
medical professional rendered a diagnosis; once a diagnosis is 
provided, by definition, it is no longer an undiagnosed illness and 
therefore not subject to the regulations created to help Gulf War 
veterans obtain service connection.
    One solution to this problem could be better usage of VA's 
disability benefits questionnaires (DBQs). DBQs are a standardized form 
utilized by medical providers to evaluate the level of disabilities 
suffered by veterans; both VA and private sector medical professionals 
have the ability to access the forms.
    Because many veterans are denied compensation benefits related to 
Persian Gulf related conditions upon receiving a diagnosis, even if the 
diagnosis changes over the course of months or years. This lack of 
access to benefits can provide an extraordinary hardship to veterans 
and their family members; meanwhile, their health continues to 
deteriorate. If VA would identify veterans with Persian Gulf service 
and allow medical professionals to opine on DBQs if the sought medical 
conditions could at least as likely as not be related to Persian Gulf 
service despite having diagnosis, it provides the necessary outlet to 
medical providers, VA, and most importantly, our veterans, to finally 
receive their VA disability compensation. Through this, examiners and 
VA would have the necessary latitude to provide benefits.

Guard and Reserve Medical Records:

    The American Legion has spoken at length about concerns with the 
implementation of the Virtual Lifetime Electronic Record (VLER) for 
veterans. While there is some progress on the VA side, there are still 
issues with obtaining Department of Defense (DOD) records. Even 
whatever meager progress the DOD has made does not begin to address the 
serious problems tracking down records for Guard and Reserve component 
service members. Veterans' claims for environmental exposures require 
proof of duty station, yet this is absent from medical records, and 
must be included in a veteran's file for the record to be considered 
complete for benefits. Veterans' claims for disability rely on the 
ability to prove events or symptoms manifested during a veteran's 
period of service. This becomes impossible in the absence of records.
    The Persian Gulf War, beginning with Desert Shield and Desert 
Storm, represented a massive reliance on Guard and Reserve component 
service members. Unlike Vietnam, which saw little use of this portion 
of the force structure, the post Reagan drawdown of forces placed the 
military in a position where proper troop strength was not achievable 
utilizing solely the active duty components. The men and women of the 
National Guard and Reserve answered the call and have been doing so as 
a major and critical component of United State military strength ever 
since, right through the Global War on Terror. The quality and 
character of the service of these components has been excellent in the 
field.
    However, reliance on these reserve elements has led to problems 
obtaining military records. Each National Guard component relies not 
only on federal combined records maintained by DOD, but also state 
record keeping which can vary from state to state. Service members who 
deploy as part of an activated National Guard unit may find portions of 
their records in DOD files in St. Louis, portions in their state 
archives, portions in field hospitals in Kuwait, Iraq, or elsewhere 
overseas, and portions in the military posts such as Fort Bragg, Fort 
Dix, or Fort McCoy where the parent unit mobilized for deployment. 
Often there is little to connect these distributed files.
    Both the veteran and the claims adjudicator may not know that the 
critical information to prove the claims exists in one of these 
distributed files because they have some government records, so there 
is no reason to believe they don't have all the relevant information. 
In this way a veteran's file may be incomplete and there is not always 
an easy way to discover that fact.
    The way this must be fixed is to ensure better consolidation of 
records. There has to be a better way to ensure all players - VA, DOD, 
Guard and Reserve units, forward hospitals in the field - communicate 
freely and continuously update a veteran's file to ensure a complete 
record. Without a complete record, veterans have little chance of a 
successful claim.

Systemic Problems:

    Some of the systemic problems have already been addressed. VA 
employees who don't know to look for clusters of symptoms diagnosed 
several different ways within a veteran's file would never be able to 
see the pattern necessary to establish service connection. Other 
systemic problems involve improving outreach and understanding for 
veterans.
    Some of the problems involve perception amongst veterans. There is 
a belief among many Gulf War veterans, communicated to service 
officers, that "VA is more interested in helping the Vietnam veterans 
and the current crop of veterans than those of us who fought the first 
Gulf War." While this is unlikely to be an accurate representation of 
the policy of VA, the fact that the perception is out there amongst 
veterans means there is work to be done. This is not uncommon or 
unprecedented. As a wartime service organization that has served 
members of all wars since our inception following the conclusion of 
World War I, The American Legion has seen some of this same perception 
among Korean War veterans, who feel lost between World War II and 
Vietnam. This is not the first "forgotten war." Better outreach and 
education can help these veterans.
    Other veterans struggle with their claims just from dealing with 
the sheer weight of fighting such a long battle. For nearly a quarter 
century they have been passed from one doctor to another repeated told 
it was all in their head, repeatedly given conflicting diagnoses, 
repeatedly given more questions than answers. The whole time they are 
kept locked out of VA treatment because they cannot obtain service 
connection. This lack of access to benefits can provide an 
extraordinary hardship to veterans and their family members; meanwhile, 
their health continues to deteriorate.
    It is a long, very difficult road for Gulf War veterans, and the 
lack of answers and widespread confusion related to their suffering 
makes it all the more difficult. The American Legion appreciates the 
level of difficulty associated with claims pertaining to Persian Gulf 
service; however, veterans have now suffered up to 25 years. VA's 
continuous reliance upon the medical community to discover the etiology 
and defined conditions have cost many veterans years of disability 
compensation. We call upon a liberalization of the manner Gulf War 
claims are adjudicated and provide an opportunity for our Gulf War 
veterans to finally receive the benefits they have earned their 
honorable service. \4\
---------------------------------------------------------------------------
    \4\ Resolution No. 127: GULF WAR ILLNESS - AUG 2014, Charlotte, NC
---------------------------------------------------------------------------
                              Conclusion:
    There have to be better answers for the men and women who served 
and continue to serve in the Persian Gulf region. There are some 
solutions that can and should see immediate implementation - 
improvements to VLER to include Guard and Reserve records, improvements 
to the DBQs to better educate medical professionals on how to evaluate 
veterans for undiagnosed illnesses, better training for VA employees to 
recognize the hidden patterns of Gulf War diagnoses in claims. Other 
solutions, such as improved outreach and better inclusion of the 
service members from the first Gulf War era will require more 
thoughtful responses and plans from VA. As with all plans to address 
concerns, they will be best formulated when they include all the 
stakeholders - VA, Congress and importantly the veterans themselves 
through the Veterans Service Organizations. Through this partnership we 
can find solutions to help address this dreadful denial rate for the 
men and women who have suffered without answers for far too long.
    The American Legion thanks this committee for their diligence and 
commitment to our nation's veterans on this topic. Questions concerning 
this testimony can be directed to Warren J. Goldstein, Assistant 
Director in The American Legion Legislative Division (202) 861-2700.

                                 
                Prepared Statement of Aleksandr Morosky
    March 15, 2016

    Chairmen Coffman and Abraham, Ranking Members Kuster and Titus and 
members of the Subcommittees, on behalf of the men and women of the 
Veterans of Foreign Wars of the United States (VFW) and our 
Auxiliaries, I would like to thank you for the opportunity to testify 
on VA's disability claims process with respect to Gulf War Illness.
    Today's hearing is extraordinarily timely, as this year our nation 
recognizes the 25th anniversary of the Persian Gulf War. While symbolic 
recognition is important, the VFW strongly believes that the most 
meaningful way to honor the service of Persian Gulf veterans is to 
ensure that they have access to the benefits they need and deserve. All 
too often, however, this does not happen. This is largely due to the 
fact that the signature condition associated with the Persian Gulf War, 
commonly known as Gulf War Illness, presents itself in a way that is 
not conducive to the traditional VA disability claims process. 
Consequently, our VFW service officers and appeals staff report that VA 
denies disability compensation claims for conditions associated with 
Gulf War service at a consistently higher rate than other types of 
claims.
    Part of the challenge is that Gulf War Illness is an inherently 
difficult condition to diagnose and treat. This is because it presents 
itself as a host of possible symptoms common to many veterans that 
served in the Persian Gulf region, rather than a single condition that 
is clearly identifiable and unmistakable. What is certain is that more 
than 200,000 Persian Gulf War veterans suffer from symptoms that cannot 
be explained by medical or psychiatric diagnoses, such as chronic 
widespread pain, cognitive difficulties, unexplained fatigue, and 
gastrointestinal problems, to name a few. Since these conditions also 
exist in the general public, Persian Gulf veterans often have a 
difficult time proving the nexus between their conditions and their 
service necessary for VA to establish service connection.
    Instead of Gulf War Illness, VA uses the term "medically 
unexplained chronic multisymptom illness" (MUCMI) to describe those 
symptoms. Although MUCMI is considered a presumptive condition for 
Persian Gulf veterans, there are certain factors that prevent many 
veterans from receiving favorable decisions when claiming that 
condition. MUCMI claims prove to be problematic for a number of 
reasons. When claiming MUCMI, the veteran lists the symptoms he or she 
is experiencing. These symptoms are often seemingly unrelated to one 
another, affecting multiple different body systems. As a result, VA 
assigns separate disability benefits questionnaires (DBQ) for each 
symptom, and separate exams are scheduled. The current Gulf War DBQ 
asks the physician whether there is a condition of each body system 
present, and then asks them to complete the relevant DBQs. Only after 
that are MUCMI questions asked.
    We find that this practice of assigning separate DBQs for each 
symptom being claimed in connection with MUCMI has the effect of 
promoting diagnoses, even when those diagnoses are minimally supported. 
Once a symptom receives a diagnosis, it is no longer considered 
connected with MUCMI, which requires that the illness be undiagnosed. 
Since MUCMI is ruled out for that condition, the veteran no longer has 
the opportunity to be granted on a presumptive basis. Often lacking any 
evidence of the condition in the service treatment record, a nexus 
cannot be established, and the claim is denied.
    VFW staff at the Board of Veterans Appeals notes that remands 
become numerous in these cases, and veterans often receive several 
different diagnoses for the same symptoms from different doctors. They 
believe that this is due to the minimal support for those diagnoses in 
the first place. It is apparent to them that VA seems to go to great 
lengths to find diagnoses for each symptom, simply so MUCMI can be 
ruled out.
    The practice of parsing out symptoms has the additional effect of 
preventing a holistic evaluation for MUCMI. When the claim is for an 
undiagnosed illness, the physician should be asked more questions about 
the cluster of symptoms, which could be one illness leading to symptoms 
in multiple body systems, rather than separate conditions related to 
each symptom. Only if there are confirmed diagnoses should separate 
DBQs be completed. To improve the current system, the Gulf War DBQ 
should be analyzed by a team of physicians including those from War 
Related Illness and Injury Study Center. Additionally, VA should grant 
veterans reasonable doubt when deciding whether or not a veteran's 
symptoms should be considered MUCMI.
    Another common problem anecdotally reported by VFW service officers 
is inconsistency in the way Gulf War claims are decided from one 
Regional Office to the next. To correct this, we suggest that VA should 
be required to provide current statistics on how many veterans are 
service connected for undiagnosed illnesses, and for Gulf War 
Presumptive Conditions, broken down by Regional Office of adjudication 
to analyze consistency. There are specific diagnostic codes used for 
these, so the numbers should be easy to obtain. Statistics should be 
compared to other toxic exposures claims that are decided at a 
centralized location versus those that are decentralized. A good 
example would be Agent Orange claims (decentralized) and Agent Orange 
C-123 claims (centralized). Future decisions about distributing work in 
the National Work Queue could be informed by this analysis.
    VFW service officers report that there are two types of Gulf War 
claims that are consistently granted at a normal rate. The first are 
claims for presumptive conditions other than MUCMI. These include 
certain infectious diseases and amyotrophic lateral sclerosis (ALS). 
Since these conditions are relatively easy to identify, veterans with 
those diagnoses need only prove that they served in the Persian Gulf 
theater in order to receive favorable ratings. Unlike with MUCMI, a 
clear diagnosis of a known condition benefits their claims.
    The second category that is regularly granted is benefits delivery 
at discharge (BDD) claims. Since BDD examinations are conducted prior 
to separation, any diagnoses are necessarily linked to service and 
service connection may be granted on a direct basis. Because of this, 
however, conditions that are presumptively related to Persian Gulf 
service are not indicated by VA as being presumptive. VFW BDD service 
officers report that VA decisions sometimes say that the condition is 
not presumptive, simply because the veteran did not have a Gulf War 
Registry exam.
    While direct service connection often produces more favorable 
results, the VFW believes that these claims should be tracked as being 
associated with service in Southwest Asia, to form a more comprehensive 
database of which medical conditions are related to deployments to 
those locations. In addition, separating service members should be 
offered Gulf War Registry exams, if they have deployed to Southwest 
Asia at any point in their careers. These could be provided at DOD 
facilities as part of the separation physical. Once the fully 
integrated health record is implemented, VA would easily be able to see 
which conditions should be considered presumptive for tracking 
purposes.
    More troublingly, VFW service officers report that, on at least two 
occasions, veterans were contacted by VA staff encouraging them to drop 
their BDD claims for MUMCI. It was explained that those exams could not 
be completed by QTC contract physicians, and it would take longer to 
process their claims. Instead, they were advised to refile these claims 
after separation so that a VA physician could perform the exam, and 
they would receive the same effective date, so long as they did so 
within the first year of separation from service. While the VFW cannot 
speculate on why BDD contract examiners are forbidden from conducting 
MUCMI exams, we believe that asking the veteran to refile separately is 
not only overly burdensome, but also undermines the entire purpose of 
the BDD system. For this reason, we believe that the Gulf War DBQ and 
proper training on how to complete those exams should be provided to 
all examiners VA utilizes, including contract physicians and those 
located abroad.
    Finally, we note that VA recently updated the M21-1 adjudication 
procedures manual section on Gulf War Illness. With that in mind, we 
ask that Congress exercise oversight to ensure VA continuously provides 
proper training on Gulf War Illness to all those involved in 
adjudicating these claims.
    Mr. Chairman, this concludes my testimony and I will be happy to 
answer any questions you or the Committee members may have.
 Information Required by Rule XI2(g)(4) of the House of Representatives
    Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW 
has not received any federal grants in Fiscal Year 2016, nor has it 
received any federal grants in the two previous Fiscal Years.
    The VFW has not received payments or contracts from any foreign 
governments in the current year or preceding two calendar years.

                                 
                 Prepared Statement of Richard Weidman
    March 15, 2016

    Good afternoon Mr. Chairman, Ranking Member Kuster, and 
distinguished Members on the Subcommittee on Oversight & Investigation, 
House Committee on Veterans Affairs. On behalf of VVA National 
President John Rowan and all of our officers and members, we thank you 
for the opportunity for Vietnam Veterans of America (VVA) to appear 
here today to share our views on the adjudication of Compensation 
claims of Persian Gulf War Veterans by the Department of Veterans 
Affairs. I ask that you enter our full statement in the record, and I 
will briefly summarize the most important points of our statement.
    No doubt you are each asking yourselves the obvious question: 
"Since Vietnam Veterans of America (VVA) is a single generation 
organization, what are you doing here? Did you get lost and wander in 
here?" The answer to this question is several-fold.
    First, the Founding principle of VVA is "Never again shall one 
generation of American veterans abandon another." We take that 
principle as words to live by, both individually and as an 
organization. The buttons you see me and some others wearing this 
morning, "Leave no veteran behind" is merely a shortened version of 
that founding principle that will fit on a button.
    Second, the parallels of what the Persian Gulf War veterans have 
been going though in regard to Gulf War Illness is all too familiar to 
those of us who have had similar experiences with the VA and with DOD 
in regard to Agent Orange, Agent Blue, Agent White, Agent Pink, SHAD or 
Shipboard Hazards and Decontamination, Project 112 in all of its 
multiple machinations, all of it presided over by Dr. J. Clifton 
Spendlove, located in the arid high country at Deseret, Utah. Trying to 
winnow out the baloney thrown out by both the Department of Defense and 
VA to try and prevent us from making any progress was (and still is) 
just shameful.
    The DOD kept (and still keeps to this day) much of the material 
that documented what toxins in what quantities American service members 
had been exposed to in the period that went at least from 1962 through 
1973 classified as Secret or Top Secret. This was not done to protect 
the nation (al Qaeda, ISIS, and other assorted bad guys already had 
this information because our military gave it to the Iraqis in their 
war against Iran, and from there became available to the world wide 
networks of terrorists of various flavors).
    No, this material is being kept classified to keep it from the 
American public and from the patriotic service members injured by one 
or another of a number of toxic substances. This is being done so that 
DOD can shirk their responsibility, as well as to avoid any liability 
or culpability.
    It is worth noting, by the way, that the herbicide program was by 
1962 part of Project 112. There were two principle purposes to the 
herbicide program, which were crop destruction and defoliation to deny 
the enemy cover. In late 1969 Kissinger had the herbicide program 
removed from Project 112, which was for all chemical and biological 
weapons programs. Kissinger did not want to go to the upcoming sessions 
to re-negotiate the Geneva Accords on the Rules of Warfare with the 
herbicides under the command of the Chemical & Biological command of 
the US Army.
    That was when the "D" in SHAD was changed from `decontamination' to 
"defense" so that they could claim that this was all to test defenses, 
and not to test offensive weapons. Similarly, there was a concerted 
effort from that point on to only stress herbicides was to deny the 
enemy cover, inasmuch as destruction of the civilian food supply was 
specifically outlawed under the Geneva Accords. (The North Vietnamese 
Army (NVA) and the Viet Cong or National Liberation Front (NLF) taxed 
the farmers in areas they controlled for a percentage of their civilian 
food supply crops in order to feed their troops.)
    That level of lying by DOD went on for the next 45 years, up to 
this day, and we still see no sign that the lies are going to stop 
until both DOD and VA clean out the rat's nest of the arrogant spinners 
of mendacity from both the key sections of VA, (both VHA and VBA), and 
from DOD.
    The DOD/VA "Management of Chronic Multi-symptom Illness" is a real 
study in how to cloak claims that there are no physical cause(s) of 
Gulf War Illness, but rather symptoms that cannot be tracked to any 
exposures in the Gulf. In fact, however, there is clear evidence that 
multitudes of troops were exposed to a variety of toxins. All of that 
is disregarded in this little bit of clever doublespeak.
    All that is missing from this so-called "clinical practice 
guideline" is the snake oil to wash down this pseudo-prescriptive 
pabulum of puerile prognostications masquerading as a serious clinical 
guide.
    The fact is that VA has never really tried to do serious research 
work into the causes of Gulf War Illness. It is all too reminiscent of 
the lack of serious research into the long term adverse effects of the 
herbicides used in Vietnam or of the organic phosphates pesticides used 
in the Vietnam War and in the Persian Gulf War, as well as in the Iraq 
and Afghanistan wars that continue to this day.
    Given the fact that there are VBA policy people who think that a 
hack who has never published any article in a reputable peer reviewed 
scientific journal is the pre-eminent scientific expert on Agent Orange 
and other herbicides in the whole world, it should surprise no one that 
VA continues to drag its feet on the epidemiological studies that IOM 
and others have strongly recommended for year, or that there is almost 
no real work into looking at toxicological research looking seriously 
into the various toxins that our troops were exposed to during Vietnam.
    The same dearth of serious scientific effort is now being 
perpetuated against Persian Gulf War veterans, as well as the troops 
who served in the current wars.
    It is no wonder that 80% of all Gulf War illness claims are denied, 
given the science denier motif of some of the key permanent staff 
members in VBA. At VVA we were astonished at the sham of ensuring that 
in the latest IOM review of Gulf War Illness, that half of the panel, 
including the Chairwoman, were mental health clinicians. Is it any 
wonder that this bunch recommended abandoning any "hard" science 
investigations into the cause(s) of Gulf War Illness? The mental health 
clinicians on that panel may all be very good mental health clinicians, 
but it is the manipulation of the process by the VA that is maddening.
    If you set out to make sure that you find nothing, and you 
structure the process to find no physical cause, and you work 
assiduously toward ensuring you find nothing, then it should be no 
surprise that you indeed find nothing. That would sum up the latest IOM 
panel on Gulf War Illness, which has the effect of setting science on 
its head.
    As you know, Mr. Chairman, VVA has worked very hard with Chairman 
Benishek and with Chairman Miller on the Toxic Exposures Research Act 
of 2016 which we need to enact as soon as possible this year. It will 
force VA to do the research it should have been doing right along 
regarding toxic exposures and toxic wounds. Secretary McDonald has said 
that he does not need any additional authority to do what HR 1769 
directs him to do. That is technically true, but VA has done nothingin 
the way of funding serious research regarding the ionizing radiation 
that so dramatically affected the health of so many in the World War II 
generation, and those who came right behind them.
    Nor has the VA funded serious research into the adverse health 
impact of Agent Orange and other toxins used in Vietnam. Virtually all 
of the useful studies utilized in the biennial reviews were from the 
countries of the Pacific Rim such as Japan, Taiwan, New Zealand, 
Australia, or from Europe.
    Similarly, VA has not funded any serious work on the toxins that 
have affected Persian Gulf War Veterans, nor research into the toxins 
that affect Iraq and Afghanistan veterans. In fact, I cannot recall any 
useful research into toxic exposures by VA that the Congress did not 
specifically mandate the VA to do, and then follow up with assiduous 
oversight. I would point out, Mr. Chairman that I have been at this for 
a day or two, so that observation covers a bit of a time span.
    It is not only time to pass the Toxic Exposures Act, but to utilize 
any and all means that will force the VA to stop wasting money and 
time, and get on with the business of ensuring veterans get the 
assistance they need, when it will still do some good.
    Thank you, Chairman Coffman and Ranking Member Kuster, for this 
opportunity to share some of these observations of Vietnam Veterans of 
America with you and your distinguished colleagues. I will be pleased 
to answer any questions.
                      VIETNAM VETERANS OF AMERICA
                           Funding Statement
                             March 15, 2016
    The national organization Vietnam Veterans of America (VVA) is a 
non-profit veteran's membership organization registered as a 501(c) 
(19) with the Internal Revenue Service. VVA is also appropriately 
registered with the Secretary of the Senate and the Clerk of the Senate 
of Representatives in compliance with the Lobbying Disclosure Act of 
1995.
    VVA is not currently in receipt of any federal grant or contract, 
other than the routine allocation of office space and associated 
resources in VA Regional Offices for outreach and direct services 
through its Veterans Benefits Program (Service Representatives). This 
is also true of the previous two fiscal years.
    For Further Information, Contact:

    Executive Director for Policy and Government Affairs
    Vietnam Veterans of America.
    (301) 585-4000, extension 127
                           Richard F. Weidman
    Richard F. "Rick" Weidman is Executive Director for Policy and 
Government Affairs on the National Staff of Vietnam Veterans of 
America. As such, he is the primary spokesperson for VVA in Washington. 
He served as a 1-A-O Army Medical Corpsman during the Vietnam War, 
including service with Company C, 23rd Med, AMERICAL Division, located 
in I Corps of Vietnam in 1969.
    Mr. Weidman was part of the staff of VVA from 1979 to 1987, serving 
variously as Membership Service Director, Agency Liaison, and Director 
of Government Relations. He left VVA to serve in the Administration of 
Governor Mario M. Cuomo as statewide director of veterans' employment & 
training (State Veterans Programs Administrator) for the New York State 
Department of Labor.
    He has served as Consultant on Legislative Affairs to the National 
Coalition for Homeless Veterans (NCHV), and served at various times on 
the VA Readjustment Advisory Committee, the Secretary of Labor's 
Advisory Committee on Veterans Employment & Training, the President's 
Committee on Employment of Persons with Disabilities - Subcommittee on 
Disabled Veterans, Advisory Committee on Veterans' Entrepreneurship at 
the Small Business Administration, and numerous other advocacy posts. 
He currently serves as Chairman of the Task Force for Veterans' 
Entrepreneurship, which has become the principal collective voice for 
veteran and disabled veteran small-business owners.
    Mr. Weidman was an instructor and administrator at Johnson State 
College Vermont) in the 1970s, where he was also active in community 
and veterans affairs. He attended Colgate University (B.A., 1967), and 
did graduate study at the University of Vermont.
    He is married and has four children.

                                 
                Prepared Statement of Richard V. Spataro
                           Executive Summary
    National Veterans Legal Services Program (NVLSP) has two main areas 
of concern with respect to the VA's disability claim process related to 
Gulf War Illness. First, the Department of Veterans Affairs (VA) 
repeatedly commits certain types of errors when adjudicating Persian 
Gulf War veterans' claims for disability compensation for chronic 
undiagnosed illnesses. Second, the VA should extend the end date of the 
period during which symptoms of a qualifying chronic disability must 
first manifest in order to qualify for presumptive service connection.
    VA's Handling of Claims Related to Gulf War Illness. The VA 
frequently commits errors when adjudicating claims for disability 
compensation for a chronic disability resulting from an undiagnosed 
illness. The four most common types of errors NVLSP sees VA 
adjudicators commit are:

    1)  failing to consider the favorable rules for presumptive service 
connection for an undiagnosed illness under 38 U.S.C. Sec.  
1117(a)(2)(A) and 38 C.F.R. Sec.  3.317(a)(2)(i)(A), when a Persian 
Gulf War veteran does not explicitly claim benefits for Gulf War 
Illness, but that theory of entitlement is reasonably raised by the 
evidence;

    2)  erroneously attributing a symptom that has not been medically 
linked to a diagnosed disability with a diagnosed disability unrelated 
to military service;

    3)  denying the claim due to the lack of medical nexus evidence, 
when medical nexus evidence is not required to establish entitlement to 
service connection under 38 U.S.C. Sec.  1117 and 38 C.F.R. Sec.  
3.317; and

    4)  denying the claim due to the absence of "objective indications" 
of a chronic disability, without considering non-medical indicators 
capable of independent verification, which are sufficient to satisfy 
the "objective indications" requirement for establishing service 
connection under 38 U.S.C. Sec.  1117 and 38 C.F.R. Sec.  3.317.

    Extension of the Date by Which an Undiagnosed Illness or Medically 
Unexplained Chronic Multi-Symptom Illness Must Manifest to a Disabling 
Degree of 10 percent. Under 38 U.S.C. Sec.  1117(b), the Secretary of 
Veterans Affairs must establish the period during which a qualifying 
chronic disability must manifest to a disabling degree of at least 10 
percent following service in the Southwest Asia theater of operations 
during the Persian Gulf War in order to qualify for presumptive service 
connection. After initially establishing a 2-year presumptive period, 
the VA has repeatedly extended the end date of the presumptive period, 
which is currently December 31, 2016. The scientific community is still 
uncertain about the cause of illnesses suffered by Persian Gulf War 
veterans and the time period during which symptoms of such illnesses 
might first manifest. NVLSP, therefore, believes that the VA should 
again extend the end date of the presumptive period during which 
symptoms of a qualifying chronic disability must first manifest, if not 
indefinitely, to at least December 31, 2021.
    Messrs. Chairmen and Members of the Committees:
    I am pleased to have the opportunity to submit this testimony on 
behalf of the National Veterans Legal Services Program (NVLSP). NVLSP 
is a nonprofit veterans service organization founded in 1980 that has 
represented thousands of claimants before the Department of Veterans 
Affairs (VA), the United States Court of Appeals for Veterans Claims 
(CAVC), and other federal courts. NVLSP's efforts over the last 35 
years have resulted in billions of dollars in VA disability and death 
benefits for veterans and their families.
    NVLSP also recruits and trains volunteer attorneys, and trains 
service officers from such veterans service organizations as The 
American Legion, Military Order of the Purple Heart, and Vietnam 
Veterans of American. NVLSP has trained thousands of these veterans 
advocates in veterans law. NVLSP publishes numerous advocacy materials 
that thousands of veterans advocates regularly use as practice tools to 
assist them in their representation of VA claimants. On behalf of The 
American Legion, NVLSP conducts local outreach and quality reviews of 
VA regional office claims adjudications.
    NVLSP is one of the four veterans service organizations that 
comprise the Veterans Consortium Pro Bono Program, which recruits and 
trains volunteer lawyers to represent veterans who have appealed a 
Board of Veterans' Appeals decision to the CAVC without a 
representative. NVLSP attorneys also mentor the Pro Bono Program's 
volunteer attorneys.

    I. VA's Handling of Claims Related to Gulf War Illness

    NVLSP has vast experience with veterans' claims for VA disability 
compensation under 38 U.S.C. Sec.  1117, the statute that provides for 
presumptive service connection of qualifying chronic disabilities in 
Persian Gulf War veterans, and VA's associated regulation, 38 C.F.R. 
Sec.  3.317. We have represented many veterans with such claims before 
the CAVC, the Board of Veterans' Appeals, and VA regional offices. We 
have mentored attorneys in their representation of veterans with such 
claims before the VA though our Lawyers Serving Warriors program. We 
have mentored attorneys representing veterans with such claims at the 
CAVC through the Veterans Consortium Pro Bono Program. Nearly all of 
our representation and mentoring has occurred after the VA denied the 
claim. Our work on these cases has revealed that the VA frequently 
commits errors when adjudicating Gulf War Illness claims.
    38 U.S.C. Sec.  1117 requires the VA to pay compensation on a 
presumptive basis to Persian Gulf War veterans for three types of 
chronic disabilities: (1) undiagnosed illnesses; (2) medically 
unexplained chronic multi-symptom illnesses, such as chronic fatigue 
syndrome, fibromyalgia, and irritable bowel syndrome; and (3) diagnosed 
illnesses that the Secretary of Veterans Affairs determines warrant a 
presumption of service connection, which presently consist of 
brucellosis, campylobacter jejuni, coxiella burnetii (Q fever), 
malaria, mycobacterium tuberculosis, nontyphoid salmonella, shigella, 
visceral leishmaniasis, and West Nile virus. See 38 C.F.R. Sec.  3.317. 
NVLSP has seen relatively few problems with the VA's adjudication of 
claims for service connection of the second and third types of chronic 
disabilities-medically unexplained chronic multi-symptom illnesses and 
diagnosed disabilities that the Secretary has determined warrant a 
presumption of service connection. In our experience, however, the VA 
frequently commits errors when adjudicating claims for disability 
compensation for a chronic disability resulting from an undiagnosed 
illness.
    As background, it is important to know the requirements a Persian 
Gulf War veteran must satisfy to establish service connection for a 
chronic disability resulting from an undiagnosed illness. As the CAVC 
explained in Gutierrez v. Principi, 19 Vet. App. 1, 7 (2004), a case in 
which the veteran was represented by NVLSP, in order to establish 
service connection for a chronic disability resulting from an 
undiagnosed illness under 38 U.S.C. Sec.  1117 and 38 C.F.R. Sec.  
3.317, the veteran must present evidence that he or she:

    (1)  exhibits objective indications;

    (2)  of a chronic disability such as those listed in paragraph (b) 
of 38 C.F.R. Sec.  3.317 [fatigue, signs and symptoms involving skin, 
headache, muscle pain, joint pain, neurologic signs or symptoms, 
neuropsychological signs or symptoms, signs or symptoms involving the 
respiratory system, sleep disturbances, gastrointestinal signs or 
symptoms, cardiovascular signs or symptoms, abnormal weight loss, and 
menstrual disorders];

    (3)  which became manifest either during active military, naval, or 
air service in the Southwest Asia theater of operations during the 
Persian Gulf War, or to a degree of 10% or more not later than December 
31, 2006 [later extended by the VA to December 31, 2016]; and

    (4)  such symptomatology by history, physical examination, and 
laboratory tests cannot be attributed to any known clinical diagnosis.

    It has been over two decades since Sec.  1117 was added to Title 38 
of the Unites States Code, yet VA adjudicators still have a difficult 
time adjudicating "undiagnosed illness" claims. Although not the only 
types of errors committed by the VA when adjudicating "undiagnosed 
illness" claims, in our experience, the following are the most common 
errors:

    A. Failing to address the veteran's entitlement to service 
connection for an undiagnosed illness

    One of the most common errors we see is VA adjudicators failing to 
consider the favorable rules for presumptive service connection for an 
undiagnosed illness under 38 U.S.C. Sec.  1117(a)(2)(A) and 38 C.F.R. 
Sec.  3.317(a)(2)(i)(A), when a Persian Gulf War veteran does not 
explicitly claim benefits under that theory of service connection. This 
type of error typically occurs when the veteran claims entitlement to 
service connection for a particular diagnosis the veteran thinks he or 
she has (for example, "knee arthritis"), or more generally describes 
the anatomical area of the disability (for example, "a shoulder 
disability"), but does not refer to Gulf War Illness. In such cases, if 
the evidence ultimately shows that the veteran's chronic complaints 
cannot be attributed to a known diagnosis, the VA adjudicator sometimes 
denies the veteran's claim due to the lack of a diagnosed disability, 
which is a requirement for establishing service connection under all 
other theories of entitlement. Although VA adjudicators have an 
affirmative duty to consider all reasonably raised theories of service 
connection (see, e.g., Robinson v. Mansfield, 21 Vet. App. 545, 552 
(2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 
2009)), they often fail to consider service connection for an 
undiagnosed illness under 38 U.S.C. Sec.  1117(a)(2)(A) and 38 C.F.R. 
Sec.  3.317(a)(2)(i)(A), when that theory of entitlement is reasonably 
raised by the evidence.
    Similarly, we sometimes see cases in which the VA fails to consider 
a Persian Gulf War veteran's entitlement to service connection for an 
undiagnosed illness manifested by symptoms of chronic fatigue under 38 
U.S.C. Sec.  1117(a)(2)(A) and 38 C.F.R. Sec.  3.317(a)(2)(i)(A), when 
the veteran claims entitlement to service connection for "chronic 
fatigue" or "chronic fatigue syndrome," but is ultimately found not to 
meet the full diagnostic criteria for chronic fatigue syndrome. Persian 
Gulf War veterans are entitled to presumptive service connection for 
chronic fatigue syndrome as a medically unexplained chronic multi-
symptom illness under 38 U.S.C. Sec.  1117(a)(2)(B) and 38 C.F.R. Sec.  
3.317(a)(2)(i)(B). However, if the veteran suffers from symptoms of 
chronic fatigue that are not attributable to a diagnosed illness such 
as chronic fatigue syndrome, the veteran is likely entitled to service 
connection for an undiagnosed illness manifested by symptoms of chronic 
fatigue. We have seen multiple VA adjudicators deny a veteran's claim 
solely on the basis that he or she is not diagnosed with chronic 
fatigue syndrome, without addressing the veteran's entitlement to 
service connection for an undiagnosed illness manifested by the symptom 
of chronic fatigue.

    B. Attributing symptoms that have not been associated with a 
diagnosed condition to a diagnosed condition.

    VA adjudicators often erroneously attribute a symptom that has not 
been medically linked to a diagnosed disability with a diagnosed 
disability unrelated to military service. The VA then denies the claim 
on the basis that the veteran does not have an undiagnosed illness, 
because all of the veteran's disability symptoms are associated with 
known diagnoses. We have seen several cases like this in which a 
careful review of the medical evidence shows that, contrary to the VA's 
finding, not all of the symptoms identified by the veteran are linked 
to a specific diagnosis. In some cases, the medical evidence is 
equivocal regarding the cause of the symptom. In other cases, the 
medical evidence attributes some, but not all of the veteran's symptoms 
to a diagnosed disability, and the VA adjudicator over-broadly 
interprets the medical evidence as showing that all of the veteran's 
symptoms are attributable to the diagnosis, even those not specifically 
listed by the medical expert. In one of our cases, the VA denied the 
veteran's claim for an undiagnosed liver disability on the basis that 
he was diagnosed with hepatitis C. The only medical record that 
provided the hepatitis diagnosis, however, was for a different person 
and had been erroneously associated with the veteran's claims file. 
There are many possible reasons why VA adjudicators commit this type of 
error, but the most likely is simple lack of attention to detail.

    C. Denying the claim due to the absence of medical nexus evidence 
or the presence of negative nexus evidence

    Under 38 U.S.C. Sec.  1117 and 38 C.F.R. Sec.  3.317, a Persian 
Gulf War veteran is entitled to the presumption of service connection 
for a chronic undiagnosed illness if certain requirements are met. In 
2004, the CAVC emphasized that medical evidence specifically linking 
the disability to military service or the Persian Gulf War is not one 
of those requirements. See Gutierrez v. Principi, 19 Vet. App. 1, 19 
(2004). Rather, as noted above, service connection is warranted if the 
veteran: (1) exhibits objective indications; (2) of a chronic 
disability such as fatigue, headache, muscle pain, joint pain, etc.; 
(3) which became manifest either during active military, naval, or air 
service in the Southwest Asia theater of operations during the Persian 
Gulf War, or to a degree of 10% or more not later than December 31, 
2016; and (4) such symptomatology by history, physical examination, and 
laboratory tests cannot be attributed to any known clinical diagnosis. 
See Gutierrez, 19 Vet. App. at 7.
    The VA, however, continues to deny some claims for service 
connection for undiagnosed illnesses under 38 U.S.C. Sec.  1117 and 38 
C.F.R. Sec.  3.317, due to the erroneous imposition of a medical nexus 
requirement. We have seen VA decisions stating that symptoms for which 
a medical explanation has not been found must be linked by a medical 
expert to an undiagnosed illness. We have seen claims denied because 
the veteran did not present medical evidence of a relationship between 
his symptoms and an undiagnosed illness or service in Southwest Asia. 
We have seen decisions in which the VA denied the claim because a 
medical expert expressed an opinion that the symptoms were less likely 
than not related to the veteran's Persian Gulf War service, without 
offering a diagnosis or alternative etiology for the symptoms. All of 
these denials were erroneous, because medical nexus evidence is not 
required to establish entitlement to service connection under 38 U.S.C. 
Sec.  1117 and 38 C.F.R. Sec.  3.317.

    D. Denying the claim due to the absence of "objective indications" 
of a chronic disability, without considering non-medical indicators 
capable of independent verification.

    As noted above, in order to establish entitlement to service 
connection for an undiagnosed illness, the veteran must exhibit 
"objective indications" of a chronic disability. "Objective 
indications" include "both `signs,' in the medical sense of objective 
evidence perceptible to an examining physician, and other, non-medical 
indicators that are capable of independent verification." 38 C.F.R. 
Sec.  3.317(a)(3) (emphasis added). We have identified multiple cases 
in which the VA erroneously denied the veteran's claim for entitlement 
to service connection for an undiagnosed illness on the basis that the 
veteran did not exhibit "objective indications" of a chronic 
disability, solely due to the lack of objective evidence perceptible to 
a VA physician at a Compensation and Pension examination, without 
considering other, non-medical indicators that are capable of 
independent verification. In these cases, the VA adjudicators relied on 
the findings in the VA Compensation and Pension examination report. The 
adjudicators, however, ignored corroborating lay statements about the 
veteran's observable symptoms, such as joint swelling, twitching, and 
complaints of pain; and ignored records showing that the veteran sought 
medical treatment for the symptoms. Such lay statements and medical 
treatment records are "indicators that are capable of independent 
verification" sufficient to satisfy the "objective indications" 
requirement for establishing service connection under 38 U.S.C. Sec.  
1117 and 38 C.F.R. Sec.  3.317.

    II.Extension of the Date by Which an Undiagnosed Illness or 
Medically Unexplained Chronic Multi-Symptom Illness Must Manifest to a 
Disabling Degree of 10 percent.

    In 38 U.S.C. Sec.  1117(b), Congress directed the Secretary of 
Veterans Affairs to prescribe by regulation the period of time 
following service in the Southwest Asia theater of operations during 
the Persian Gulf War that the Secretary determines is appropriate for 
the presumption of service connection for qualifying chronic 
disabilities. The Secretary initially established a 2-year post-Persian 
Gulf War service period during which symptoms of an undiagnosed illness 
needed to manifest to a degree of 10 percent in order to qualify for 
presumptive service connection. See Compensation for Certain 
Undiagnosed Illnesses, 60 Fed. Reg. 6660 (Feb. 3, 1995). In 1997, the 
Secretary updated 38 C.F.R. Sec.  3.317 to require manifestation of the 
symptoms no later than December 31, 2001. See Compensation for Certain 
Undiagnosed Illnesses, 62 Fed. Reg. 21,138 (Apr. 29, 1997) (Interim 
Final Rule). In 2001, the VA extended the end date of the presumptive 
period to December 31, 2006. Extension of the Presumptive Period for 
Compensation for Gulf War Veterans' Undiagnosed Illnesses, 66 Fed. Reg. 
56614 (Nov. 9, 2001) (Interim Final Rule). In 2006, the VA extended the 
end date of the presumptive period to December 31, 2011. Extension of 
the Presumptive Period for Compensation for Gulf War Veterans, 71 Fed. 
Reg. 75669 (Dec. 18, 2006) (Interim Final Rule).
    Most recently, in 2011, the VA extended the end date of the 
presumptive period to December 31, 2016. Extension of Statutory Period 
for Compensation for Certain Disabilities Due to Undiagnosed Illnesses 
and Medically Unexplained Chronic Multi-Symptom Illnesses, 76 Fed. Reg. 
81,834 (Dec. 29, 2011) (Interim Final Rule). The VA noted that the 
scientific and medical literature available at that time suggested that 
"while the prevalence of chronic multi-symptom illness may decrease 
over time following deployment to the Gulf War, the prevalence remains 
significantly elevated among deployed veterans more than a decade after 
deployment. At present, there is not a sufficient basis to identify the 
point, if any, at which the increased risk of chronic multi-symptom 
illness may abate." Id. at 81835. The VA concluded that extension of 
the presumptive period was warranted because "scientific uncertainty 
remains as to the cause of illnesses suffered by Persian Gulf War 
veterans and the time period in which such veterans have an increased 
risk of chronic multi-symptom illness" as well as the fact that 
National Academy of Sciences reviews were ongoing. Id.
    A review of the most recent report of the Institute of Medicine of 
the National Academies of Science, Engineering, and Medicine, Gulf War 
and Health, Volume 10, Update of Health Effects of Serving in the Gulf 
War, 2016 (prepublication copy), reveals that little has changed with 
respect to the level of scientific certainty regarding the cause of 
illnesses suffered by Persian Gulf War veterans and the time period 
during which symptoms of such illnesses might first manifest. Due to 
this continued state of uncertainty in the scientific community, NVLSP 
believes that the VA should again extend the end date of the 
presumptive period during which symptoms of a qualifying chronic 
disability must first manifest to a disabling degree of at least 10 
percent. NVLSP believes that end date should be extended indefinitely, 
but at the very least to December 31, 2021.
    I would be pleased to answer any questions you may have.

    Thank you.

                                 
                       Statements For The Record

                             ANTHONY HARDIE
    Thank you, Chairmen Coffman and Abraham, Ranking Members Kuster and 
Titus, and Members of the Committee for today's hearing and for this 
opportunity to present this information to you.
    I'm Anthony Hardie, a 1991 Gulf War and Somalia veteran, and 
Director of Veterans for Common Sense. VCS and I have provided 
testimony on many previous occasions, most recently my testimony as a 
witness at your February 23, 2016 hearing on Gulf War veterans' health 
outcomes on the 25th anniversary of the 1991 Gulf War.

1998 PERSIAN GULF WAR VETERANS LEGISLATION

    As I noted in my testimony of February 23, it took almost eight 
years after the war before Gulf War veteran' major legislative victory, 
with the enactment of the Persian Gulf War Veterans Act of 1998 (Title 
XVI, PL 105-277) and the Veterans Programs Enhancement Act of 1998 (PL 
105-368, Title I-"Provisions Relating to Veterans of Persian Gulf War 
and Future Conflicts") - two landmark bills that set the framework for 
Gulf War veterans' healthcare, research, and disability benefits.
    For those of us involved in fighting for the creation and enactment 
of these laws, they seemed clear and straightforward, with a 
comprehensive, statutorily-mandated plan that would guarantee research, 
treatments, appropriate benefits, and help ensure that lessons learned 
from our experiences would result in never again allowing what happened 
to us to happen to future generations of warriors.
    The legislation included a long list of known Gulf War exposures. 
VA was to presume our exposure to all of these, and then, with the 
assistance of the National Academy of Sciences (NAS), evaluate each 
exposure for associated adverse health outcomes in humans and animals. 
In turn, the VA Secretary would consider the reports by the NAS's 
Institute of Medicine (IOM), "and all other sound medical and 
scientific information and analyses available," and make determinations 
granting presumptive conditions. There was a new guarantee of VA health 
care. There would also be a new national center for the study of war-
related illnesses and post-deployment health issues, which would 
conduct and promote research regarding their etiologies, diagnosis, 
treatment, and prevention and promote the development of appropriate 
health policies, including monitoring, medical recordkeeping, risk 
communication, and use of new technologies. There was to be an 
effective methodology for treatment development and evaluation, a 
medical education curriculum, and outreach to Gulf War veterans. 
Research findings were to be thoroughly publicized. To ensure the 
federal government's proposed research studies, plans, and strategies 
stayed focused and on track, VA was to appoint a research advisory 
committee that included Gulf War veterans - presumably those who were 
ill and affected - and their representatives.
    Instead, we learned that enactment of those laws was just another 
battle in our long war.
    From the beginning, VA officials fought against implementing these 
laws, dragging their feet and upending their implementation.
    In addition to the failures I noted in my February 23 testimony, 
the process for determining presumptions has failed to yield new 
presumptions without Congressional intervention. And, the laws aimed at 
providing at clear path for Gulf War veterans' compensation by VA while 
awaiting the development of effective treatments has been not just 
problematic, but with extraordinarily high denial rates, as VA's own 
data shows and as will be discussed below.
    For Gulf War veterans, getting VA to approve a disability claim for 
a presumptive condition has been nearly impossible for most. And, as 
with all denied VA claims, the backlog of appealed claims is daunting 
and adds years to the process.

DESPITE REPEATED VA INTERVENTIONS, VA'S GULF WAR VETERAN CLAIMS DENIAL 
    RATES ARE WORSENING OVER TIME

    The rates of VA's denial of Gulf War veterans' presumptive claims - 
for "undiagnosed illness" and for the "chronic multisymptom illnesses" 
such as Fibromyalgia, Irritable Bowel Syndrome/Functional 
Gastrointestinal Disorders, and Chronic Fatigue Syndrome - have been 
getting worse over time.
    This worsening has been despite repeated high-level interventions 
by VA - interventions made ostensibly to improve VA's review processes 
for Gulf War veteran's presumptive claims.

                                                2007 VA Denial Rate of 
                                                Gulf War Veterans' 
                                                Presumptive Undiagnosed 
                                                Illness Claims

    In 2007 and 2008, I did a series of presentations about Gulf War 
veterans' severe challenges with VA research, healthcare and benefits. 
The presentations were made to a number of national and regional groups 
around the country and were entitled, "Lost in the Shuffle". Among the 
data presented was VA's abysmal claims failures for Gulf War claims:
    Based on a May 2007 report from VA's Gulf War Information System 
(GWVIS), out of 696,842 Gulf War veterans, 280,623 had filed service-
connected disability claims. Of those, 13,027 were "undiagnosed illness 
claims" (what VA terms "UDX" claims), just 3,384 had been approved - a 
74 percent denial rate.

2010 VA Intervention

    According to a February 4, 2010, "All VA Regional Offices Training 
Letter," (10-01), with the subject, "Adjudicating Claims Based on 
Service in the Gulf War and Southwest Asia,":
    "The chronic disability patterns associated with these Southwest 
Asia environmental hazards have two distinct outcomes. One is referred 
to as "undiagnosed illnesses" and the other as "diagnosed medically 
unexplained chronic multisymptom illnesses" that are without conclusive 
pathophysiology or etiology. Examples of these medically unexplained 
chronic multi-symptom illnesses include, but are not limited to: (1) 
chronic fatigue syndrome, (2) fibromyalgia, and (3) irritable bowel 
syndrome."
    This letter preceded regulatory amendments and provided guidance to 
VA claims examiners to more appropriately adjudicate Gulf War veterans' 
claims.

2014 VA Denial Rate of Gulf War Veterans' Presumptive Claims

    Data provided by VA to the office of then-Congressman Kerry 
Bentivolio on March 28, 2014 showed a nearly 80% denial rate for what 
VA termed in the response, "a Gulf War-related illness". It appears 
that this is the cumulative VA denial rate of all presumptive 
undiagnosed illness and presumptive chronic multisymptom illness 
(Fibromyalgia, Irritable Bowel Syndrome; Chronic Fatigue Syndrome) 
claims by Gulf War veterans.

Key findings (2014)

      80% Gulf War Illness Claims Denial Rate. Of 54,193 Gulf 
War-related illness claims filed with VA, four out of five - nearly 80 
percent (80%) - were denied.
      52% of the denied for something else. A full 52 percent 
of the denied Gulf War-related illness claims were approved by VA for 
something else, implying a VA bias against approving Gulf War Illness 
claims.
      38% denied for everything. A full 38 percent (38%) of 
veterans' claims for Gulf War-related illness were had their claims 
denied entirely, both for Gulf War-related illness and other 
conditions.

By the Numbers (2014)

    696,842 Veterans: The total number of veterans deployed to the 
Persian Gulf theatre of operations during the 1991 Gulf War.
    54,193 GWI Claims: The number of Gulf War-related illness claims 
veterans have filed with VA, to March 2014. [VA notes this figure 
represents original claims for service-connection; it does not include 
reopened claims or claims for an increased disability rating.]
    11,216 Approved: The number of Gulf War Illness claims that VA 
granted. [VA notes that due to data limitations, this figure does not 
include some Veterans who have been granted service connection on a 
direct basis (meaning that the disability became manifest during active 
service) rather than under the provisions of 38 C.F.R. Sec.  3.317.]
    42,977 Denied: The total number of Gulf War-related illness VA has 
denied.
    20% Approved: The percentage of Gulf War-related illness that VA 
granted (11,216 approved out of 54,193 filed = 20.7%).
    80% Denied: The percentage of Gulf War-related illness VA has 
denied (42,977 denied out of 54,193 filed = 79.3% denial rate).
    22,470 Approved for Something Else: The number of veterans filing 
Gulf War-related illness claims that were denied but VA approved the 
veterans' claims for some other condition(s).
    42% Denied for GWI but Approved for Something Else: The percent of 
veterans filing Gulf War-related illness claims that were denied but VA 
approved their claims for some other condition(s) (22,470 approved for 
something else out of 54,193 total Gulf War-related illness claims 
filed = 41.5%).
    52% of the Denied were Approved for Something Else: The percent of 
denied Gulf War-related illness claims approved for some other 
condition. (22,470 approved for something else out of 42,977 denied 
Gulf War-related illness claims = 52.3%)
    20,507 Denied for all Conditions: The number of veterans filing 
Gulf War-related illness claims that were denied for GWI and not 
receiving compensation for other conditions. (54,193 Gulf War-related 
illness claims filed minus 22,470 claims approved for something else = 
20,507)
    38% Denied for all conditions: The percent of all Gulf War-related 
illness claims filed that were denied for Gulf War-related illness and 
also not receiving compensation for other conditions (20,507 denied out 
of 54,193 = 37.8%)
    67% Average Disability Rating: The average disability rating 
granted by VA for Gulf War-related illness claims filed.

VSO Response to 2014 Denial Rates

    In a July 16, 2014 letter from two of the largest veterans service 
organizations (VSOs), AMVETS and VVA, to then-Acting VA Secretary Sloan 
Gibson highlighted the newly released VA claims denial information and 
provided insight into why this was being allowed within VA:

    "VA acknowledges that 250,000 suffer from Gulf War illness. (The 
recent VA `Gulf War Review,' for example, states that nearly 700,000 
U.S. troops deployed to the 1991 war and that VA's major 2005 study 
showed that 37% of those (roughly 250,000) have chronic multisymptom 
illness, VA's term for Gulf War illness. The 2010 report of the 
Institute of Medicine also found 250,000 veterans were ill and that 
their illness was associated with Gulf War service.
    "Yet, VA's own most recent statistics, provided in response to a 
Congressional inquiry this Spring, show that only 11,216 Gulf War-
related illness claims have been granted and 80% of such claims are 
denied. (See VA report to Congressman Bentivolio, attached.) Even 
including all claims approved for other conditions, the total number of 
Gulf War veterans approved for care and benefits is only 36,000, out of 
the 250,000 afflicted.
    "VA hides that damning fact in its official statements. The April 
2014 VA Gulf War `Fact Sheet' states that "currently, nearly 800,000 
Gulf War era Veterans are receiving compensation benefits for service-
connected issues." What VA doesn't say is that their definition of the 
`Gulf War era' includes every veteran who has served from 1990 to the 
present, not just 1990-1991 Gulf War veterans. (See Fact Sheet 
attached.)
    "Recent statements by Undersecretary for Benefits Allison Hickey 
provide the answer why VA is hiding this information. An April 22, 2014 
article in Military Times reported that she was concerned that even 
using the term `Gulf War illness' `might imply a causal link between 
service in the Gulf and poor health which could necessitate legislation 
for disability compensation for veterans who served in the Gulf.' And 
on December 13, 2013, she testified that VA would be able to meet its 
2015 goal of processing claims within 125 days, barring `something like 
we experienced in Agent Orange [when we added] 260,000 claims in our 
inventory overnight in Oct. 2010. That will kill us.'"

Recent Rates of VA Denial of Gulf War Veterans' Presumptive Claims

    Despite the latest VA intervention in 2010, the rate of denial of 
Gulf War veteran presumptive claims has been steadily worsening, year 
by year, as showna by data provided by VA for fiscal years 2011 through 
the first half of 2015. These claims include two types: chronic 
multisymptom illness claims (Fibromyalgia; Irritable Bowel Syndrome/
Functional Gastrointestinal Disorders; Chronic Fatigue Syndrome); and, 
undiagnosed illness claims authorized under 38 U.S.C. 3.317.

A. VA Denials of Presumptive Chronic Multisymptom Illness Claims

    The rate of denial of Gulf War veteran presumptive chronic 
multisymptom illness claims (Fibromyalgia; Irritable Bowel Syndrome/
Functional Gastrointestinal Disorders; Chronic Fatigue Syndrome) has 
been steadily worsening, year by year. By the first half of FY15, VA 
was denying these claims at a rate of nearly four-out-of-every-five.

    FY2011: 72.5%
    FY2012: 72.1%
    FY2013: 75.3%
    FY2014: 77.0%
    FY2015 Q1, Q2: 79.2%

    "CMI = Chronic Multisymptom Illness (fibromyalgia 5025, IBS 7319, 
and chronic fatigue syndrome 6354) in either the hyphenated or primary 
code. If condition is both UDX and CMI, it is included in UDX counts."

    (G) = Total Conditions Granted ("Vets")
    (D) = Total Conditions Denied ("Vets")
    (T) = Total Conditions Granted or Denied ("Vets")

    Formulas: (G) + (D) = (T); (D)/(T) = denial rate

    FY2011: 743 (G) + 1,961 (D) = 2,704 (T); 1,961 (D) / 2,704 (T) = 
72.5% CMI denial rate
    FY2012: 1,114 (G) + 2,877 (D) = 2,704 (T); 2,877 (D) / 3,991 (T) = 
72.1% CMI denial rate
    FY2013: 1,638 (G) + 5,002 (D) = 2,704 (T); 5,002 (D) / 6,640 (T) = 
75.3% CMI denial rate
    FY2014: 1,300 (G) + 4,341 (D) = 2,704 (T); 4,341 (D) / 5,641 (T) = 
77.0% CMI denial rate
    FY2015 Q1,Q2: 746 (G) + 2,849 (D) = 2,704 (T); 2,849 (D) / 3,595 
(T) = 79.2% CMI denial rate

B. VA Denials of Presumptive Undiagnosed Illness Claims

    VA's denial of Gulf War veteran presumptive undiagnosed illness 
claims is at even higher rates than VA's denial of presumptive chronic 
multisymptom illness claims.
    The rate of denial of Gulf War veteran presumptive undiagnosed 
illness claims has also been steadily worsening, year by year. By the 
first half of FY15, VA was approving only 14.7 percent of these claims 
- approaching the limited odds of winning a scratch-off lottery.

    FY2011: 80.5%
    FY2012: 78.4%
    FY2013: 78.6%
    FY2014: 83.1%
    FY15 Q1, Q2: 85.3%

    "UDX = Undiagnosed Illness, defined as diagnostic codes containing 
88xx in either the hyphenated or primary code."

    Formulas: (G) + (D) = (T); (D)/(T) = denial rate

    FY2011: 480 (G) + 1,977 (D) = 2,457 (T); 1,977 (D) / 2,457 (T) = 
80.5% UDX denial rate
    FY2012: 628 (G) + 2,278 (D) = 2,906 (T); 2,278 (D) / 2,906 (T) = 
78.4% UDX denial rate
    FY2013: 925 (G) + 3,402 (D) = 4,327 (T); 3,402 (D) / 4,327 (T) = 
78.6% UDX denial rate
    FY2014: 627 (G) + 3,086 (D) = 3,713 (T); 3,086 (D) / 3,713 (T) = 
83.1% UDX denial rate
    FY2015 Q1,Q2: 339 (G) + 1,970 (D) = 2,309 (T); 1,970 (D) / 2,309 
(T) = 85.3% UDX denial rate

C. VA Denials of Gulf War Presumptive Claims (Chronic Multisymptom and 
    Undiagnosed Illness Combined):

    FY2011: 76.3%
    FY2012: 74.7%
    FY2013: 76.6%
    FY14: 79.4%
    FY2015 Q1, Q2: 81.6%

    Formula: [(CMI D) + (UDX D)] / [(CMI T) + (UDX T)] = denial rate

    FY2011: [1,961 (CMI D) + 1,977 (UDX D)] / [2,704 (CMI T) + 2,457 
(UDX T)] = 76.3% CMI+UDX denial rate
    FY2012: [2,877 (CMI D) + 2,278 (UDX D)] / [3,991 (CMI T) + 2,906 
(UDX T)] = 74.7% CMI+UDX denial rate
    FY2013: [5,002 (CMI D) + 3,402 (UDX D)] / [6,640 (CMI T) + 4,327 
(UDX T)] = 76.6% CMI+UDX denial rate
    FY2014: [4,341 (CMI D) + 3,086 (UDX D)] / [5,641 (CMI T) + 3,713 
(UDX T)] = 79.4% CMI+UDX denial rate
    FY2015 Q1, Q2: [2,849 (CMI D) + 1,970 (UDX D)] / [3,595 (CMI T) + 
2,309 (UDX T)] = 81.6% CMI+UDX denial rate

                                                VA Intervention: 
                                                Amending the M21-1

    It appears that VA has made a new intervention by amending the M21-
1 "Veterans Benefits Manual," which is supposed to be used for rating 
VA claims. However, it is not clear whether VA rating staff are aware 
of, let alone utilizing this manual to rate Gulf War veterans' claims.
    With no new Gulf War claims data released since the second quarter 
of FY15, it is unclear whether this intervention has had any positive 
effect on improving VA's terrible denial rates for Gulf War veterans' 
UDX and CMI claims.
    Given VA's past record, it is unclear whether this latest 
intervention will be just one more in a long line of ineffective 
"solutions". Past VA "solutions" have done nothing to quell VA's 
extraordinarily high denial rates of these veterans' claims.

Claims Denial Conclusions

    In short, VA's denial rates for Gulf War UDX and CMI claims 
remained high over time. In recent years, VA's denial rates have been 
increasing for these Gulf War veterans' claims.
    This is in complete contravention to the intent of the 1998 laws 
passed to improve Gulf War veterans' ability to get their claims 
approved, while prioritizing treatments was made an even higher 
priority - but not by VA.

CLAIMS DATA RECOMMENDATIONS

VA Needs to Track, Analyze, and Regularly Report VA Utilization Data 
    for 1990-91 Gulf War Veterans.
    In 2010, VCS Director Paul Sullivan testified, "In 2002, VA staff 
conducted a thorough review of granted and denied claims among Gulf War 
veterans at the diagnostic code level. VA staff concluded that VA 
regional offices with large claim backlogs and without training on UDX 
claims under 38 CFR 3.317 approved few (about 4 percent) of Gulf War 
veterans claims. In contrast, VA regional offices with small backlogs 
that received training from VA Central office approved far more UDX 
disability benefit claims (about 30 percent). At present, VA has no 
idea how many UDX claims have been granted or denied."
    Today, it is unclear whether VA is consistently tracking UDX claim 
denials and approvals. Certainly, VA is not publicly reporting that 
data, at least not in any way that is regularly and readily accessible 
to Gulf War veterans or the veterans advocacy community.
    VA must return to the regular public reporting of carefully 
collated and analyzed Gulf War veterans' claims and VA usage data.
    VA must return to the regular public reporting of carefully 
collated and analyzed Gulf War veterans' claims and VA usage data. VA 
must be held accountable for its actions, and without easy public 
access to this VA data, accountability will remain difficult to 
achieve.

CONCLUSIONS

    If we measure VA's success by how it has approved Gulf War 
veterans' claims twenty-five years after the war, VA has failed most 
ill and suffering Gulf War veterans. VA has circumvented or ignored 
most of the aims of the 1998 laws. Despite various high-level 
interventions by VA to improve the claims process, the denial rates 
remain unacceptably high and are getting worse each year.
    In twenty-five years, VA has made little progress in finding 
effective, evidence-based treatments for Gulf War Illness, denied Gulf 
War veterans disability claims nearly across the board, and relegated 
these veterans to the realm of mental health interventions.
    VA has the authority to develop new presumptives for these ill and 
suffering veterans, but unlike with Agent Orange, has failed to 
identify any new conditions beyond a set of rare endemic infectious 
diseases that affect almost no one. The latest report by the Institute 
of Medicine, shaped by VA's contract, argues that individual Gulf War 
exposures are forever unknowable. We knew that when seeking the 1998 
legislation, aimed at connecting generic exposure data with health 
outcomes. VA has stymied those efforts.
    Twenty-five years later, ill Gulf War veterans are still in pain. 
They are suffering. They have been begging for help for years and 
years. As I noted in my February 23 testimony, the letter, the spirit, 
and the intent of the 1998 Persian Gulf War laws have yet to be 
achieved.
    On this 25th anniversary of the war, our Gulf War veterans are 
still waiting for VA to provide effective, evidenced-based treatments 
for Gulf War Illness. Given their level of disability, the least we can 
do is to cause VA to approve their presumptive, service-connected 
disability claims.
    Please help fix these serious issues, once and for all.

    ****

ADDITIONAL INFORMATION

    Public Law 102-1, enacted in January 1991, authorized the President 
to start the Persian Gulf War, known at the time as Operation Desert 
Shield and Desert Storm. Offensive U.S. military action against Iraq 
began on January 17, 1991 local time (the evening of January 16 in the 
United States).
    Public Law 102-25, enacted in April 1991, retroactively established 
the start date of the Gulf War as August 2, 1990, the date Iraq invaded 
Kuwait. Neither Congress nor the President have ever ended the Gulf 
War, and the conflict continues through to the present. According to 38 
CFR 3.317(e)(2), "The Southwest Asia theater of operations refers to 
Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi 
Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of 
Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, 
and the airspace above these locations. (Authority: 38 U.S.C. 1117, 
1118)."
    Public Law 102-85, enacted in November 1992, authorized the 
creation of the Gulf War Registry as well as the Gulf War Veterans 
Information System (GWVIS). VA began preparing GWVIS reports in 2000, 
and VA ceased producing the reports in 2008 after VCS observed that 
VA's GWVIS reports were incomplete. VA has since confirmed that it 
failed to update computer programming to identify all disabled Gulf War 
veterans.
    Public Law 103-210, enacted in December 1993, required VA to 
provide healthcare on a priority basis (Priority Group 6).
    Public Law 103-446, enacted in November 1994, expanded access to VA 
disability benefits so ill Gulf War veterans could obtain VA medical 
care under for the undiagnosed illnesses. The law included a long list 
of toxins to which Gulf War veterans were presumably exposed, including 
depleted uranium, fumes and smoke from military operations, oil well 
fires, diesel exhaust, paints, pesticides, depleted uranium, infectious 
agents, investigational drugs and vaccines, indigenous diseases, and 
multiple immunizations.
    Public Law 105-277, enacted in 1998, significantly expanded the 
list of toxins it presumed Gulf War veterans were exposed to during 
deployment to Southwest Asia, and mandated contracts between VA and the 
National Academy of Science (which ultimately was conducted by NAS's 
Institute of Medicine (IOM)) to determine association between Gulf War 
exposures and Gulf War veterans' health conditions.
    Public Law 105-368, enacted on Veterans Day 1998, expanded Public 
Laws 103-210 and 103-446. It also directed the creation of the the 
Research Advisory Committee on Gulf War Veterans' Illness (RAC), which 
VA failed to create the RAC until 2002 - more than three years after 
the statutorily mandated deadline.

                                 
                            RONALD E. BROWN
    Thank you, Chairman Coffman, Ranking Member Rep. Ann McLane Kuster, 
Rep. Dr. Ralph Abraham, Rep. Dina Titus, and Members of the House 
Veterans' Affairs Subcommittee on Oversight and Investigations. I thank 
you for holding this joint investigative hearing on the VA's Disability 
Claim Process with Respect to Gulf War Illness claims.
    My name is Ronald Brown; I'm President of the National Gulf War 
Resource Center (NGWRC). The NGWRC is a small 501 (c) (3) non-profit 
veteran service organization, which is comprised of sick Persian Gulf 
War veterans who volunteer our time to advocate for our fellow veterans 
suffering from the complexities of modern warfare. We specialize in 
Gulf War Illness claims, we work with veterans to educate and assist 
them in the claims process. We also work with policy makers inside the 
VA, in an attempt to accomplish two goals: first, to insure clinicians 
are better trained about conditions facing this group of veterans to 
insure the veterans receive the best health care possible. Secondly, we 
are working to address and correct issues affecting this group of 
veterans, such as the high denial rate of Gulf War illness related 
claims.
    This year marks the 25th anniversary of the liberation of Kuwait. 
Of the nearly 700,000 U.S. military personnel that served in the 1990-
1991 Persian Gulf War (Operation Desert Storm) studies indicate that 
approximately 25-32% of these veterans became ill with what is now 
referred to as Gulf War Illness. These U.S. Warfighters face a higher 
denial rate than any other era veteran.
    In May 2015 the VBA provided the NGWRC data on Gulf War claims. The 
data wasn't exactly what we had asked for but it did show some very 
disturbing numbers. Out of 193,436 Undiagnosed Illness (UDX) or Chronic 
Multi-Symptom conditions claimed only 32,631 was approved service 
connection leaving 160,805 conditions denied. That's an approval rate 
of 17% and a denial rate of 83%. The VBA has stated that the denial 
rate is actually around 70%-74%.
    This data shows that Desert Storm veterans are compensated for 
direct service connection conditions (50,523) equivalent to other era 
veterans. Emphatically, this data revealed disturbing data that showed 
most Gulf War veterans are denied presumptions of service connection 
for illnesses (CMI) associated with service in the Persian Gulf 
Theater.
    The NGWRC asked the VBA for clarification. The VBA provided us with 
data in July 2015 that shows the reasons for denials of first time 
claims filed from 2011 through 2015.
    This data is for denials of claims for the diagnosable but 
medically unexplained chronic multisymptom illness (CMI) conditions 
such as Chronic Fatigue Syndrome, Fibromyalgia, and Functional 
gastrointestinal conditions which are presumed by Congressional intent 
(See: U.S.C 38 Sec.  1118) to be caused by service in the Southwest 
Asia Theater of operations. This data shows that a total of 18,218 
veterans filed claims for 22,863 conditions that were denied.
    The data is broken down by specific categories with the number of 
claims denied in each category, they are as follows:

      No Causation - 8 conditions.
      No Diagnosis - 9,710 conditions.
      Not aggravated by service - 25 conditions.
      Not Established by Presumption - 2,176 conditions.
      Not in Country - 10 conditions.
      Not Caused/Incurred by Service - 10,568 conditions.
      Not Secondary - 344 conditions.
      Not Well Grounded - 1 condition.
      Not in Line of Duty - 3 conditions.

    The NGWRC finds two of these categories extremely troubling and 
evidence of systemic problems within the Veterans Benefit 
Administration (VBA) in regards to Gulf War Illness claims. The 
categories "Not Established by Presumption - 2,176 conditions denied" 
and "Not Caused/Incurred by Service - 10,568 conditions denied". These 
two categories account for 57% of the 22,863 conditions that were 
denied. These two categories absolutely make no sense given the fact 
that by statue (U.S.C 38 Sec.  1118) these conditions are presumptions 
of service connection for illnesses associated with service in the 
Persian Gulf War. Congressional intent is such that these illnesses 
"shall be considered to have been incurred in or aggravated by service 
notwithstanding that there is no record of evidence of such illness 
during the period of such service".
    To date the Veterans Benefit Administration (VBA) has not been able 
to provide a rational explanation as to why these two categories 
warrant denials given the statue. I addressed this issue with former 
Under Secretary of Benefits Allison Hickey who acknowledged a potential 
problem and stated that she would have VBA randomly pull a statistical 
portion of these claims to check for accuracy. She stated that she 
would have the results by October or November 2015. Her replacement, 
Danny Pummill, has also promised to get us the results from this 
accuracy check but as of today we still do not have the results.
    The Veterans Benefit Administration (VBA) has worked with us to 
update both their training and procedure manual, the M21-1. They did an 
outstanding job, the new changes to their M21-1 provides sufficient 
guidance to enable C&P examiners to provide accurate Gulf War Illness 
exams and it provides VA adjudicators all the necessary information to 
accurately decide these claims.
    Unfortunately, the Veterans Benefit Administration (VBA) has been 
ineffective in getting the front line raters at the regional Benefits 
offices to do the training or use the updated M21-1 manual. This is 
evident by recent denials of chronic multisymptom illness (CMI) claims 
in which the adjudicator or the C&P examiner imposed a nexus 
requirement and denied the veteran's claim because "no record or 
evidence of such illness was found in the veteran's military medical 
records". The front line adjudicators are not following statue, VA 
regulations, VA procedure (M21-1) and U.S. Court of Appeals for 
Veterans' Claims case law.
    The NGWRC has been very successful in winning appeals at the 
Regional Benefits Office level, by simply pointing out the statue, VA 
regulation (38 CFR 3.317), the appropriate section in the M21-1 
procedure manual, and the U.S. Court of Appeals for Veterans' Claims 
case Gutierrez v. Principi, 19 Vet.App.1 (2004) in which the court 
upheld U.S.C 38 Sec.  1118 and determined that a Gulf War veteran does 
not have to prove any link to the veteran service and his or her 
current CMI condition.
    The NGWRC has also been successful working with policy makers 
inside the Veterans Benefit Administration (VBA). We are very thankful 
to these policy makers for the positive changes made to the M21-1 
manual, yet we find ourselves awestruck by the VBA's inability to train 
the front line adjudicators on these types of claims. As positive as 
the changes are to the M21-1, these changes are useless if the 
examiners and raters aren't using and following the regulations 
highlighted in the manual.
    The only hope Gulf War Veterans have to fix the high denial rate of 
Gulf War illness related claims is for the Veterans Benefit 
Administration to first recognize the problem and provide ongoing 
training to the front line adjudicators in all Regional Benefits 
Offices. This training would further serve to reduce the growing number 
of appeals.

    Recommendations:

      Training. Training the front line adjudicators concerning 
Gulf War illness related claims would be the most effective tool in 
solving the high denial rate of Gulf War illness related claims. Gulf 
War illness related claims make up 29% of the current back log. This 
training would further serve to reduce the growing number of appeals. 
If the policy makers in the Central office are serious about fixing the 
high denial rates of Gulf War illness related claims, they need to 
ensure that each regional office around the country is doing mandatory 
training.
      The upper management in the Central office should direct 
the directors of each Regional Benefits Office to ensure their front 
line adjudicators are using the M21-1 manual. This manual provides the 
adjudicators all the references needed to accurately adjudicate claims. 
References in this manual include U.S. code, VA Regulation (CFR) and 
related U.S. Court of Appeals for Veterans' Claims cases. This manual 
is an excellent tool if used.
      Transparency, the VBA must continue to provide Veteran 
Service Organizations with data on these types of claims. This ensures 
that VSO organizations can monitor and keep tract of denial and 
approval rates as well as provide critical information to the veterans 
they represent.
      I think it would help if VA also provided more 
specificity to veterans on why their claims are denied. For example, VA 
doesn't always inform the veteran about what exactly could be done to 
help move the claim - but I believe the following is critical for 
veterans to know so they can meet the 10% threshold:
      The veteran must specifically indicate the condition is 
"due to Gulf War;"
      The veteran must describe the symptoms related to the 
condition and its existence of more than 6 months;
      The veteran should provide any medical or nonmedical 
evidence (such as personal statements from family on the impact of the 
condition to the veteran, family, etc.

    Respectfully,

    Ronald E. Brown
    President
    National Gulf War Resource Center
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