Serve, Support, Simplify

Report of the President’s Commission on Care

 for America’s Returning Wounded Warriors

July 2007

LETTER OF TRANSMITTAL

July 30, 2007

Dear President Bush:

We are pleased to transmit the fi nal report of the President’s Commission on 

Care for America’s Returning Wounded Warriors, created March 6, 2007. To 

arrive at our recommendations, the Commission has visited a number of DOD 

facilities, VA hospitals, and other care sites across the country. We have listened 

to injured service members, their families, professionals who provide medical 

and rehabilitative services, program administrators and many, many others.

Our recommendations are few, but they are actionable. They are based on the 

priorities of patients and families. Essentially, our recommendations hope to 

accomplish three goals:

• To serve those injured in the line of duty while defending their nation

• To support their recovery and successful rehabilitation and

• To simplify the sometimes overly complex systems that frustrate some 

injured service members and their families and impede effi cient care.

Our charge was to address the needs of the current generation of “wounded 

warriors,” but if implemented, they will help other deserving veterans as well.

The dedicated personnel working in our nation’s military and veterans’ medical 

care, disability, and rehabilitation systems are working very hard. They are 

making substantial technical and administrative improvements. But America 

can do better. We are all concerned about the care provided to those most seriously injured in Iraq and Afghanistan. The number sustaining serious injuries is 

not overwhelming, so it is a problem that can be addressed quickly.

It has been a privilege to serve on this Commission and to provide you with an 

agenda for moving forward. 

Bob Dole, Co-Chair Donna Shalala, Co-Chair

 
COMMISSIONERS

Commissioner Edward A. Eckenhoff

Commissioner Tammy Edwards

Commissioner Kenneth Fisher

Commissioner Marc Giammatteo

Commissioner C. Martin Harris, MD

Commissioner Jose Ramos

Commissioner Gail Wilensky, PhD
CHARGE TO THE COMMISSION

THE WHITE HOUSE

March 6, 2007 

Executive Order: Establishing a Commission on Care

for America’s Returning Wounded Warriors 

By the authority vested in me as President by the Constitution and the laws of 

the United States of America, and to provide a comprehensive review of the care 

provided to America’s returning Global War on Terror service men and women 

from the time they leave the battlefi eld through their return to civilian life, it is 

hereby ordered as follows: 

The mission of the Commission shall be to: 

(a) examine the effectiveness of returning wounded service members’ transition 

from deployment in support of the Global War on Terror to successful return 

to productive military service or civilian society, and recommend needed 

improvements; 

(b) evaluate the coordination, management, and adequacy of the delivery of 

health care, disability, traumatic injury, education, employment, and other benefi ts and services to returning wounded Global War on Terror service mem bers 

by Federal agencies as well as by the private sector, and recommend ways to 

ensure that programs provide high-quality services; 

(c) (i) analyze the effectiveness of existing outreach to service members regarding 

such benefi ts and services, and service members’ level of awareness of and ability 

to access these benefi ts and services, and (ii) identify ways to reduce barriers to 

and gaps in these benefi ts and services; and 

(d) consult with foundations, veterans service organizations, non-profi t groups, faithbased or ganizations, and others as appropriate, in performing the Commission’s 

functions under subsections (a) through (c) of this section. 

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THE PRESIDENT’S COMMISSION ON CARE 

FOR AMERICA’S RETURNING WOUNDED WARRIORS

Final Report — July 2007

“It is almost cliché now to fi nd examples of a wounded Marine having initially been treated by a Navy Corpsman fi nd himself medevac’ed by an Army helicopter to undergo emergency surgery at an Air Force Theater Hospital.”1

LtCol Moore’s testimony demonstrates how the skills and resources of the U.S. mili tary can be brought together to aid an injured service member—without regard for 

traditional bureaucracies and hierarchies. Under the best circumstances, the entire 

system smoothly joins forces to provide exactly what is needed, precisely when it is 

needed. His example embodies the kind of effi cient care, centered on the needs of the 

patient, that we envision for our injured service members throughout the process of 

treatment, rehabilitation, and return to their military unit or home community.

In our few months of operation, we nine Commissioners—health care, disability, and 

housing experts, injured service members, and family—have visited 23 Depart ment 

of Defense (DoD), Department of Veterans Affairs (VA), and private-sector treatment 

facilities. We have heard fi rst-hand from injured service members and their families, 

from health care professionals, and from the people who manage military and 

veterans’ programs. More than 1,700 injured service members responded to a national survey we conducted,2

 and we received more than 1,250 letters and emails from 

service members, veterans, family members, and health care personnel. We have analyzed the recommendations of past commissions and task forces, including several 

issued earlier in 2007.3

 And, we have drawn on the extensive knowledge of our fellow

Commissioners. 

1 Testimony of Air Force LtCol Andrew E. Moore, MD, at the Commission’s public hearing in San 

Antonio, Texas, May 4, 2007.

2 Our survey was conducted from June 7 to June 19, 2007. A random sample of 5,995 active duty, reserve 

component, and retired, medically retired, or separated service members and veterans treated for 

wounds sustained in Iraq and Afghanistan that led to evacuation to the United States. The survey 

received responses from 1,730 individuals—a 30 percent response rate.

3 These are listed in an Appendix at the end of this report.

4 32 CFR Sec 199.2

5 Americans with Disabilities Act, 1990.

6 DoDD 1241.01, February 28, 2004, Section E3.P5.2.2.

SOME DEFINITIONS

Serious injury

A physiological condition 

affecting one or more 

body systems that has 

lasted or is expected to 

last at least 12 contigu ous 

months and that precludes 

unaided per formance of at 

least one major life activity (breathing, cognition, 

hearing, seeing, ability to 

bathe, dress, eat, groom, 

speak, use stairs or

toilet, transfer, walk).4

Disability

A physical or mental

impairment that substantially limits one or more 

major life activities.5

Combat-related

Injuries and illnesses

attributable to the special 

dangers associated with 

armed confl ict or the 

preparation or training for 

armed confl ict.6
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The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

We want to emphasize that we’ve heard time and again about the overall high quality 

of our military’s battlefi eld medicine and the care delivered by the staffs in our nation’s military medical facilities and the VA health system. These clinical professionals’ 

skill and intense commitment to the wounded is palpable. In the Vietnam era, fi ve out 

of every eight seriously injured service members survived; today, seven out of eight 

survive, many with injuries that in previous wars would have been fatal. This is a remarkable record. The number of “seriously injured” service members on whom much 

of this report focuses is, without doubt, eminently manageable.

The following chart compiles recent data from several sources, which don’t all use 

the same defi nitions and include some double-counting (some individuals have both 

traumatic brain injuries and amputations, for example). The data nevertheless provide 

a sense of the scale of the problem of seriously injured service members and the kinds 

of injuries being addressed in this report.

Number of deployments 2,200,000

Number of service members deployed 1,500,000

Air evacuated for illness or injuries 37,851

Wounded in action 28,000

Treated and returned to duty within 72 hours 23,270

Seriously injured (TSGLI recipients)7 3,082

Traumatic Brain Injuries 2,726

Amputations 644

Serious burns 598

Polytrauma 391

Spinal cord injuries 94

Blind 48

Despite accomplishments in clinical care, problems do occur—particularly in handoffs 

between inpatient and outpatient care and between the two separate DoD and VA 

health care and disability systems. To resolve these problems, we have concentrated 

on ways to better:

Serve the multiple needs of injured service members and their families

Support them in their recovery and return to military duty or to their communities and

Simplify the delivery of medical care and disability programs.

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7 TSGLI (Traumatic Servicemembers’ Group Life Insurance) helps severely injured service members 

with a one-time payment, depending on their injury.
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The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

We believe our recommendations will produce a patient-centered system that fosters 

high-quality care, increases access to needed care and programs, promotes effi ciency, 

supports families, and facilitates the work of the thousands of dedicated individuals 

who provide a gamut of health care and disability programs to injured service members 

and veterans. Our nation needs a system of care that enables injured service members 

to maximize their recovery and their opportunity to return to the mainstream of 

American life. Such a system not only should treat all service members—whether 

active duty or reserve component (that is, the National Guard and reserve)—evenhandedly, but it also must be perceived as doing so. 

Our Commission was established at a time of great change in U.S. health care. Many 

of the statements—good and bad—that we have heard about care in the DoD and VA 

systems could apply to the nation’s health care delivery system as a whole. While numerous aspects of U.S. medical care are excellent, problems in coordination and continuity of care are common; our nation’s hospitals and health systems are struggling to 

develop effective information technology systems; the stigma associated with seeking 

mental health care is slowly diminishing, but far from gone; our overall health system 

is oriented to acute care, not long-term rehabilitation; and shortages in critical staff 

categories are felt nationwide. 

In the past few months, the health care and disability systems for our service members 

and veterans have been under a media microscope and the subject of several reports 

cited earlier. Public concern arises because Americans recognize and respect the sacrifi ces of our young men and women fi ghting in Iraq and Afghanistan and the great 

debt we owe those injured and killed.8

 Many of the concerns already are being addressed by Congress and in the two Departments.

The reports published earlier this year provided invaluable background information 

and analyses for our work. Because they are so recent, we did not need to reiterate 

their fi ndings. Rather, we focused on ways to move forward. One other difference 

between our Commission and previous ones is that, while they addressed discrete 

pieces of the DoD and VA medical care and disability systems, President Bush charged 

us with looking at the whole continuum of care and programs for wounded service 

members, as well as what is needed to assure their successful return to military duty 

or civilian life. 

We don’t recommend merely patching the system, as has been done in the past. 

Instead, the experiences of these young men and women have highlighted the need 

for fundamental changes in care management and the disability system. Our recommendations address these fundamental changes. We believe they will help military 

service members and veterans of today and of tomorrow, as well.

8 In Operation Iraqi Freedom and Operation Enduring Freedom, the latter of which is focused 

primarily in Afghanistan, but has involved smaller operations in other geographic areas, as well.
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The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

Making the signifi cant improvements we recommend requires a sense of urgency and 

strong leadership. The tendency to make systems too complex and rule-bound must be 

countered by a new perspective, grounded in an understanding of the importance of 

patient-centeredness. From the time injured service members are evacuated from the 

battlefi eld to the time they go back to active duty or are discharged home to complete 

their education, go to work, and be active family and community members, their 

needs and aspirations should inform the medical care and disability systems. 
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The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

RECOMMENDATIONS

Our recommendations will serve, support, and simplify health care and rehabilita tion 

for injured service men and women, and return them as quickly as possible to their 

mil itary duties or to civilian life. To make these recommendations a reality, the 

Presi dent, Congress, and Departments of Defense (DoD) and Veterans Affairs (VA) 

should initiate the steps described in this report.

Immediately Create Comprehensive Recovery Plans to Provide the 

Right Care and Support at the Right Time in the Right Place

Recommendation: Create a patient-centered Recovery Plan for every seri ously 

injured service member that provides the right care and support at the right time 

in the right place. A corps of well-trained, highly-skilled Recovery Coordinators 

must be swiftly developed to ensure prompt development and execution of the 

Recovery Plan. 

Goals: Ensure an effi cient, effective and smooth rehabilitation and transition 

back to military duty or civilian life; establish a single point of contact for patients 

and families; and eliminate delays and gaps in treatment and services.

What it is:

The Recovery Plan should smoothly and seamlessly guide and support service 

mem bers through medical care, rehabilitation, and disability programs.

The Recovery Plan will help service members obtain services promptly and in the most 

appropriate care facilities—whether DoD, VA, or civilian. 

The Recovery Coordinator is the patient and family’s single point of contact, who 

makes sure each service member receives the care specifi ed for them in the plan when 

they need it, and that no one gets “lost in the system.” 

The Recovery Coordinator moves injured service members through the system in a 

timely way, because experience shows that people recover better when treatment and 

services are provided promptly. 

Who oversees it:

A Recovery Coordinator would oversee implementation of the Recovery Plan. Recovery 

Coordinators would have the authority to coordinate medical care, rehabilitation, 

education, and employment-related programs, as well as disability benefi ts. This is 

a diffi cult and complex job, and both Departments must be committed to making it 

work. 

Recovery Coordinators would ensure that patients and families understand the likely 

trajectory of the service member’s recovery, the types of care and services that will be 

needed, and how much time recovery may take.

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The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

DoD and VA should develop integrated care teams (physicians, nurses, allied health 

professionals from relevant specialties, social workers, and vocational rehabilitation 

staff). These teams would create injured service members’ initial Recovery Plans, 

which should start with a comprehensive clinical evaluation. 

• • •

DoD and VA should direct that Recovery Plans be created for all service members 

seriously injured since the beginning of the Afghanistan and Iraq confl icts who still 

would benefi t from them.

• • •

DoD & VA must work with the Commissioned Corps of the Public Health Service, 

Department of Health and Human Services, to develop a cadre of well-trained, highly 

skilled Recovery Coordinators. 

Completely Restructure the Disability and Compensation Systems

Recommendation: DoD maintains authority to determine fi tness to serve. 

For those found not fi t for duty, DoD shall provide payment for years served. VA 

then establishes the disability rating, compensation and benefi ts. 

Goals: Update and simplify the disability determination and compensation 

system; eliminate parallel activities; reduce inequities; and provide a solid base 

for the return of injured veterans to productive lives.

The following data from our survey illustrate why we believe an overhaul is needed 

(Throughout this report, our survey results appear in blue):

• 38 percent of active duty, 34 percent of reserve component, and 38 percent of 

retired/separated service members are “very” or “somewhat” satisfi ed with the 

disability evaluation system.

• 46 percent of active duty, 36 percent of reserve component, and 40 percent of 

retired/separated service members say they “completely” or “mostly” understand 

the military’s disability evaluation process. 

• 42 percent of retired/separated service members who fi led a VA claim report that 

they “completely” or “mostly” understand the VA claims process. 

Department of Defense Responsibilities

Each branch of the armed services would retain authority for determining whether a 

service member is fi t for continued military service. 

If not medically fi t, the service member should receive DoD annuity payments, the 

dollar value of which would be based solely on rank and length of service.

Action Steps

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The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

Department of Veterans Affairs Responsibilities

The VA should assume all responsibility for establishing disability ratings and for all 

disability compensation and benefi ts programs. 

The VA should initiate its education, training, and work-related benefi ts early in the 

rehabilitation period.

The Department’s education, training, and employment programs should include incentives to encourage veterans to participate and stay enrolled. (Our survey found 

that 21 percent of demobilized reservists and 31 percent of retired/separated service 

members are enrolled in an educational program leading to a degree.)

Periodic Review

The disability status of veterans should be reevaluated every three years and compensation adjusted, if their condition has worsened or improved.

Vocational Rehabilitation & Education Program (VRE)

The effectiveness of various vocational rehabilitation programs is not well established, 

and the VA should undertake an effort to determine which have the greatest long-term 

success.

VA policies should encourage completion of effective programs by increasing the fl exibility of scheduling for those whose disability does not permit taking a full course 

load. This can be done without increasing the dollar amount of the benefi t.

Also, the VA should develop fi nancial incentives that would encourage completion.

Congress should clarify the objectives for DoD and VA disability systems, in line with 

this recommendation. 

• • •

DoD and VA should create a single, comprehensive, standardized medical examination 

that DoD administers. It would serve DoD’s purpose of determining fi tness and VA’s of 

determining initial disability level. 

• • •

Service members found unfi t because of their combat-related injuries should receive 

comprehensive health care coverage and pharmacy benefi ts for themselves and their 

dependents through DoD’s TRICARE program.9

• • •

Congress should restructure VA disability payments to include: 

1. “transition payments”—–to cover living expenses for disabled veterans and their 

families. They should receive either

 • 3 months of base pay, if they are returning to their community and not participating in further rehabilitation 

Action Steps

9 TRICARE is the Department of Defense’s health care program for members of the military, their 

families, and survivors and serves more than 9.1 million benefi ciaries worldwide.

continued
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The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

 OR

 • longer-term payments to cover family living expenses, if they are participating in further rehabilitation or education and training programs

2. once transition payments end, disabled veterans should receive earnings-loss

payments—–to make up for any lower earning capacity remaining after training

3. quality-of-life payments—–to compensate for non-work-related effects of permanent physical and mental combat-related injuries

• • •

The VA should commission a six-month study to determine the appropriate level and 

duration of longer-term transition payments. 

• • •

The VA should move swiftly to update (and thereafter keep current) its disability rating schedule to refl ect current injuries and modern concepts of the impact of disability on quality of life.

• • •

To improve completion rates in its VRE program, VA should:

• allow veterans to suspend training for a time or attend part-time (for up to 72 

months), with approval of their Recovery Coordinator and vocational counselor

• pay a bonus (10 percent of annual transition pay) for completing the fi rst and second 

years of VRE training and 5 percent for completing the third year

Aggressively Prevent and Treat Post-Traumatic Stress Disorder and 

Traumatic Brain Injury

Recommendation: VA should provide care for any veteran of the Afghanistan 

and Iraq confl icts who has post-traumatic stress disorder (PTSD). DoD and VA 

must rapidly improve prevention, diagnosis, and treatment of both PTSD and 

traumatic brain injury (TBI). At the same time, both Departments must work 

aggressively to reduce the stigma of PTSD.

Goals: Improve care of two common conditions of the current confl icts and 

re duce the stigma of PTSD; mentally and physically fi t service members will 

strengthen our military into the future.

• In our survey, around 70 percent of active duty, reserve component, and retired/

separated service members report they had been asked whether they were exposed 

to an event or blast that caused a jolt or blow to the head.

• 59 percent of active duty and 52 percent of reserve component and 65 percent of 

retired/separated service members had been exposed to such an event.

Workforce Strategies

We recognize that augmenting DoD’s mental health workforce will not be easy, because 

of national shortages in mental health professionals. DoD personnel requirements 

Action Steps

continued

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The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

must take into account the expanding need for such personnel, due to the military’s 

expanded prevention and education missions in behavioral health; and, both Departments should prepare for the expected long-term demand that may arise from 

chronic or delayed-onset symptoms of PTSD.

Reduce Stigma

DoD should intensify its efforts to reduce the stigma associated with PTSD.

Congress should enable all veterans who have been deployed in Afghanistan and 

Iraq who need PTSD care to receive it from the VA. 

• • •

DoD should aggressively address its acute shortage of mental health clinicians. 

• • •

DoD should establish a network of public and private-sector expertise in TBI 

and partner with the VA on an expanded network for PTSD, so that prevention, 

diagnosis, and treatment of these two conditions stay current with the changing 

science base. Specifi cally, it should:

 • conduct comprehensive training programs in PTSD and TBI for military 

leaders, VA and DoD medical personnel, family members, and caregivers

 • disseminate existing TBI and PTSD clinical practice guidelines to all involved 

providers; where no guidelines exist, DoD and VA should work with other 

national experts to develop them.

Signifi cantly Strengthen Support for Families 

Recommendation: Strengthen family support programs including expanding 

DoD respite care and extending the Family and Medical Leave Act for up to six 

months for spouses and parents of the seriously injured. 

Goals: Strengthen family support systems and improve the quality of life for 

families. 

• In our survey, 33 percent of active duty, 22 percent of reserve component, and 37 

percent of retired/separated service members report that a family member or close 

friend relocated for extended periods of time to be with them while they were in the 

hospital.

• 21 percent of active duty, 15 percent of reserve component, and 24 percent of retired/

separated service members say friends or family gave up a job to be with them or act 

as their caregiver.

Many of the recommendations in this report serve and support families and simplify 

their lives. Prime examples are the Recovery Coordinator and increased availability of 

online resources that will be helpful to family caregivers. 

Action Steps

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The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

DoD and VA should explore the applicability for service members and their families 

of innovative private-sector initiatives that have been developed and tested in the past 

few years.

DoD should establish a standby plan for family support of injured service members, 

drawing on the experiences and model programs developed during this confl ict, to 

enable a quicker program ramp-up in any future large deployments.

Congress should make combat-injured service members eligible for the TRICARE 

respite care and aide and personal attendant benefi ts currently provided in the 

Extended Care Health Option program.

• • •

DoD and VA should provide families of service members who require long-term 

personal care with appropriate training and counseling to support them in their new 

caregiving roles. 

• • •

Congress should amend the Family Medical Leave Act to allow up to six months’ 

leave for a family member of a service member who has a combat-related injury and 

meets the other eligibility requirements in the law.

Rapidly Transfer Patient Information Between DoD and VA 

Recommendation: DoD and VA must move quickly to get clinical and benefi t 

data to users. In addition, DoD and VA should jointly develop an interactive 

“My eBenefi ts” website that provides a single information source for service 

members. 

Goals: Support a patient-centered system of care and effi cient practices.

Three Strong Caveats:

Congress and the Departments should recognize that information technology is 

not the “silver bullet” that will solve various quality, coordination, and effi ciency 

problems within the Departments’ medical and benefi ts systems. 

Underlying organizational problems must be fi xed fi rst, or information technology merely perpetuates them. 

Every effort must be made not to make systems unnecessarily complex, diffi cult to 

use, or redundant.

DoD and VA should make information about benefi ts and services available online, 

via a password-protected site (which we call “My eBenefi ts), in which service members 

and veterans can securely enter personal information. Based on this profi le, they 

would receive tailored information about relevant programs and benefi ts in both the 

public and private sectors.

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Action Steps

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The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

Within 12 months, in order to implement our Recovery Plan recommendation, DoD 

and VA must make patient data much more accessible—to begin with, in viewable 

form. All essential health, administrative, and benefi ts data must be immediately 

viewable by any clinician, allied health professional, or program administrator who 

needs it.

• • •

DoD and VA should continue the work under way at present to create a fully interoperable information system that will meet the long-term administrative and clinical 

needs of all military personnel over time.

• • •

DoD and VA must develop a plan for a user-friendly, tailored, and specifi c services 

and benefi ts portal for service members, veterans, and family members.

Strongly Support Walter Reed By Recruiting and Retaining

First-Rate Professionals Through 2011

Recommendation: Until the day it closes, Walter Reed must have the authority 

and responsibility to recruit and retain fi rst-rate professionals to deliver fi rst-rate 

care. Walter Reed Army Medical Center has a distinguished history and, with 

one in fi ve injured service members going directly to Walter Reed, continues to 

play a unique and vital role in providing care for America’s military. 

Goals: Assure that this major military medical center has professional and 

administrative staff necessary for state-of-the art medical care and scientifi c 

research through 2011.

Approximately one in fi ve injured service members go directly to Walter Reed, and 

more than 700 outpatients remain on the campus. 

Not only is it active today, but Walter Reed is scheduled to continue operation for at 

least four more years and must have the resources—professional and otherwise—to 

continue its historic role as a vital tertiary care and research center until the day it 

actually ceases operation.10

Action Steps

10 The decision to close Walter Reed came from the Department of Defense’s Base Realignment and 

Closure Commission (BRAC).

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The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

DoD must assure that Walter Reed has the resources it needs to maintain a standard 

of excellence in both inpatient and outpatient care.

• • •

DoD must implement tailored incentive packages to encourage civilian health care 

and administrative professionals to continue working there and to enable recruitment of new professionals, as needed.

A SYSTEM THAT SERVES

America has recognized the nation’s responsibility to care for injured soldiers ever 

since the early days of the War of Independence. More than 80 years later, near the 

end of the Civil War, Abraham Lincoln reaffi rmed that responsibility, admonishing 

the country to strive “to care for him who shall have borne the battle . . .” And, today, 

a huge and generally well regarded infrastructure has developed to sustain this commitment to our service members, veterans, and their families:

68 military treatment facilities 

154 military outpatient clinics

153 VA medical centers and

875 VA outpatient clinics. 

The nation also has developed non-medical programs for those injured during 

military service—not just disability compensation, but a wide array of supporting 

programs and benefi ts to help veterans and their families with recovery, transition to 

civilian life, education, and employment. Federal and state government programs are 

augmented by more than a thousand private-sector, community, volunteer, and faithbased initiatives that help injured service members and their families meet housing, 

transportation, and short-term fi nancial needs.

In 1956, the President’s Commission on Veterans’ Pensions, chaired by General of the 

Army (Ret.) Omar N. Bradley, concluded that there was “no clear national philosophy 

of veterans’ benefi ts.” That Commission developed a philosophy and guiding principles that remain relevant today. Not only did it assert a national responsibility “to 

do justice by those who were injured or disabled as a consequence of their military 

service,” but it also laid out a rationale for disability programs. Despite the Bradley 

Commission’s urging, neither Congress nor the Executive Branch has established 

clear overall objectives, such as those we recommend, for the constellation of veterans’ 

benefi ts the government offers. To this day, lack of a specifi c objective hinders the 

design, coordination, and evaluation of both individual veterans’ programs and the 

disability system as a whole. We recommend that these objectives should include recognition of the degree of disability, effects on quality of life, and earnings loss, and 

should facilitate participation in education, training, and employment programs to 

maximize life recovery.

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Action Steps

“The rehabilitation of disabled veterans and their 

reintegration into useful 

economic and social life 

should be our primary 

objective.”

—The Bradley

Commission, 1956
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The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

A Continuum of Care

The acute medical care that injured service members receive in the fi eld and in military 

hospitals back home is consistently and demonstrably of high quality. Clearly, today’s 

skilled medical corps and our military surgeons, physicians, and critical care teams 

save many lives. But DoD never intended to provide the long-term, rehabilitative programming now understood as necessary to optimal recovery. Rehabilitation and longterm care were a VA specialty. What is needed now is to improve the continuity and 

integration of medical and rehabilitation programming across the two Departments. 

Injured service members receive clinical care in many settings. It may be provided in 

military hospital inpatient units and outpatient departments, in the private practices 

of physicians and mental health care professionals, and in various physical rehabilitation programs connected with the hospital, the nearby community, the VA, or back 

home in their own communities. They also are eligible for numerous education, 

training, and employment programs that, although not clinical, depend for their effectiveness on service members’ level of physical and mental functioning. 

We recommend that DoD and VA medical care, support programs, vocational rehabilitation programs, and disability benefi ts for seriously injured service members be 

integrated under a comprehensive, patient-centered Recovery Plan that sets goals for 

recovery and facilitates transitions across settings and programs. Development of the 

plan should begin as soon as possible during the acute care 

phase of a service member’s recovery. 

The initial plan should include a complete clinical evaluation

by a team that includes physicians, nurses, mental health 

and allied health professionals, rehabilitation and vocational rehabilitation specialists, and social workers, as appropriate. The plan should take into account the goals of the 

patient with respect to future activities—including return to 

military duty, community, education, or employment—and 

it should be adjusted periodically, as appropriate. Because 

families are so important to the recovery of individuals with 

serious injuries, Recovery Plans should, insofar as possible, 

address family needs, too. In short, the Recovery Plan should 

be designed to move seriously injured service members effi ciently through treatment and rehabilitation. 

Well-trained and highly skilled Recovery Coordinators should oversee the implementation of service members’ Recovery Plans. Recovery Coordinators would work with existing case managers involved in discrete aspects of care, engage family members, arrange 

for support programs, make sure care is timely, and advocate for service members across 

systems. Working across departments, benefi ts programs, and both public and private 

sectors is enormously diffi cult and will require energy and tenacity. 

The majority (68 to 80 

percent) of individuals in 

our survey are “very” or 

“somewhat” satisfi ed with 

inpatient care. 

Our Vision:

A care system that continually strives to offer 

injured service members 

the highest standard of 

quality. 

A Patient-Centered Recovery Plan Should:

• Identify patient goals for: post-acute, outpatient, 

and rehabilitation care; and return to military 

duty, home community, or into education, training, and employment programs

• Specify all resources—clinical and other—needed 

to meet these goals 

• Specify milestones and estimates of time for 

recovery phases

• Assess where these clinical and rehabilitative 

needs can be most appropriately addressed

• Evaluate and provide for family needs

• Monitor for timeliness of receipt of care and 

patient progress
14

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

To make this system work, Recovery Coordinators need considerable authority and 

to be paid accordingly. Recruitment, training, and oversight by a new unit of the 

U.S. Public Health Service’s Commissioned Corps, in the Department of Health and 

Human Services, should be strongly considered. 

Recovery Coordinators would manage many more issues than case managers currently do in the DoD and VA systems. Now, patients typically have several case mana gers, each concerned with a different component of their care. We heard reports of 

high turnover among case managers and that some are not adequately trained. (In 

particular, some families of patients with traumatic brain injury and post-traumatic 

stress disorder believed that case managers did not well understand these conditions, 

the issues they present, and how they should be managed.) 

The Recovery Plan concept also requires cross-Departmental health information exchange that does not exist at present. Every health care and rehabilitation professional 

working with injured service members, as well as the administrative personnel involved with various benefi ts programs, would need access to relevant information 

regarding those individuals—not just “read-only” access, but also the ability to add 

information to the record.

Serious Injuries of the Afghanistan and Iraq Confl icts 

Tremendous strides in military medicine have led to markedly reduced mortality rates 

among U.S. service members—many of whom require lengthy hospital stays and extensive rehabilitation. Those with serious burns, for example, need several years of 

treatment in order to reach their maximum functioning. State-of-the-art burn care, 

such as that provided at Brooke Army Medical Center in San Antonio, often requires 

a year in the hospital, multiple rounds of surgical reconstruction, and two to four 

years of rehabilitation. Likewise, amputees require numerous fi ttings and trials of 

different artifi cial limbs. Some of the world’s most advanced prosthetic technologies 

are available at Walter Reed Army Medical Center. It also has the highly trained staff 

needed to fi t prostheses properly and help service members learn how to use them. 

For service members with these types of injuries, military treatment facilities are often 

their best choice.

Our military personnel in Iraq and Afghanistan are constantly at risk for car bombs, 

suicide bombers, and improvised explosive devices. They face diffi cult military operations, largely carried out in crowded urban environments, where civilians are 

active players and anyone—young or old—might be a suicide bomber. The stress is 

enormous. These battlefi eld conditions have highlighted two particularly challenging 

consequences of combat:

post-traumatic stress disorder (PTSD)—an anxiety disorder that develops in 

reaction to traumatic events—and 

■

“We are now training our 

seventh case manager.”

—family member,

Washington, DC

Our Vision:

A system in which families 

of seriously injured service members would have 

a primary point of contact 

to coordinate their care.

“We’re thinking about 

what this person will be 

like fi ve or ten years from 

now.”

—Chief, Brooke

Army Medical Center Burn 

Center 

Our Vision:

A patient-centered,

integrated care model that 

addresses the needs of 

the “whole patient.” 
15

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

traumatic brain injury (TBI)—a physical injury to the brain, often caused by 

exposure to one or more explosions, or other blows to the head. Injuries can be 

penetrating or closed, and the latter can be mild, moderate, or severe. 

A sizeable fraction of service members returning from Iraq and Afghanistan suffer 

from PTSD. Best estimates are that PTSD of varying degrees of severity affects 12 to 20 

percent of returnees from Iraq and 6 to 11 percent of returnees from Afghanistan. To 

date, 52,375 returnees have been seen in the VA for PTSD symptoms. Severe and penetrating head injuries are readily identifi ed, but cases of mild-to-moderate TBI can 

be more diffi cult to identify and their incidence harder to determine. A recent report 

indicated that when some 35,000 returnees believed to be healthy received a screening 

test, ten to 20 percent had apparently experienced a mild TBI during deployment. 

Many have both PTSD and TBI. Multiple deployments increase the risk. 

In an attempt to increase resilience and prevent PTSD, the military has developed new 

ways of training service members, and it has deployed mental health personnel with 

battle units in order to de-stigmatize mental health issues and facilitate early identifi cation of individuals with problems. Post-deployment, the military services try to 

identify individuals with PTSD and mitigate its effects. For example, post-deployment 

health assessments include mental health screening questions, and a reassessment 

process has been added, in order to identify cases that develop over time. However, 

we heard many reports that service members, believing that revealing psychological 

symptoms will delay their return home or jeopardize their careers, do not report them. 

By contrast, some service members will report PTSD symptoms to “game the system,” 

in order to avoid deployment or to receive disability benefi ts.

For both PTSD and TBI, prompt, correct treatment improves the chances for recovery. DoD is working to increase its medical professionals’ expertise in treating TBI, 

although clinical guidelines are needed for rehabilitation. Because the VA recognized 

that injury to the brain often occurs at the same time as other, more visible injuries 

and should be treated as aggressively, it designated four Polytrauma Rehabilitation 

Centers11 to tackle such multidimensional care. These Centers, although within the VA 

system, accept patients from the active-duty military. 

The VA has a long history of treating combat-related PTSD. Yet, clinicians are not 

necessarily informed about state-of-the-art treatment or available resources, public 

and private. Other mental health-related problems, including substance abuse, depression, suicide, and family disruption, often co-occur with PTSD and likewise merit 

attention. The VA recently announced a major expansion of mental health services, to 

increase their availability system-wide.

■

56 percent of active duty, 

60 percent of reserve 

component, and 76 percent of retired/separated 

service members say they 

have reported mental 

health symptoms to a 

health care provider.

“The biggest thing you 

could do is to beat down 

the stigma of being 

treated.”

—PTSD patient, Brooke 

Army Medical Center

Our Vision:

A military that focuses 

on strengthening warrior 

resilience and preventing PTSD, TBI, and their 

consequences and gives 

mental health and physical 

health the same importance. 

11 These Centers are at the James A. Haley Veterans Affairs Medical Center, Tampa, Fla.; Minneapolis 

Veterans Affairs Medical Center; Veterans Affairs Palo Alto Health Care System, Calif.; and Hunter 

Holmes McGuire Veterans Affairs Medical Center, Richmond, Va.
16

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

Simplifying the Path to Recovery

Theatre System 

of Care Right Care, Right Time, Right Place

• Walter Reed

• National Naval Medical Center

• Brooke AMC

• One of 77 other DoD or VA Facilities

• Private Facilities

Recovery Coordinator Introduced

Patient and Family-Centered Recovery

Plan Developed

Medical Board DoD

Single Comprehensive

Physical Examination

Recovery Care Coordinator

Implements Recovery Plan

Information Technology

DoD and VA Implement Interoperable System
17

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

Fit

Not Fit

Return to Duty

Discharged 

from Duty

Disability Rating (VA)

Using DoD Physical 

Evaluation VA 

Determines the

Disability

Civilian Life

• Education Training

• Employment Services

• Family Support
18

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

The military’s laudable efforts to prevent mental health problems and identify 

symp toms more quickly have severely stretched its already thin mental health program 

staff. Multiple deployments of uniformed mental health professionals have increased 

the rate at which they are leaving military service. Hospitals located in geographically 

isolated or less “desirable” areas report great diffi culty recruiting civilian staff. 

However, for PTSD, the larger problem may be cultural, not clinical. Many service 

members believe it unmilitary or a sign of weakness to betray the symptoms of psychological distress. As recently as last month, a DoD Mental Health Task Force concluded that the stigma attached to mental health problems remains pervasive.

Concentrating specialized care—like burn and amputee care—at specifi c centers 

makes sense not only for reasons of economy, but, more important, for quality of 

care. A hospital needs enough patients in a specifi c category in order to attract specialized staff, keep their skills sharp, and maximize patient outcomes. By contrast, 

service members with relatively common conditions, like mild traumatic brain injury 

and post-traumatic stress disorder, should fi nd high-quality care regardless of where 

they are treated. 

Medical Rehabilitation

Rehabilitation of injured service members is geared to restoring patients to their 

highest possible level of functioning. It takes place in a wide variety of inpatient and 

outpatient facilities, in DoD, VA, and community settings, and is provided by an 

array of health care specialties, depending on the nature of an individual’s injuries. 

As noted, DoD’s specialized centers provide initial care for the most seriously injured. 

This approach enables DoD to offer the most expert care, but it can confl ict with the 

desires of service members—especially those from the reserve components—to be 

cared for closer to home and to reduce the burden on their families. 

We observed that the supply and demand for medical rehabilitation care are not well 

balanced. Some facilities—like the VA’s Polytrauma Rehabilitation Centers—are not 

being optimally used, whereas others—like Walter Reed’s outpatient units—are over 

capacity. An overall, coordinated plan for use of existing DoD and VA facilities is 

needed, with attention to where private sector facilities may fi ll gaps. Because seriously 

injured service members’ rehabilitation needs can be very long-term, their individual 

Recovery Plans should consider whether these needs can be met close to home. 

A SYSTEM THAT SUPPORTS

More than 3,000 service members have been seriously injured during operations in 

Iraq and Afghanistan. In virtually every case, a wife, husband, parent, brother, or sister 

67 to 70 percent of active 

duty and reserve component members are “very” 

or “somewhat” satisfi ed 

with rehabilita tive care, as 

are 60 per cent of those 

retired or separated.

Our Vision:

A system that lets in jured 

service members and their 

families concentrate on 

healing, not dealing with 

bureaucracy.
19

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

has received the heart-stopping telephone call telling them that their loved one is sick 

or injured, halfway around the world. While recovery from most injuries is relatively 

quick, and service members soon return to their units, one telephone call has changed 

the lives of many service members’ families forever.

The most seriously injured service members and their families are embarking on a long 

journey together, one that may require family to temporarily relocate to a different 

part of the country to be near the facility where their loved one is being treated. Relocation may require them to give up the lives they know—jobs, school, homes—and 

live for an uncertain period far from their existing network of friends and family. 

Family support is critical to patients’ successful rehabilitation. Especially in a prolonged 

recovery, it is family members who make therapy appointments and ensure they are 

kept, drive the service member to these appointments, pick up medications and make 

sure they are taken, provide a wide range of personal care, become the impassioned 

advocates, take care of the kids, pay the bills and negotiate with the bene fi ts offi ces, 

fi nd suitable housing for a family that includes a person with a disability, provide 

emotional support, and, in short, fi nd they have a full-time job—or more—for which 

they never prepared. When family members give up jobs to become caregivers, income 

can drop precipitously. 

Military families are changing. The majority of spouses work. The Iraq and Afghanistan 

confl icts rely more heavily than in the past on the reserve components. The husbands, 

wives, and parents of these troops are distributed across many communities, not concentrated in and around the large installations where military treatment facilities and 

family support programs are located. 

Temporary Housing

When family members receive the call telling them that their service member has 

been injured, their fi rst thought is “How fast can I get there?” Only after they arrive 

at the medical treatment facility do they begin to think through all of the day-to-day 

logistics of being at their loved one’s bedside. 

One of the fi rst issues to resolve is housing. Every major military medical center and 

a number of VA medical centers have Fisher Houses on their grounds—residential 

facilities built with private money, then donated to and operated by the government. 

Fisher Houses are available free of charge to family members of hospitalized service 

members and those receiving intensive outpatient care. The nation’s 38 Fisher Houses 

serve approximately 8,500 families a year, with more houses slated for construction. 

When the number of injured service members with long recuperation times has occasionally stretched the capacity of temporary lodging facilities at some military installations, additional housing is arranged on base or in the community. 

Family or close friends 

stayed to assist recovery 

of almost 66 percent of 

active duty and 54 percent of reserve component service members. 

“Even though things went 

relatively smooth for us, 

it’s a lot. We basically do 

not have a life any more.”

—father of a severely 

wounded soldier

Our Vision:

A restructured, more

fl exible system of benefi ts for addressing the 

multiple needs of families—

especially those who must 

take on a major, long-term 

caregiving role.

50 percent of active duty, 

24 percent of reserve 

component, and 26 percent of retired/separated 

service members say their 

family members staying 

with them were provided 

with comfortable, convenient housing.

Our Vision: 

A system better integrated 

with private-sector care 

facilities for service members who want care closer 

to home.
20

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

Support Programs

Support programs for injured service members and their families help in meeting a 

wide variety of needs: temporary housing, transportation, fi nancial assistance, meals, 

counseling, and information about benefi ts. 

Family Service Centers exist on every military installation. These Centers provide 

referrals to a wide range of programs—from child care to employment assistance. 

In partnership with community-based organizations, the Centers provide families a 

“safety net” during long hospital stays. Ironically, the sheer number of overlapping 

support programs, public and private, and their varying requirements and benefi ts 

can at times be overwhelming. 

Having a coordinated Recovery Plan and the Recovery Coordinator as a single point 

of contact may make it easier for families to fi gure out which programs are most appropriate for them, at what point during recovery. DoD, VA, and private entities have 

made an effort to put information about their resources online.12 Families comfortable 

with accessing and acting upon Web-based information may fi nd these compendiums 

a promising start. In the long run, online resources will be of greatest help if they can 

provide information specifi c to service members’ home communities and tailored to 

their specifi c questions and needs. 

Employment, Education, and Training

Employment is the dominant concern of most service members reentering civilian 

life. VA vocational rehabilitation programs—such as vocational assessment, education, 

retraining, development of alternative employment plans, identifi cation of assistive 

technologies, and assistance with job-seeking skills—focus on helping veterans with 

disabilities enter a different job or career. For severely disabled veterans for whom 

paid employment is not an option, these programs focus on enhancing the ability to 

live more independently in their homes and communities. Further, an array of federal, 

state, and private-sector programs and employer incentives promotes employment 

opportunities for veterans in general and disabled veterans in particular. Education 

and training assistance also is widely available.

Participation in vocational rehabilitation programs can signifi cantly increase employment and quality of life for people with disabilities. Unfortunately, the VA does 

not—and should—routinely track vocational rehabilitation participants over time to 

evaluate program outcomes and identify factors associated with success. As a result, 

it is impossible to determine which programs work best. Research does show that 

“Returnees tell me ‘It’s like 

drinking out of a fi re hose’ 

when all these programs 

are described to them.”

—transition coordinator,

Ft. Bragg

Our Vision:

Simple, user-friendly ways 

for service members and 

families to learn about 

benefi ts, when and where 

they are needed. 

12 For example, the military’s online resource and telephone hotline, Military OneSource; the DoD’s 

“America Supports You,” which compiles information on many charitable organizations; and an 

Army website currently under development, MyArmyBenefi ts.mil.

21 percent of demobilized 

reserve component and

31 percent of retired/

separated service members are enrolled in an 

educational program leading to a degree.

33 and 36 percent of 

these groups are “very” or 

“somewhat” satisfi ed with 

VA employment services.

73 and 44 percent of 

these groups are working 

at a paid job.
21

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

vocational rehabilitation and employment programs should be provided as early as 

possible after the onset of the disability, in order to have the greatest impact on the 

service member’s likelihood of returning to work; likewise, the sooner an injured 

person can return to regular activities, the more successful the transition is. 

Veterans who qualify for and complete VA’s Vocational Rehabilitation and Employment 

program achieve good results in the short run. However, of the 65,000 veterans who 

apply for the program each year, only half qualify for it; of these, less than 40 percent 

complete either the education or independent living tracks. Including a vocational 

rehabilitation component in the Recovery Plan should increase the number of participants and program completion rates. Financial incentives also could increase 

program retention. 

A SIMPLER SYSTEM

Many aspects of the DoD and VA medical care, support program, and disability 

systems have become tremendously complex over the years. As various needs have 

arisen, the Departments have undertaken initiatives to augment or clarify existing 

policy and programs. Often these initiatives are—or were—good solutions for limited 

problems, but ripple through the entire system in undesirable ways. Unplanned and 

uncoordinated programmatic evolution creates redundancies, while gaps are unfi lled. 

It adds layers of complicated policies and rules. Then, because different individuals, 

offi ces, and military service branches interpret rules differently, the result can be real 

or perceived inequities. 

The patchwork of programs, rules, and regulations affecting injured service members 

is mirrored in the complicated, uncoordinated information technology systems that 

support these activities. Efforts to streamline IT have to be built on a more coherent underlying structure. As stated earlier in this report, although IT systems are important, 

they cannot by themselves solve all the information fl ow and quality problems the 

Departments face. They are a means to an end, not the end itself. 

Consequences for Families of a Complex System

Families thrust into stressful new situations by a loved one’s serious injury understandably are confused and anxious. They cannot be expected to know about care or 

benefi ts available, and they may feel incapable of determining the best course. Our 

recommendation for a Recovery Coordinator should ease this burden. 

“We cannot begin piecing 

our lives back together or 

caring for ourselves until 

our loved ones are cared 

for fi rst.”

—wife of a severely

injured soldier

Our Vision: 

An easier return to normal 

life for service members 

and families.
22

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

Complexity in Disability Determination & Compensation Systems

The DoD’s disability determination system focuses on whether service members 

are fi t or unfi t to perform their primary military duties. DoD’s disability ratings determine how much service members will receive in military disability compensation 

and whether this compensation is lifelong or one-time-only. It determines whether 

they and their families receive lifetime TRICARE medical benefi ts or coverage for only 

180 days after discharge. Similarly, the VA’s disability ratings determine the amount 

of VA compensation veterans receive and their eligibility for an array of vocational 

rehabilitation and other benefi ts that help them recover. 

The DoD and VA each have their own complicated disability rating processes that take 

several months to complete. If a service member appeals the rating decision, the case 

may not be resolved for several years (for the VA, an average of 657 days). A positive step 

is a joint VA/DoD initiative—the Benefi ts Delivery at Discharge Program—intended 

to provide medically separating or retiring service members a smoother transition 

into the VA health care system and prompt receipt of VA disability compensation.

Research confi rms that there are indeed differences in ratings, depending on which 

military service determines the DoD rating and which regional offi ce determines the 

VA rating. Disability ratings assigned by DoD are scored differently and are usually 

lower than those assigned by the VA. 

Despite their disability systems’ different intents, processes, and outcomes, DoD and 

VA use the same outdated rating schedule to establish a service member’s percent 

disability.13 The rating schedule has not been completely revised since 1945, although 

portions have been updated over the past 20 years. The schedule is problematic for 

service members injured in Iraq and Afghanistan, because of:

the number of injuries that are new or for which diagnostic criteria are changing 

rapidly, such as traumatic brain injury

a new appreciation of the disabling impact of other conditions, such as posttraumatic stress disorder and

advances in medical care and rehabilitation that change the prognosis for certain 

conditions, such as serious burns and amputations.

Future confl icts may produce their own “signature conditions,” and at the same time 

clinical treatment continues to advance. This dynamic situation requires that the VA 

review and adjust the disability rating system at frequent and regular intervals. 

■

■

■

Less than half of service 

members understand the 

DoD’s disability evaluation 

process. 

Just 42 percent of retired/separated service 

members who had fi led 

VA claims understand that 

process.

13 Institute of Medicine. A 21st Century System for Evaluating Veterans for Disability Benefi ts. Washington, DC: National Academies Press, 2007.
23

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

As long as injured service members remain in the military, they receive their military 

pay. Once their disability rating is established and they leave the military, they receive 

disability compensation and may be eligible for health care and other programs. For 

most injured service members, military pay is more than their disability pay will be. 

Service members may therefore believe it is to their advantage to stay in a “pending” 

category for as long as possible, continue to receive their military pay, and not face the 

uncertainties of the disability rating system. 

Once they do leave the military, most veterans with disabilities will end up with the 

higher of either DoD or VA disability compensation pay. Since 2004, individuals with 

more than 20 years of military service who have a 50 percent or greater VA disability 

rating for combat-related injuries may receive payment from both systems.14

In DoD, the objective of the disability payment system is not well-defi ned and, once 

again, it is governed by a complex set of rules and procedures. In part, DoD disability 

payments appear intended to compensate injured service members for the premature 

end to their military careers—in effect, a “retirement benefi t” for those unable to reach 

actual retirement. The VA’s system, as noted above, is intended to replace lost earnings 

capacity. A 21st century view acknowledges a disability’s effects not just on earnings, 

but also on social, family, and community participation. The current system touches 

on these issues indirectly, not by explicit policy. 

As long ago as the Bradley Commission, we were warned about the debilitating potential of policy aimed merely at income replacement. Such a focus reduces recipients’ 

incentives to work, to obtain education and training—in short, to get on with life. In 

line with our belief that the goal of the disability system should be to return disabled 

veterans to normal activities, insofar as possible, and as quickly as possible, strong incentives to encourage education, training, and employment are urgently needed. 

14 Receiving both benefi ts is called “concurrent receipt.” Almost all other government programs have 

rules requiring that people eligible for the same type of benefi t from different programs to choose one or 

the other; they cannot receive both.
24

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

Our recommendation regarding the disability rating and compensation system for 

injured service members would accomplish the following:

DoD and VA should create a single, comprehensive, standardized medical examination that DoD administers. It would serve DoD’s purpose of determining 

fi tness and VA’s of determining initial disability level.

The service branches would remain in charge of determining whether an injured 

service member is fi t for duty

If not, he or she would be separated from the military and receive a lifetime 

annuity payment, based on military rank and years of military service 

Service members’ disability rating would be determined by the VA and continued 

eligibility for payments and benefi ts reassessed periodically (at least every three 

years)

All disability-related payments and benefi ts for veterans would be obtained 

through the VA. Veterans would be eligible for compensation that would refl ect 

three components, as shown in the accompanying chart: 

 a. transition payments after they leave military service—either: 

 • short-term, to help with expenses related to their return to the community 

or 

 • longer-term, to cover family living expenses while they participate in education and training programs or prepare for independent living 

■

■

■

■

■

A STREAMLINED DOD/VA RETIREMENT & 

DISABILITY COMPENSATION SYSTEM

At any point in time, disabled veterans would receive three types of payments:

 Point of Discharge Point of Retirement

 Throughout the “working years,” veterans would receive . . . After retirement . . .

 1. DoD’s Military

 Annuity Payments $ amount based on rank and years of military service

 2. VA Quality of

 Life Disability

 Payments $ amount based on impacts on quality of life

 3. VA Transition payments* 4. Followed by . . . 5. Followed by . . . 

 EITHER Long-term living expense Earnings loss payments Social Security

 support while in school/VRE when employment begins** 

 OR 3 months Earnings loss payments when employment begins** Social Security 

 

*To help veterans become established and move into work or, if unable to work, to enable independent living.

**These payments would contribute to veterans’ earnings for Social Security eligibility; the amount would be recalculated periodically as veterans’ 
25

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

 b. earnings-loss payments to make up for any reduced earning capacity and

 c. quality-of-life payments to compensate for permanent losses of various kinds.

Service members found unfi t because of their combat-related injuries should 

receive lifetime, comprehensive health care coverage and pharmacy benefi ts for 

themselves and their dependents through DoD’s TRICARE program. 

This recommendation gets the DoD completely out of the disability business. It eliminates 

the confusing, parallel systems of ratings and compensation and the notion of “concurrent receipt.” The objective of the DoD system would be to maintain a fi t force and 

acknowledge years of military service, and the objective of the VA system would be to 

compensate for disability.

Information Technology (IT)

The design of information systems must be driven by the needs of an organization for 

effective management, operations, and support programs. The current information 

technology (IT) systems within DoD and VA are fragmented and compartmentalized. 

Information is collected and stored in isolated yet overlapping data systems that are 

rarely integrated. Some parts of the system collect more information than needed; 

others duplicate information available in other parts of the system, increasing opportunities for errors and inconsistencies. We were told that users of these complex data 

systems often do not know what data are already available to them. 

The DoD and VA are working to facilitate the exchange of medical information and 

the sharing of personnel and disability information. At present, they do not fully 

integrate health care data with benefi t information. Understanding organizational 

needs and simplifying the processes are the fi rst priority. Meanwhile, congressional or 

departmental reform efforts should resist imposing new requirements that may result 

in duplicative or uncoordinated electronic systems and, instead, should encourage the 

streamlining of today’s systems and facilitate communication across them.

With our proposed comprehensive Recovery Plan, patient records would need to be 

electronically available to the Recovery Coordinator, health care professionals, and 

program staff across the continuum—from acute care, to rehabilitation, to long-term 

support, education, and employment programs, if needed. The system must be secure 

and designed so that various professionals have access to the information germane to 

their work. 

■
26

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

Drawing information from these systems, an interactive web portal, such as the prototype “My eBenefi ts” page shown on the next page, could provide tailored information to each service member and veteran, specifi c to their situation, and enable 

them to make appointments, do fi nancial planning, maintain confi dential personal 

health records, and apply for various benefi ts programs. Today, in order to fi nd such 

information, armed service members and veterans must navigate a disparate, confusing, and cumbersome array of websites. First-rate content exists online for service 

members and their families; however, the presentation and organization of this information simply have not evolved to meet the needs and expectations of the next 

generation of service members. 

There is a timely and unmistakable need for the VA and DoD to work together to 

create a single, one-stop “information shop.” As we envision it, a site such as “My

eBenefi ts” would be a consumer-friendly, interactive, evolving, fully customizable and 

personalized information portal. It would host almost every type of data important 

to a patient’s Recovery Plan. It also would include tailored, up-to-date information 

on federal and state benefi ts, inpatient and outpatient care, disability evaluation and 

application status, local and national resources from veterans service organizations 

and community organizations, area employment opportunities, doctors’ names and 

contact information, news, and the ability to connect easily with other armed service 

members and veterans.
27

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007
28

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

IMPLEMENTING OUR RECOMMENDATIONS

The following chart summarizes the locus of responsibility for implementing the 

action steps that support our recommendations.

Recommendation Action Steps Congress DoD VA

1. Implement comprehensive Recovery Plans

 • Develop integrated care teams X X

 • Create Recovery Plans X X

 • Develop corps of Recovery Coordinators (with Public Health Service) X X

2. Restructure disability and compensation systems

 • Clarify the objectives of DoD and VA disability programs X 

 • Create a single, comprehensive medical exam X X

 • Provide lifetime TRICARE benefi ts for combat-injured X 

 • Restructure VA disability payments X 

 • Determine appropriate length and amounts of transition payments X

 • Update and keep current the disability rating schedule X

 • Develop fl exibility within Vocational Rehabilitation and Education (VRE) program X

3. Improve care for people with post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI)

 • Enable all Iraq & Afghanistan veterans who need PTSD care to receive it from the VA X 

 • Address shortage in mental health professionals X 

 • Establish and expand networks of experts in PTSD and TBI X X

 • Expand training regarding PTSD and TBI X X

 • Develop or disseminate clinical practice guidelines X X

4. Strengthen support for families

 • Expand eligibility for TRICARE respite care and aide and attendant care X 

 • Expand caregiver training for families X X

 • Cover family members under the Family Medical Leave Act X

5. Transfer patient information across systems 

 • Make patient information available to all personnel who need it, initially in readable form X X

 • Continue efforts for fully interoperable information system X X

 • Develop a user-friendly single web portal for service members and veterans X X

6. Support Walter Reed until closure

 • Assure adequate resources X 

 • Strengthen recruitment and retention of needed administrative and clinical staff X 
29

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

APPENDIX

Bibliography

Major Past Reports by Commissions, Task Forces, and Committees

2007 (forthcoming) Institute of Medicine. PTSD Compensation and Military 

Service. Washington, DC: National Academies Press. 

Available at http://books.nap.edu/openbook.php?record_

id=11870&page=R1 

June 2007 Department of Defense Task Force on Mental Health. An 

Achievable Vision: Report of the Department of Defense Task 

Force on Mental Health. Available at: http://www.ha.osd.

mil/dhb/mhtf/MHTF-Report-Final.pdf

June 2007 Institute of Medicine. A 21st Century System for Evaluating 

Veterans for Disability Benefi ts. Washington, DC: National 

Academies Press. Available at http://books.nap.edu/catalog.

php?record_id=11885 

April 2007 President’s Task Force on Returning Global War on Terror 

Heroes. Task Force Report, Returning Global War on Terror 

Heroes. Available at: http://www1.va.gov/taskforce/

April 2007 Independent Review Group. Rehabilitative Care and 

Administrative Processes at Walter Reed Army Medical Center 

and National Naval Medical Center. Available at: http://

www.usuhs.mil/vpe/IRGReport.pdf

 (AKA the West and Marsh Commission)

March 2007 Military Health Treatment Record Interagency Task Force 

Report. . Available at: https://www.mpm.osd.mil/owa/jrio/

pkg_jrio.page?id=HTR&wgsid=

March 2004 VA Vocational Rehabilitation and Employment Task Force. 

Report to the Secretary of Veterans Affairs: The Vocational 

Rehabilitation and Employment Program for the 21st Century 

Veteran. The chair’s testimony regarding this report is 

available at http://www.va.gov/OCA/testimony/hvac/

040401DH.asp. 
30

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

May 2003 President’s Task Force to Improve Health Care Delivery for 

Our Nation’s Veterans. Available at: http://veterans.senate.

gov/documents/ihcdfi nal.pdf

 (AKA the Wilensky Commission)

1999 Congressional Commission on Servicemembers and 

Veterans’ Transition Assistance. Report of the Congressional 

Commission on Servicemembers and Veterans Transition

Assistance. Available at: http://www.vetbiz.gov/library/

Transition%20Commission%20Report.pdf

 (AKA the Dole Commission; AKA the Transition

Commission)

1996 Presidential Advisory Committee on Gulf War Veterans’ 

Illnesses. Final Report. Available at: http://www.gulfl ink.osd.

mil/gwvi/ 

1956 The President’s Commission on Veterans’ Pensions. A 

Report to the President, Veterans’ Benefi ts in the United 

States. Available at: http://www.vetscommission.org/

Bradley_Report.pdf

 (AKA the Bradley Commission)

GAO Reports15

U.S., Government Accountability Offi ce. GAO-07-614 Veterans’ Benefi ts 

Administration: Progress made in Long-Term Effort to Replace Benefi ts Payment 

System, but Challenges Persist, April 2007

U.S., Government Accountability Offi ce. GAO-07-512T Veterans’ Disability Benefi ts: 

Claims Processing Challenges Persist, March 2007

U.S., Government Accountability Offi ce. GAO-07-589T DOD and VA Health Care: 

Challenges Encountered by Injured Servicemembers during Their Recovery, March 

2007

U.S., Government Accountability Offi ce. GAO-07-562T Veterans’ Disability Benefi ts: 

Processing of Claims Continues to Present Challenges, March 2007

15 GAO stood for the federal government’s “General Accounting Offi ce” until July 2004, at which point 

the agency’s name changed to Government Accountability Offi ce.
31

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

U.S., Government Accountability Offi ce. GAO-07-606T DOD and VA Health Care: 

Challenges Encountered by Injured Servicemembers during Their Recovery Process, 

March 2007

U.S., Government Accountability Offi ce. GAO-06-1085 DOD Civilian Personnel: 

Greater Oversight and Quality Assistance Needed to Ensure Force Health Protection 

and Surveillance for Those Deployed, September 2006

U.S., Government Accountability Offi ce. GAO-06-794R VA and DOD Health Care: 

Efforts to Provide Seamless Transition of Care for OEF & OIF Servicemembers & 

Veterans, June 2006

U.S., Government Accountability Offi ce. GAO-06-648 VA Health Care: Selected 

Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of 

Privileging Process Needs Improvement, May 2006

U.S., Government Accountability Offi ce. GAO-06-561T Military Disability 

Evaluation: Ensuring Consistent and Timely Outcomes for Reserve and Active Duty 

Service Members, April 2006

U.S., Government Accountability Offi ce. GAO-06-315 VA and DOD Health Care: 

Opportunities to Maximize Resource Sharing Remain, March 2006

U.S., Government Accountability Offi ce. GAO-06-362 Military Disability System: 

Improved Oversight Needed to Ensure Consistent and Timely Outcomes for Reserve 

and Active Duty Service Members, March 2006

U.S., Government Accountability Offi ce. GAO-06-105 Military Personnel: Top 

Management Attention Is Needed to Address Long-standing Problems with 

Determining Medical and Physical Fitness of the Reserve Force, October 2005

U.S., Government Accountability Offi ce. GAO-05-1051T Computer-Based Patient 

Records: VA and DOD Made Progress, but Much Work Remains To Fully Share 

Medical Information, September 2005

U.S., Government Accountability Offi ce. GAO-05-1052T VA and DOD Health Care: 

VA Has Policies and Outreach Efforts to Smooth Transition from DOD Health Care, 

but Sharing of Health Information Remains Limited, September 2005

U.S., Government Accountability Offi ce. GAO-05-626 Federal Disability Assistance 

- Wide Array of Program Needs to be Examined in Light of New 21st Century 

Challenges, June 2005
32

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

U.S., Government Accountability Offi ce. GAO-05-722T DOD and VA: Systematic 

Data Sharing Would Help Expedite Servicemembers’ Transition to VA Services, May 

2005

U.S., Government Accountability Offi ce. GAO-05-749T Veterans’ Disability Benefi ts: 

Claims Processing Problems Persist and Major Performance Improvements May Be 

Diffi cult, May 2005

U.S., Government Accountability Offi ce. GAO-05-655T VA Disability Benefi ts: 

Board of Veterans’ Appeals Has Made Improvements in Quality Assurance, but 

Challenges Remain for VA in Assuring Consistency, April 2005

U.S., Government Accountability Offi ce. GAO-05-310R DOD and VA Health Care: 

Incentives Program for Sharing Health Resources, February 2005

U.S., Government Accountability Offi ce. GAO-05-167 Vocational Rehabilitation: 

More VA and DOD Collaboration Needed to Expedite Services for Seriously Injured 

Servicemembers, January 2005

U.S., Government Accountability Offi ce. GAO-05-64 VA and Health Care: Efforts to 

Coordinate a Single Physical Exam Process for Servicemembers Leaving the Military, 

November 2004

U.S., Government Accountability Offi ce. GAO-04-1031 Military Personnel: DOD 

Needs to Address Long-term Reserve Force Availability & Related Mobilization and 

Demobilization Issues, September 2004

U.S., Government Accountability Offi ce. GAO-04-792 VA and DOD Health Care: 

Resource Sharing at Selected Sites, July 2004

U.S., General Accounting Offi ce. GAO-04-853 VA Vocational Rehabilitation 

and Employment Program: GAO Comments on Key Task Force Findings and 

Recommendations, June 2004

U.S., General Accounting Offi ce. GAO-04-687 Computer-Based Patient Records: VA 

and DOD Efforts to Exchange Health Data Could Benefi t from Improved Planning 

and Project Management, June 2004

U.S., General Accounting Offi ce. GAO-04-402T Computer-Based Patient Records: 

Sound Planning and Project Management Are Needed to Achieve a Two-Way 

Exchange of VA and DOD Health Data, March 2004

U.S., General Accounting Offi ce. GAO-04-495R DOD and VA Health Care: 

Incentives Program for Sharing Resources, February 2004
33

The President’s Commission on Care for America’s Returning Wounded Warriors / July 2007

U.S., General Accounting Offi ce. GAO-04-271T Computer-Based Patient Records: 

Short-Term Progress Made, but Much Work Remains to Achieve a Two-Way Data 

Exchange between VA and DOD Health Systems, November 2003

U.S., General Accounting Offi ce. GAO-04-158T Defense Health Care: DOD Needs to 

Improve Force Health Protection and Surveillance Processes, October 2003

U.S., General Accounting Offi ce. GAO-03-904R DOD and VA Health Care: Access 

for Dual Eligible Benefi ciaries, June 2003

U.S., General Accounting Offi ce. GAO-01-153 SSA Disability: Other Programs May 

Provide Lessons for Improving Return-to-Work Efforts, January 2001

Joint Reports

U.S., General Accounting Offi ce. GAO/HEHS-00-52 VA and Defense Health Care: 

Evolving Health Care Systems Require Rethinking of Resource Sharing Strategies, 

May 2000

U.S., General Accounting Offi ce. GAO/T-HEHS/AIMD-00-146 Veterans Benefi ts 

Administration: Problems and Challenges Facing Disability Claims Processing,

May 2000

U.S., General Accounting Offi ce. GAO/NSIAD-94-36 Reserve Forces: DOD Policies 

Do Not Ensure That Personnel Meet Medical and Physical Fitness Standards,

March 1994