**DRAFT**

DRAFT

Final Report Draft

July 24 edit

**The President’s Commission on Care**

**for America’s Returning Wounded Warriors**

**Final Report – July 2007**

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

LtCol Moore’s testimony demonstrates how the skills and resources of the U.S. military 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 efficient 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 Department of Defense (DoD), Department of Veterans Affairs (VA), and private-sector treatment facilities.  We have heard first-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, 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.  And, we have drawn on the extensive knowledge of our fellow Commissioners.  

The following chart compiles recent data from several sources, which don’t all use the exact same definitions 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.

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.

We believe our recommendations will produce a patient-centered system that fosters high-quality care, increases access to needed care and programs, promotes efficiency, 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)*—*even-handedly, 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 sacrifices of our young men and women fighting in Iraq and Afghanistan and the great debt we owe those injured and killed.  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 findings.  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.

Making the significant 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 battlefield 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. 

**Recommendations**

**Our recommendations will serve, support, and simplify health care and rehabilitation for injured service men and women, and return them as quickly as possible to their military duties or to civilian life.  To make these recommendations a reality, the President, Congress, and Departments of Defense (DoD) and Veterans Affairs (VA) should initiate the steps described in this report.**

**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 reaffirmed 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 benefits 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 faith-based initiatives that help injured service members and their families meet housing, transportation, and short-term financial needs.

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.

***A Continuum of Care***

into account the *goals of the patient* with respect to future activities—including return to military duty, community, education, or employment—and it would 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 efficiently 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, benefits programs, and both public and private sectors, is enormously difficult and will require energy and tenacity.  

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 benefits 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 Conflicts***

Our military personnel in Iraq and Afghanistan are constantly at risk for car bombs, suicide bombers, and improvised explosive devices. They face difficult 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 battlefield 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 

· 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 identified, but cases of mild-to-moderate TBI can be more difficult 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 identification 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 benefits.

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 Centers to tackle such multidimensional care.  These Centers, although within the VA system, accept patients from the active-duty military.  

***Medical Rehabilitation***

**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 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.

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

***Support Programs***

***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, identification 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.

**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 unfilled.  It adds layers of complicated policies and rules.  Then, because different individuals, offices, 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 flow and quality problems the Departments face.  They are a means to an end, not the end itself.  

***Consequences for Families of a Complex System***

***Complexity in Disability Determination & Compensation Systems***

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 Benefits 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 confirms that there are indeed differences in ratings, depending on which military service determines the DoD rating and which regional office 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.  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 post-traumatic stress disorder and

· advances in medical care and rehabilitation that change the prognosis for certain conditions, such as serious burns and amputations.

Future conflicts 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*. 

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.  

In DoD, the objective of the disability payment system is not well-defined 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 benefit” 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.  

**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

                               (                                                                                    (

*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’ condition or earnings change.

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 fitness and VA’s of determining initial disability level.

· The service branches would remain in charge of determining whether an injured service member is fit 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 benefits reassessed periodically (at least every three years)

· All disability-related payments and benefits for veterans would be obtained through the VA.  Veterans would be eligible for compensation that would reflect 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 

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 unfit because of their combat-related injuries should receive lifetime, comprehensive health care coverage and pharmacy benefits 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 fit 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 benefit information.  Understanding organizational needs and simplifying the processes are the first priority.  Meanwhile, congressional or departmental reform efforts should resist imposing new requirements that may result in duplicative or uncoordinated electronic systems and, instead, 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.  

Drawing information from these systems, an interactive web portal, such as the prototype “My eBenefits” page shown above, could provide tailored information to each service member and veteran, specific to their situation, and enable them to make appointments, do financial planning, maintain confidential personal health records, and apply for various benefits programs.  Today, in order to find 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 eBenefits” would be 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 benefits, in-patient and out-patient 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.

***A Gratifying Accomplishment . . .***

Sometimes Commission work can seem long-term or theoretical.  This time, we already have something good to report.  In the course of our work with veterans and their families, we learned that service members’ remaining enlistment bonuses were not being paid when they were injured and medically retired or separated from active duty.

The DoD was applying a rule that enlistees who leave the service early cannot receive their full enlistment bonus. We were confident that this rule was surely not intended to apply to service men and women whose combat-related injuries forced them to leave the military.

Upon learning about the problem, we contacted the Department of Defense and received assurances that these payments will be made to all applicable injured service members, retroactive to 2001.

**Implementing Our Recommendations**

The following chart summarizes the locus of responsibility for implementing the action steps that support our recommendations.

APPENDIX

**Bibliography**

**Major Past Reports by Commissions, Task Forces, and Committees**

**GAO Reports**

U.S., Government Accountability Office. GAO-07-614 Veterans' Benefits Administration: Progress made in Long-Term Effort to Replace Benefits Payment System, but Challenges Persist, April 2007

U.S., Government Accountability Office. GAO-07-512T Veterans' Disability Benefits: Claims Processing Challenges Persist, March 2007

U.S., Government Accountability Office. GAO-07-589T DOD and VA Health Care: Challenges Encountered by Injured Servicemembers during Their Recovery, March 2007

U.S., Government Accountability Office. GAO-07-562T Veterans' Disability Benefits:  Processing of Claims Continues to Present Challenges, March 2007

U.S., Government Accountability Office. GAO-07-606T DOD and VA Health Care:  Challenges Encountered by Injured Servicemembers during Their Recovery Process, March 2007

U.S., Government Accountability Office. 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 Office. 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 Office. 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 Office. GAO-06-561T Military Disability Evaluation:  Ensuring Consistent and Timely Outcomes for Reserve and Active Duty Service Members, April 2006

U.S., Government Accountability Office. GAO-06-315 VA and DOD Health Care:  Opportunities to Maximize Resource Sharing Remain, March 2006

U.S., Government Accountability Office. 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 Office.  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 Office. 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 Office. 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 Office.  GAO-05-626 Federal Disability Assistance - Wide Array of Program Needs to be Examined in Light of New 21st Century Challenges, June 2005

U.S., Government Accountability Office. GAO-05-722T DOD and VA:  Systematic Data Sharing Would Help Expedite Servicemembers' Transition to VA Services, May 2005

U.S., Government Accountability Office.  GAO-05-749T Veterans' Disability Benefits: Claims Processing Problems Persist and Major Performance Improvements May Be Difficult, May 2005

U.S., Government Accountability Office.  GAO-05-655T VA Disability Benefits:  Board of Veterans' Appeals Has Made Improvements in Quality Assurance, but Challenges Remain for VA in Assuring Consistency, April 2005

U.S., Government Accountability Office. GAO-05-310R DOD and VA Health Care:  Incentives Program for Sharing Health Resources, February 2005

U.S., Government Accountability Office. GAO-05-167 Vocational Rehabilitation: More VA and DOD Collaboration Needed to Expedite Services for Seriously Injured Servicemembers, January 2005

U.S., Government Accountability Office. 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 Office. 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 Office.  GAO-04-792 VA and DOD Health Care:  Resource Sharing at Selected Sites, July 2004

U.S., Government Accountability Office. GAO-04-853 VA Vocational Rehabilitation and Employment Program: GAO Comments on Key Task Force Findings and Recommendations, June 2004

U.S., General Accounting Office. GAO-04-687 Computer-Based Patient Records:  VA and DOD Efforts to Exchange Health Data Could Benefit from Improved Planning and Project Management, June 2004

U.S., General Accounting Office.  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 Office. GAO-04-495R DOD and VA Health Care:  Incentives Program for Sharing Resources, February 2004

U.S., General Accounting Office.  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 Office. GAO-04-158T Defense Health Care:  DOD Needs to Improve Force Health Protection and Surveillance Processes, October 2003

U.S., General Accounting Office. GAO-03-904R DOD and VA Health Care: Access for Dual Eligible Beneficiaries, June 2003

U.S., Government Accountability Office. GAO-01-153 SSA Disability: Other Programs May Provide Lessons for Improving Return-to-Work Efforts, January 2001

**Joint Reports**

U.S., General Accounting Office. 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 Office. GAO/T-HEHS/AIMD-00-146 Veterans Benefits Administration:  Problems and Challenges Facing Disability Claims Processing, May 2000

U.S., General Accounting Office. GAO/NSIAD-94-36 Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet Medical and Physical Fitness Standards, March 1994

� Testimony of Air Force LtCol Andrew E. Moore, MD, at the Commission’s public hearing in San Antonio, Texas, May 4, 2007.

� 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.

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

� 32 CFR Sec 199.2

� Americans with Disabilities Act, 1990.

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

� TSLGI (Traumatic Servicemembers’ Group Life Insurance) helps severely injured service members with a one-time payment, depending on their injury.

� 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.

� 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 beneficiaries worldwide.

� The decision to close Walter Reed came from the Department of Defense’s Base Realignment and Closure Commission (BRAC).

� 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.

� 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, MyArmyBenefits.mil.

� Institute of Medicine.  A 21st Century System for Evaluating Veterans for Disability Benefits.  Washington, DC: National Academies Press, 2007.

� Receiving both benefits is called “concurrent receipt.” Almost all other government programs have rules requiring that people eligible for the same type of benefit from different programs to choose one or the other; they cannot receive both.

� GAO stood for the federal government’s “General Accounting Office” until July 2004, at which point the agency’s name changed to Government Accountability Office.

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