Agent Orange is one of several herbicides sprayed by the U.S. government in Vietnam in the 1960s and 1970s as a defoliant. It contains tetrachlorodibenzo-para-dioxin (dioxin), a chemical that the Environmental Protection Agency and the Occupational Safety and Health Administration have classified as highly toxic and carcinogenic. DOD sprayed an estimated 11 million gallons of Agent Orange in Vietnam during the war. In the ensuing years, dioxin has been a focus of research and has been associated with a number of latent illnesses, including cancer and most recently diabetes, which have developed among people who have been exposed to the chemical. The use of Agent Orange has also spawned much litigation over the years, including suits against the manufacturers of the product and against the United States. Until 1991, when Congress passed the Agent Orange Act, military veterans who believed their illnesses were caused by dioxin exposure had limited success in obtaining medical benefits and other compensation. Previously, the VA had denied benefits to most veterans who claimed adverse health effects from the herbicide because poor records made it difficult for many of them to demonstrate where and when they had come into contact with the chemical, and because VA had not accepted proof of a direct link between certain illnesses and dioxin. The Agent Orange Act subsequently authorized awards on the presumption that any veteran who served in Vietnam and who develops certain diseases identified by the National Academy of Sciences’ Institute of Medicine (IOM) and accepted by VA had been exposed to Agent Orange. The act also gave VA responsibility for providing information to veterans about health conditions related to Agent Orange exposure and assistance in preparing their claims. Over time, the body of research on the health effects of dioxin exposure has grown, and in recent years, research organizations such as IOM have learned more about positive associations between exposure and certain medical conditions. Further, both the National Institutes of Health and the Environmental Protection Agency consider dioxin a carcinogen on the basis of studies showing associations between exposure and medical conditions such as lung cancer. Under the Agent Orange Act, IOM is required to review and analyze all medical research on dioxin exposure every 2 years and advise VA on the degree to which it believes Agent Orange is associated with certain health conditions. On the basis of this research, VA has accepted a number of medical conditions associated with Agent Orange exposure. Most of these conditions are types of cancers, such as non-Hodgkin’s lymphoma and soft-tissue sarcomas, or skin disorders, such as chloracne. More recently, prostate cancer and diabetes were added to the list after research showed a higher than expected rate of these conditions among those exposed to dioxin. (See fig. 1.) Federal employees and employees who worked under contract to the U.S. government in Vietnam are not covered by the Agent Orange Act. Rather, federal employees who are injured or become ill as a result of their employment, including those who worked in Vietnam, may file a claim under FECA, a comprehensive workers’ compensation law for federal employees. To obtain benefits under FECA, claimants must show that (1) they were employed by the U.S. government, (2) they were injured (exposed) in the workplace, (3) they have filed a claim in a timely manner, (4) they have a disabling medical condition, and (5) there is a causal link between their medical condition and the injury or exposure. Unlike veterans, federal employees who file claims under FECA based on Agent Orange exposure must demonstrate that they were personally exposed to Agent Orange while in Vietnam and that their medical conditions were “proximately caused” by this exposure, (i.e., that there was a causal link between the exposure and their condition). Labor has primary responsibility for processing all FECA claims and has assigned the processing of special types of claims, such as those for Agent Orange exposure, to specific OWCP offices. Labor also processes all appeals from claimants regarding claims that were denied. Claimants have three levels of appeal: (1) reconsideration by an OWCP claims examiner, (2) a hearing or review of the written record by OWCP’s Branch of Hearings and Review, and (3) a review by the Employees’ Compensation Appeals Board. Either a request for reconsideration by a senior claims examiner not involved in the initial decision or a hearing request is generally the first level of appeal, followed by an appeal to the Employees’ Compensation Appeals Board. A decision of the Employees’ Compensation Appeals Board is final—claimants cannot appeal Labor’s decisions in federal court. However, if new evidence becomes available after the decision, the claimant can request the claim be reopened for reconsideration and further review by Employees’ Compensation Appeals Board. Workers’ compensation coverage for employees who work under contract to the U. S. government outside the United States is provided by the employing contractor under DBA. Under DBA, individuals who can show that they were harmed and that working conditions could have caused this harm are entitled to a presumption that their claims are work-related and valid. Claimants must also establish that their claim was filed timely and show proof of employment, exposure to Agent Orange, a disabling medical condition, and that their condition arose naturally out of employment (i.e., that their condition was related to their employment in Vietnam). Under DBA, Labor is required to license the insurance carriers that provide the employers’ workers’ compensation coverage. To prevent employers and insurance carriers from an undue financial burden for insuring employees during a time of armed conflict, Congress enacted the War Hazards Compensation Act, which allows insurance carriers to obtain reimbursement from Labor when a claim is paid for an injury or death caused by a “war-risk hazard.” Contract employees who are injured file workers’ compensation claims directly with their employers and their employers’ private insurance carriers. The insurance carrier may either accept or “controvert” (deny) the claim. Claimants may request that OWCP review the insurance carrier’s decision and may ask for a hearing with one of Labor’s administrative law judges. The administrative law judge issues a decision and order awarding or denying benefits. Claimants may appeal an administrative law judge’s decision to Labor’s Benefits Review Board. Claimants may also obtain review of the Benefits Review Board’s decisions in federal court. Many of the agencies we contacted were unable to locate records on federal and contract workers employed in Vietnam, but on the basis of the limited data available, we estimated that at least 72,000 civilian employees and as many as 171,000 may have worked in Vietnam between 1964 and 1974. We developed these estimates using data we obtained from the Department of State and DOD but were unable to determine the reliability of the data. Most of the federal agencies we identified as likely to have had employees in Vietnam—DOD, CIA, and the Departments of State, Agriculture, and Treasury—were unable to provide us with the exact number of civilian employees they had working in Vietnam during the war. Agency officials told us they had difficulty identifying these workers because personnel records were kept solely on paper, as computers were not in common use at that time. Agency officials told us that these paper records may have been destroyed or, if such records still exist, were not indexed or organized in searchable formats. In addition, the location of some records was unknown because of the loss of institutional knowledge resulting from staff turnover over the years. Both the State Department and DOD located some historical data that we used to develop estimates of the number of civilians who worked in Vietnam. Three of the five agencies we contacted—CIA and the Departments of Agriculture and Treasury—were unable to provide us with any data on the number of federal and contract employees they had working in Vietnam during the war. The Department of State was able to identify its federal employees who worked in Vietnam between January 1964 through November 1965 and January 1967 through November 1974 from published quarterly lists of employees, but the agency was unable to determine the number of employees working for the agency in Vietnam under contract. Although DOD officials were unable to locate data, we located historical reports of civilian personnel strength by year at DOD’s Directorate for Information, Operations, and Reports but were not able to obtain an unduplicated count of civilians who were in Vietnam between 1964 and 1974. This office later located service contract amounts during the Vietnam War period published in historical reports, from which we were able to estimate the number of contract employees. Using data from the Department of State and DOD, we estimated that at least 72,000 and as many as 171,000 civilian employees may have worked in Vietnam during the war. From the quarterly lists of employees provided to us by the Department of State, we estimated that the agency had about 6,000 employees in Vietnam between 1964 and 1974. To estimate the number of DOD federal employees, we used annual civilian personnel strength data from historical DOD reports and assumed a 2-year rotation similar to that of military personnel to develop an unduplicated count of about 4,600 employees. We obtained the personnel strength data from published DOD reports but were unable to determine how the data were collected; therefore, we were unable to determine the reliability of these data. To estimate the number of DOD contract employees, we obtained from DOD the dollar amount of DOD service contracts, by year from 1966 to 1974, where the workplace was Vietnam, and divided these annual amounts by a range of “burdened labor rate” estimates to calculate the number of employees represented by these contracts each year. However, DOD was unable to provide us with information on the range of salaries paid to contract employees in Vietnam. Therefore, for our analysis, we assumed annual salaries of $7,500, $15,000 and $25,000—-which represent a range of low, middle, and high salaries of federal employees during that time—to obtain burdened labor rates of $15,000, $30,000 and $50,000 per person. As with the annual estimates of federal DOD employees, we assumed a 2-year rotation to obtain an unduplicated count, which ranged from about 43,000 to 142,000 contract workers. To determine the number of federal and contract employees from the CIA and the Departments of Agriculture and Treasury, we used numbers from the Department of State as a proxy, assuming that these agencies all had roughly the same number of employees in Vietnam and would not have had as many employees in Vietnam as the much larger number of DOD contract employees needed to support military operations. On the basis of these assumptions, we estimated that these four agencies may have had about 24,000 employees in Vietnam during the war. See appendix I for additional information on the methods we used to develop these estimates. Although Labor’s claims examiners and the insurance carriers we interviewed had difficulty identifying claims, our review of the claims identified showed that civilians faced difficulty in pursuing them because of difficulty obtaining information about the claims process, their former employers, and their employers’ insurance carriers, and because of processing delays. Labor denied 11 of the 12 claims filed by federal employees (1 was withdrawn), primarily because the claimants were not able to prove a direct relationship between exposure to Agent Orange and their medical conditions, as required by FECA. Of the 20 claims filed by contract employees, 9 were initially denied by the insurance carriers and 1 was approved for payment. We were unable to review the case files for the remaining 10 cases to determine whether or not they were paid because they were identified too late in our review to include them. Labor and the insurance carriers we contacted had difficulty identifying Agent Orange claims using their databases but were able to identify 12 claims from federal employees and 20 claims from contract employees. However, because we were unable to determine whether additional claims that were not identified exist, the information we obtained about these claims does not necessarily represent the nature of all Agent Orange claims or their disposition. Most of the claims they identified were filed in the past 10 years. Because Labor does not assign a unique code to identify Agent Orange claims in its database, the agency was unable to locate any of the claims filed by federal employees under FECA by querying its database. Although Labor has a code for injuries caused by exposure to chemicals and toxins, this code is used for many claims involving toxins other than dioxin and therefore was not useful in identifying Agent Orange claims. In addition, this code was not used for several of the Agent Orange claims identified. Unable to locate claims using Labor’s database, we asked the claims examiners in OWCP assigned to review Agent Orange claims from federal employees if they could recollect how many of these claims they had processed. They identified 12 claims using information from e-mails, personal notes, and personal recollections of information about the claims. However, we were unable to confirm that they had identified all Agent Orange claims from federal employees. Of the 12 claims identified, most were filed in the past 10 years, although 2 were filed in 1988 and 1 in 1991. In addition, inaccurately coded claims and inconsistent coding procedures prevented identification of Agent Orange claims. For example, for 9 of the 12 claims identified by the claims examiners, the “cause of injury” code recorded in Labor’s database was “99—cause unknown,” a catch-all code used to identify the type of injury when the cause of injury reported by the claimant on the claim form is not clear. Other fields in the database, such as the type of medical condition, were not useful in identifying Agent Orange claims because such exposure could cause more than one type of condition, and because most of the medical conditions associated with Agent Orange exposure could also have other causes. One clerk who codes the claims told us she was sometimes uncertain which codes should be used for Agent Orange claims and that she received limited guidance on how to code them. For example, two of the claims files showed that Labor coded the same condition, diabetes, with two different nature of injury codes, “cardiovascular disease—other” for one, and “blood disorder” for the second claim. In addition, the agency has no procedures for checking for data entry errors, and our review of Agent Orange claims identified errors. For example, one claim coded as “exposure to chemicals and toxins” was actually a heart condition. One Agent Orange claim for breast cancer was coded “sprain/strain of ligament, muscle, tendon, not back.” Claims examiners told us that although they can request that the clerks who entered the codes go back and correct coding errors, there is little incentive for them to request that errors be corrected because it does not affect their ability to process claims. Labor and representatives from insurance carriers had difficulty identifying Agent Orange claims filed by contract employees under DBA largely because they did not have a unique code to identify these claims. However, with our assistance, Labor was able to identify 20 claims. Ten of the claims were initially identified by Labor using its database and recollections of claims by Labor officials. Labor located 5 claims by—upon our request—querying its database for claims where the date of injury was during the Vietnam War (January 1, 1964, through December 31, 1975) and the nature of the injury was an occupational disease, and then reviewing the list of claims produced to identify claims they remembered as being related to Agent Orange. In addition, Labor officials remembered the names of 3 claimants that were not identified in their query of the database. The insurance carriers we interviewed identified 2 additional Agent Orange claims. Labor located 1 of these claims but was not able to find the other claim because, according to Labor officials, it was not sent to the agency by the insurance carrier, as required. All but 1 of these 10 claims was filed in the past 10 years. In addition, we assisted Labor in identifying 10 more claims from contract employees. Although 7 of these claims appeared on the printout from their initial database query, Labor officials initially told us they were not Agent Orange claims. In addition, because the employer noted on the printout for some of these claims was the same as the employer for 1 of the Agent Orange claims we reviewed, we asked Labor to go back and review the other claims to make sure that they were not Agent Orange claims. From this second review, Labor identified 3 additional claims. However, because they were identified so late in our review, we were not able to include these 10 claims in our analysis of the disposition of the claims. Both federal and contract employees faced difficulties pursuing claims for Agent Orange exposure because they lacked key information on the filing process, had difficulty identifying responsible parties and obtaining needed documentation, and experienced processing errors and delays. Our review of the files showed that several claimants had little information about the claims process because their first point of contact, their former employer, was difficult to locate. Although claims processing for both federal and contract employees begins with their former employer, the process differs thereafter. As shown in figure 2, federal employees obtain the appropriate forms and documentation from their former employers and file claims with those agencies or departments, which then forward the claims to Labor for a decision. As shown in figure 3, contract employees also obtain the appropriate forms and documentation from their former employers but file their claims with their employer’s insurance carriers. Our review of the claims files showed that federal and contract employees sometimes filed their claims incorrectly because they were unable to locate their former employers in order to obtain information about the filing process. Although the first source of information in filing workers’ compensation claims is the employer, since the Vietnam War, some employers have reorganized or are no longer in business. Of the claims we reviewed, 6 claimants had difficulty locating their former employer. Even federal employees can have difficulties locating their employer because of the many government reorganizations over the 30 years since the end of the Vietnam War. For example, one claimant who worked for DOD in Vietnam had difficulty determining which office to send his claim to because the workers’ compensation office of his former employer, the U.S. Army Audit Agency, had been renamed and relocated. He initially filed his claim with his current DOD employer, the Defense Finance and Accounting Service, which advised him to send the claim to the Department of the Army’s Personnel and Employee Services, the office that now handles claims for former employees of the U.S. Army Audit Agency. Our review of the claims files also showed that contract employees and Labor had difficulty locating the responsible insurance carriers because of industry mergers, changes in carriers over time, and lack of easily accessible records. Some employers changed insurance carriers over time, so their current carrier was not the one that had provided coverage during the Vietnam War. Although Labor licensed the insurance carriers that provided coverage for contract employees during the war, the agency does not track information about the carriers in a format that is easily researchable. Labor officials told us that they keep the information on the licensed insurance carriers on handwritten 3 x 5 cards that are filed by employer name in filing cabinets. Searching for a carrier is a time- consuming effort because there are hundreds of cards for multiple policies covering various periods of time. In addition, Labor does not track historical changes in the ownership of the insurance carriers over time, and companies may have been acquired by other companies—a common practice in the insurance industry, according to Labor officials. For example, an insurance company that provided coverage for contract employees for 3 of the claims we reviewed was purchased by another company, which could not locate claims for these individuals from the old company’s records. Labor had no information about the company being purchased by another company and had difficulty locating the insurance carrier liable for payment. Difficulties identifying insurance carriers can add up to extensive delays for claimants. Of the 10 claims we reviewed from contract employees, 4 claimants had difficulty locating their insurance carrier. For example, one contract employee’s claim was delayed 13 months before the correct carrier was identified. Initially, the claimant mistakenly sent his claim directly to Labor instead of his employer and the employer’s insurance carrier. Once notified by Labor of the claim, the employer requested Labor’s assistance in locating the carrier. One of OWCP’s district offices searched its paper records (the 3 x 5 cards it retains on the carriers it licenses) and identified the correct carrier. At the same time, however, the employer asserted that another carrier was the responsible party. The claim was filed with this carrier, who later denied the claim, asserting that it was not the employer’s carrier during the period when the claimant worked for the employer. During the months that this carrier was deciding the claim, another of OWCP’s district offices, apparently unaware of the other district office’s efforts, identified yet a different carrier as the responsible party. When presented with the claim, this carrier also denied it because the carrier had not been the employer’s carrier during that time. Over a year since the claim was first filed, the employer correctly identified the correct carrier. The claim was filed with the correct carrier and was ultimately denied (see table 1). Employer and insurance carrier processing errors and difficulty locating records further delayed employees’ claims. For the claims we reviewed, several employers had difficulty verifying the claimant’s employment because they were unable to locate personnel records for employees who had worked in Vietnam. For example, one employer denied that the claimant had been one of its employees, although the claimant provided copies of pay stubs, employee identification documents, and several letters of recommendation from the company. Eventually, Labor interceded on behalf of the employee and insisted that the employer recognize the claimant as an employee. Insurance carriers also had difficulty determining if they had provided coverage to employers and claimants because of difficulties locating old records. Even federal employees can experience difficulty finding their employers and locating records. For example, one federal employee’s claim was delayed over 2 years while the Department of Agriculture determined that he was an employee during the Vietnam War but was on detail to the Department of State. In its reply to Labor regarding the delay, the Department of Agriculture noted that it no longer had records for the period in question. Another federal employee, who was unable to obtain relevant medical records from his employer or the National Personnel Records Center, eventually withdrew his claim stating “at this time, I am under Hospice care and have not the energy to fight you anymore.” Once claims were submitted to Labor, both federal and contract employees faced additional delays because of processing errors at Labor, including claims being sent to the wrong office and information on the claims forms being typed incorrectly. For example, for one claim from a federal employee, Labor incorrectly processed the claimant’s request for reexamination of the written record by Labor’s Branch of Hearings and Review (typically, a claimant’s second level of appeal), instead sending it to the Employees’ Compensation Appeals Board (a claimant’s final level of appeal). This error created confusion and delayed processing of the claim for 11 months while the error was identified and the claim sent to the correct location. For the same claim, Labor continued to send notices to the claimant’s former federal employer at the wrong address for over a year, even though the post office returned these letters stamped “undeliverable” and the employer notified Labor of the correct address. Of the 12 claims filed by federal employees for medical conditions related to Agent Orange exposure, Labor denied 11 of them for failure to meet at least one of FECA’s five requirements, and 1 claim was withdrawn by the claimant. Of the 11 claims that were denied, Labor denied 10 of them because the claimant failed to prove a causal link between his medical condition and exposure to Agent Orange, and 1 claim was denied because it was not filed within the time limits prescribed by FECA. Furthermore, 5 of the claims denied by Labor were appealed by the claimants. Of those that were appealed, Labor upheld the denial of 4 claims, and a decision is still pending on 1 claim. All of the claims that were appealed were initially denied because of the claimants’ failure to prove a causal link between exposure and their medical conditions. Three of the 5 claimants requested reconsideration of their claims by a claims examiner. Labor upheld its initial denial after reconsidering 2 of these claims, and to date, neither claimant has sought a hearing by OWCP’s Branch of Hearings and Review or a review by the Employees’ Compensation Appeals Board. The third claim for which a reconsideration was requested is still pending. Of the 2 remaining claims that were appealed, one of the claimants requested an oral hearing; the denial was upheld. The other claimant sought redress through both a written review by the Branch of Hearings and Review and an appeal to the Employees’ Compensation Appeals Board. The board upheld Labor’s decision. Almost all of these claims from federal employees—10 of the 11 claims— were denied because the claimants failed to prove a causal link between their medical conditions and exposure to dioxin. Under FECA, to prove causation, claimants must provide “medical evidence establishing that the employment factors identified by the claimant were the proximate cause of the condition for which compensation is claimed, or, stated differently, medical evidence establishing that … the diagnosed condition is causally related to the employment factors identified by the claimant.” To determine whether a claimant has shown proximate cause, Labor’s claims examiners and hearings representatives told us that they examine the medical research and the “rationalized medical opinions” provided by the claimants’ doctors to demonstrate an explicit cause and effect relationship between the medical conditions and alleged exposure. Claims examiners and hearing representatives told us that the claimants’ doctors may use medical literature to support these rationalized opinions, but the doctors must apply this research to the claimants’ specific circumstances. Claimants, however, have faced three challenges to proving a causal link between their medical conditions and their exposure to dioxin. First, some of the claimants’ doctors are not familiar with the link between dioxin exposure and the development of some illnesses. In one case file we reviewed, one of the claimant’s doctors stated: “I have very little training in epidemiology and cannot tell you much about the coincidence of Agent Orange exposure with the development of prostate cancer,” and another said he was “certainly unable to provide any kind of expert opinion” on the relationship between Agent Orange and the development of prostate cancer. Second, according to Labor, some of the claimants’ doctors relied on general medical research to support their opinions without applying the research to the individual claimant. For example, in one case, the claimant’s doctor stated that he had reviewed the research on Agent Orange, relying primarily on the IOM biennial report that showed an association between prostate cancer and exposure to dioxin to support his opinion that the claimant’s prostate cancer was related to his exposure to Agent Orange. Labor denied the claim because the doctor failed to give his opinion but rather inferred a connection by presenting an excerpt from an article published by the National Academies Press. The decision letter also stated that Labor has long established that causality cannot be inferred and publications are of no evidentiary value, as they are not case specific. The third challenge the claimants faced is ruling out other factors that could have caused their medical conditions. For long-latency illnesses, such as the cancers associated with dioxin exposure, it is difficult for the claimants’ doctors to definitively rule out other factors that could have caused the medical condition during the intervening years between Agent Orange exposure and the development of the medical condition. For example, in one case that was denied by Labor, five different doctors— including one doctor to whom the claimant was referred by Labor— asserted an association between the claimant’s medical condition and his exposure to Agent Orange. The doctor to whom the claimant was referred by Labor stated that “it is reasonable to assume that his exposure to Agent Orange and to other herbicides are the causative agent for his transitional cell carcinoma .” Another doctor provided his opinion that the claimant’s bladder cancer was a consequence of his exposure to dioxin and other environmental toxins during his tenure in Vietnam. A third doctor stated in his written opinion that “chemical exposures in the course and scope of his duties as a federal employee are the cause of his bladder cancer.” However, the claim was denied because Labor determined that the claimant failed to submit medical evidence that attributed his bladder cancer to his exposure to herbicides in Vietnam. The decision letter stated that although one of the doctors provided a medical opinion stating a cause and effect relationship between the claimant’s medical conditions and his federal employment, the doctor “cannot state with certainty that non-work related factors have no connection to the claimed conditions. Specifically, he admits that cigarette smoking and exposure to asbestos are also bladder carcinogens. Therefore, his opinion is considered speculative and equivocal in nature, and has little probative value.” The claimant requested four different reconsiderations by OWCP’s claims examiners, and after his death, his widow requested a fifth reconsideration; Labor’s decision was upheld each time. Although Labor and the insurance carriers identified a total of 20 claims from contractor employees, we were not able to include 10 of them in our analysis of the disposition of the claims because Labor identified them too late for us to include them. For the 10 claims we reviewed, 1 was accepted and 9 were initially denied by the insurance carriers. Of the 9 claims denied, 5 of the claimants asked Labor to review the insurance carriers’ decisions, and 4 claimants took no further action on the claims. Of the 5 claims that the claimants asked Labor to review, 3 claimants are waiting for a hearing by one of Labor’s administrative law judges. For the other 2 claims, Labor upheld the insurance carriers’ decisions—1 because the claim was not filed within the 2-year time period allowed under the law and the other because the claimant had not sufficiently proved that he had been exposed to Agent Orange in Vietnam. For the one claim accepted for payment, the claimant asked Labor to intervene because his employer, a self-insured contractor for the CIA, was no longer in business. Absent an employer or insurance carrier, the CIA— acting in the role of the employer and the insurance carrier—stated that it “had no objections” to paying the claim. In accepting the claim, Labor referenced VA’s policy regarding Agent Orange claims and an Environmental Protection Agency report on the health effects of dioxin exposure to justify its approval of compensation. Noting VA’s presumption that any veteran who served in Vietnam and developed certain medical conditions associated with Agent Orange had been exposed, the claims examiner stated that it would be difficult for Labor to take a contrary position. This claim was also accepted for reimbursement under the War Hazards Compensation Act. Under the act, an insurer who pays a claim for an injury from a war risk may be reimbursed for the costs it bears in connection with the claim. However, according to Labor officials, some insurance carriers may not be aware that they can obtain reimbursement under the War Hazards Compensation Act. If Congress chooses to address this issue, several legislative options could provide more similar consideration of civilian claims as compared with the claims of their veteran counterparts and improve civilian access to workers’ compensation or other benefits. However, these options have cost implications, although the lack of data on the number of civilians in Vietnam and the difficulty potential claimants have in locating the information needed to file claims make it difficult to accurately assess their potential costs. In addition, these options should be carefully considered in the context of the current federal fiscal environment, as well as the significant policy and cost implications any changes could have for civilian employees involved in wars and conflicts since the Vietnam era. Congress could amend the Agent Orange Act and related legislation that authorizes benefits for veterans to include civilians. However, including civilians under these laws may raise concerns for those who feel that civilians should not be entitled to the same benefits as military veterans. Alternatively, Congress could create a separate program to cover claims for medical conditions that civilians develop as a result of their exposure to Agent Orange. In addition to the Agent Orange Act for veterans, Congress has established programs for some special populations exposed to toxic substances in the workplace that develop into serious medical conditions after long latency periods. For example, Congress passed the Radiation Exposure Compensation Act in 1990 to provide payments to individuals who contracted certain cancers and other serious diseases as a result of their exposure to radiation released during nuclear weapons tests or as a result of their employment in the uranium mining industry. More recently, Congress passed the Energy Employees Occupational Illness Compensation Program Act of 2000, as amended, which provides payments to contract employees working in Department of Energy facilities who were exposed to radioactive and hazardous materials and subsequently developed illnesses such as cancer and lung disease. Some key components of these special programs are Providing restitution: The Radiation Exposure Compensation Act was enacted to establish a procedure for making partial restitution to individuals who became ill because of radiation exposure from aboveground nuclear tests or uranium mining. Restitution payments range from $50,000 for testing victims to $100,000 for uranium miners. The Energy Employees Occupational Illness Compensation Program Act also makes payments to eligible claimants and provides medical coverage for specific illnesses. Creating eligibility criteria based on a less stringent standard of proof for the causal link between exposure and medical conditions: Because of the inherent difficulties of proving a link between exposure to radiation or toxic substances and occupational diseases that occur after long latency periods, other compensation programs rely on a less stringent burden of proof than FECA or DBA. For example, the Energy Employees Occupational Illness Compensation Program Act allows payments if employment at an energy facility was “as least as likely as not” to have caused, contributed to, or aggravated the claimed medical condition. Using ongoing research on conditions associated with exposure to determine eligibility: On the basis of recent research findings, the Radiation Exposure Compensation Act Amendments of 2000 expanded the list of diseases that may qualify individuals for compensation and decreased the level of radiation exposure that is necessary to qualify for compensation. Under the Agent Orange Act, VA uses IOM’s biennial review of research on dioxin exposure and recommendations to add to its list of accepted medical conditions related to Agent Orange exposure. Assisting claimants in processing their claims: The Energy Employees Occupational Illness Compensation Program Act, as amended, created an ombudsman position to provide information to claimants. According to the Director of Labor’s Energy Employees Occupational Illness Compensation Division, the agency provides information and assistance to claimants in a variety of ways, including resource centers located throughout the country that assist claimants in completing claim forms and obtaining the documentation needed to support their claims. He also stated that Labor has provided pamphlets, public service announcements, and direct mailings to potential claimants that explain the program, benefits available, procedures for filing claims, and where they can obtain assistance. The Radiation Exposure Compensation Act also provides for outreach and information to potential claimants. The Department of Justice administers this program and has established an Internet Web site, conducts on-site visits to groups and organizations to promote the program, and operates a toll-free telephone line for program queries. Congress could amend the GI Bill Improvement Act of 1977, which allows DOD to retroactively grant military status and authorize full VA benefits to certain civilian groups that support the military during armed conflicts. Women who served in the Women’s Air Forces Service Pilots during World War II are the model for the statute, because they comprised a quasi- military group that rendered service to the United States during wartime, but at the time, were excluded from joining the armed forces because of their gender. In 1977, Congress specifically recognized the service of that group as active military duty and directed DOD to issue regulations under which similarly situated groups could be recognized. In 1987, a federal court determined that DOD had failed to clarify the factors and criteria used in implementing this statute. As a result, DOD clarified the rules for accepting groups and issued DOD Directive 1000.20. Under this directive, a group must submit an application showing that it meets the criteria, including the criterion that it provided service to the U. S. government during a period of armed conflict, was subject to military control, and was integrated into the military organization (see table 2). Groups do not, however, have to meet all of the criteria in order to be accepted, but it remains unclear how many of the criteria must be met for a group to be accepted. Although five groups of civilians who worked in Vietnam during the war have applied for consideration under DOD Directive 1000.20, none has been accepted. To date, Slick Airways, a division of Airlift International; U.S. civil servants on temporary duty at Long Binh, Vietnam; U.S. and foreign civilian employees of CAT, Inc.; U.S. civilian crewmembers of the Flotilla Alaska Barge and Transport Company; and Vietnamese citizens who served in Vietnam as commandos under contract with the U.S. armed forces have applied for consideration under the directive. In its application, one of these groups claimed to have met all seven criteria for acceptance. In its decision, the DOD Civilian/Military Service Review Board stated that the group met the “organizational authority over the group” criterion, and that board members disagreed over whether the group met the “uniqueness of service” criterion. In addition, the board acknowledged that there was evidence of military command authority over the group but asserted that the group was not integrated into the military organization and was not subject to military discipline or military justice. The application was denied. The options presented above could have significant cost and policy implications. However, with little data available on the actual number of civilians in Vietnam, their exposure levels, and the number of claims that would be filed, it is difficult to estimate the costs of these options. According to information provided to us by VA officials, of the 2.3 million living military veterans who were in Vietnam during the war approximately 160,000 (less than 10 percent) are receiving disability compensation benefits from VA for the four most common medical conditions associated with Agent Orange exposure. VA’s average annual cost of providing workers’ compensation and medical expenses to veterans receiving benefits under the act for the four most common medical conditions is about $8,500 for disability compensation and $1,000 for medical expenses. Although these costs do not include the costs of administering the claims, when VA added diabetes as a condition related to Agent Orange exposure, it estimated that the administrative costs for each claim processed would be about $350. Including civilian employees who worked in Vietnam under these options also has policy implications. It could set a precedent that might prompt other federal and contract employees who have worked for the U. S. government in war zones since the Vietnam War—such as the Gulf War and the current conflict in Iraq—to seek similar benefits. Such a precedent could prove costly because the U.S. military has employed a much larger number of contractor personnel in recent wars and conflicts than in Vietnam. The fact that Labor does not collect data on Agent Orange claims that allow it to identify the claims using its database makes it difficult to identify trends in the number and disposition of claims. The coding errors in Labor’s database also make it difficult to identify and track these claims. In addition, while Labor is the licensor of insurance carriers for government contract employees, it is difficult, without proper records, to help claimants identify the insurance carriers or determine how well insurers are following through on their obligations. Both Labor and claimants are burdened by the difficulties the agency has in providing information to claimants—particularly contract employees filing claims under DBA—on how to file claims, locate their former employers, and identify the employers’ insurance carriers, difficulties that leave room for delays and errors in processing claims. Federal and contract employees who may have been exposed to Agent Orange while working for the United States during the Vietnam War have clearly had a different experience than their military counterparts in requesting compensation under the Agent Orange Act. In short, these employees must meet more stringent standards in pursuing claims under FECA and DBA. The cost implications of options designed to increase access to compensation for civilians exposed to Agent Orange should be carefully considered in the context of the current and projected fiscal environment. The lack of information available about the number of possible civilian Agent Orange claims, however, makes it difficult for us to estimate the potential costs were such options to be adopted. In addition, any consideration of these options should include an assessment of the policy and cost implications the changes could have for other civilian employees involved in wars and conflicts since the Vietnam War, such as the war in Iraq. Setting a precedent for expanding benefits to civilian employees could have a much larger impact in the future as the U.S. military increases its reliance on contract employees. To improve the handling of civilian Agent Orange claims, the Secretary of Labor should direct OWCP to assign a unique identifying code to Agent Orange claims and develop procedures to ensure that these claims are coded correctly; provide better oversight of licensed DBA insurance carriers by requiring the Office of Longshore and Harbor Workers to track the information it retains on licensed insurance carriers for Vietnam era employers in an easily searchable format, such as in an automated file, and track changes in ownership for each licensed carrier in order to be able to determine liability for payments; and direct the appropriate offices to provide contract employees with the information needed to file Agent Orange claims by taking such measures as posting information on Labor’s Web sites or developing informational brochures that include information on how to file a claim under DBA, such as which forms to use, and information on Vietnam era contractors with the names of their insurance carriers licensed by Labor. We provided a draft of this report to Labor, DOD, and VA for comment. Labor and VA provided written comments on the draft, which are reproduced in appendixes II and III. Labor generally agreed with our recommendations. The agency agreed to improve its handling of civilian Agent Orange claims by developing a unique code to use in identifying these claims, improving its oversight of licensed DBA insurance carriers, and assisting contract employees in obtaining information on filing claims by enhancing the information on its Web site. Regarding our recommendation to develop a better system for tracking information on licensed DBA insurance carriers, Labor stated that it does not have the funding needed to create a relational database or the resources to enter these data into such a database. However, it also stated that a current evaluation of its processes may provide some recommendations for enhancing its data capability in this area. Given the availability of easy to use, off-the-shelf database packages, we continue to believe that Labor could implement this recommendation with relatively little expense and that data entry could be phased in over time or contracted out. VA expressed serious concerns about the legislative options for easing civilians’ access to workers’ compensation benefits. It highlighted the additional costs and administrative burdens associated with the options. VA also expressed concern about the precedent-setting implications these options could have for civilian employees involved in other wars and conflicts since the Vietnam War. As noted in the report, we agree that the cost and policy implications of these options should be carefully considered. DOD provided only an informal technical comment on the report. Labor and VA also provided a few technical clarifications, which we incorporated as appropriate. We will send copies of this report to the Secretaries of Labor, Defense, Veterans Affairs, and other interested parties. We will also make copies available to others upon request. In addition, the report will be available at no charge on GAO’s Web site at http://www.gao.gov. Please contact me or Revae Moran on (202) 512-7215 if you or your staff have any questions about this report. Other contacts and staff acknowledgments are listed in appendix IV. Many of the agencies we contacted were unable to locate records on federal and contract workers employed in Vietnam, primarily because of the age of the records and the fact that they were not automated. However, using the limited historical data provided to us by the Department of State and the Department of Defense (DOD), we developed estimates of the number of civilian employees who worked in Vietnam during the war. The Department of State was not able to provide the total number of contract employees who had worked in Vietnam but was able to identify the names of federal employees who had worked there between January 1964 through November 1965 and January 1967 through November 1974 from its quarterly Foreign Service reports. As these are historical reports, we were unable to assess the reliability of these data for several reasons: Most records were not computerized in the 1960s or 1970s, most paper records have either been destroyed or were not organized in a way that would facilitate the identification of personnel, and most officials who were knowledgeable about employees in Vietnam are no longer with the agency. We entered the names from these quarterly lists into an automated file, sorted out likely duplicates, and counted the remainder. On the basis of our analysis, we estimated that about 6,000 employees of the Department of State worked in Vietnam during the war. In the absence of information from the Central Intelligence Agency (CIA) and the Departments of Agriculture and Treasury, we used the Department of State estimate as a proxy for the number of federal and contract employees each agency employed in Vietnam. We also assumed that these agencies did not have as many employees in Vietnam as the much larger number of DOD contract employees needed to support the military operations. On the basis of these assumptions, we estimated that these four agencies employed about 24,000 workers in Vietnam during the war. Although DOD officials were unable to locate information on the number of federal employees who had worked for the agency during the Vietnam War, we located historical reports of civilian personnel strength by year at DOD’s Directorate for Information, Operations, and Reports and used these data to develop estimates of the number of federal civilian employees who worked for DOD in Vietnam. These data provide a count of the number of employees for one point in time during the year. However, DOD officials told us that civilians likely stayed in Vietnam for a 2-year rotation before returning to the United States, so totaling these annual counts would overestimate the total number of employees. To obtain an unduplicated count, we used the annual civilian personnel strength data and assumed a 2-year rotation. For example, in 1964 DOD had 44 federal employees in Vietnam, but in 1965 had 51 employees—an addition of 7 new employees. In 1966, DOD had a total of 444 federal employees. However, assuming the 44 employees from 1964 had completed their 2-year rotation and returned home, they would not be included in this count. Therefore, the 444 is composed of the 7 employees who arrived in 1965 and 437 new employees who arrived in 1966. Using this methodology, we estimated that about 4,600 DOD employees were in Vietnam during the war (see table 3). We obtained the personnel strength data from published DOD reports but were unable to assess the reliability of the data for several reasons: Most records were not computerized in the 1960s and 1970s, most paper records have either been destroyed or were not organized in a way that would facilitate the identification of personnel, and most officials who were knowledgeable about employees in Vietnam are no longer with the agency. DOD was unable to provide information on the number of contract employees it had working in Vietnam during the war. However, from DOD’s Directorate for Information, Operations, and Reports we were able to obtain the annual dollar amount of DOD service contracts provided to companies between 1966 and 1974 for work in Vietnam, and we used these data to develop estimates of the number of contract workers. DOD officials told us that service contracts were the most likely type of contract to be used to pay salaries to contract workers, as opposed to other types of contracts that would have been used to purchase items such as equipment and supplies. We were unable to assess the reliability of these data for reasons similar to those noted for the data we obtained for federal employees. In addition, the data are further limited because we were unable to determine if the service contracts would have been for salaries to U.S. citizens or foreign nationals and because 3 years of data (1964, 1965, and 1975) were not available. Using the limited data available, we divided these annual amounts by a range of “burdened labor rates” to estimate the number of employees represented by these contracts each year. DOD officials told us the burdened labor rate—-salary, subsistence expenses, company overhead, profit, insurance, travel, and other costs that would have been included in the total contract amount—-could vary among contracts. However, a DOD official with experience administering contracts advised us that doubling an employee’s annual salary would approximate this burdened labor rate. However, DOD was unable to provide us with information on the range of salaries paid to contract employees in Vietnam. Therefore, to estimate annual salaries for contract employees, we obtained available salary scales for federal employees from 1964 to 1975 and selected a range of low, middle, and high salaries. For our analysis, we assumed annual salaries of $7,500, $15,000, and $25,000 and doubled them to obtain burdened labor rates of $15,000, $30,000, and $50,000 per person. We divided these burdened labor rates into the annual contract amounts to get an estimated number of contract employees employed in Vietnam each year. As with the annual estimates of federal DOD employees, we assumed a 2-year rotation to obtain an unduplicated count, which ranged from about 43,000 to 142,000 contract employees (see table 4). Nina E. Horowitz made significant contributions to this report. In addition, Margaret L. Armen, Susan C. Bernstein, Benjamin A. Bolitzer, Christina Cromley, and Jean L. McSween provided key technical and legal assistance throughout the engagement.

Summary: Concerns about difficulties civilian employees of the U.S. government may have in obtaining workers' compensation benefits for medical conditions they developed as a result of their exposure to Agent Orange in Vietnam led to GAO being asked to determine (1) what is known about the number of civilians who served in Vietnam, both those employed directly by the U.S. government and those employed by companies that contracted with the government; (2) what is known about the number, processing, and disposition of claims filed by these civilians; and (3) what options are available if Congress chooses to improve access to benefits for civilians exposed to Agent Orange in Vietnam who developed illnesses as a result of their exposure, and what are their cost implications? While many federal agencies that were likely employers of civilian federal and contract workers during the Vietnam War had little information on these employees, a few provided us with limited information on federal employees and the amounts of contracts for companies that provided services to the military in Vietnam. We were unable to determine the reliability of the data provided. However, we used these data for the limited purpose of estimating that between 72,000 and 171,000 civilians may have worked for the U.S. government in Vietnam between 1964 and 1974. Our ability to provide more accurate information on the size of this workforce was limited because most agency records maintained during this period were not computerized, and because so much time has elapsed that many paper records have been destroyed and many agency personnel knowledgeable of the period are no longer working at these agencies. For the 32 Agent Orange-related claims identified (12 from federal civilians and 20 from contract employees), we found that these claimants faced many difficulties and delays because of a lack of readily available information on how to file a claim, their Vietnam era employers, and their exposure to Agent Orange, as well as processing delays caused by employers, insurance carriers, and Labor. Both Labor and private insurance carriers had difficulty identifying the number of claims they had received, largely because they do not assign a unique code to Agent Orange claims that would enable easy identification. Most of the claims we identified were filed in the past 10 years, and most have been denied. Denials of the claims stemmed, in part, from the fact that under the laws governing these claims, claimants must demonstrate a causal link between their exposure to Agent Orange and their medical conditions, which is difficult to prove so many years later. If Congress chooses to address this issue, several legislative options could be considered to attempt to improve access to compensation for civilians who were exposed to Agent Orange and developed medical conditions as a result, although they could have significant cost and policy implications. Congress could amend current law authorizing benefits for veterans to cover certain civilians or set up a separate program to cover them. Another option is for Congress to amend the GI Bill Improvement Act of 1977, which allows DOD to retroactively grant military status and authorize full VA benefits to certain civilian groups that support the military during armed conflicts. However, it is difficult to assess the potential costs of these options because of the limited data available on the number of civilians and their claims for compensation. Despite the difficulty of assessing the potential costs, before any of these options are pursued, their fiscal impact and the precedent-setting implications for individuals involved in other wars and conflicts since the Vietnam era should be carefully considered.