Transcripts For CSPAN2 Hearing Examines Gulf War Illness Claims Processing 20170717

Good morning and welcome, everyone. This is joint hearing of the subcommittee on disability assistance and Memorial Affairs an oversight and investigation will come to order. I first want to take a moment to thank my colleagues, chambering man. Ranging member esty who should be along this morning and Ranking Member Kuster Holding the hearing on important issue were facing helping gulf war veterans get benefits they earned. It should go without saying we have a duty to take care of the men and women who have been wounded while serving in our military. Unfortunately too many injured gulf war veterans are not being taken care of. Va estimates 44 of gull war veterans develop gulf war illness, yet 26 of those veterans are receiving benefits. Something doesnt add up. On march 15th, 2016 during a similar joint hearing on gwi claims va, va testified that it was taking steps to improve service for gulf war veterans. Yet one year later, gao found va is still only approving 17 of claims of gulf war illness, which is about a third of the approved rate for other claims. For example, gao report says that only 13 of the claims were diagnosed illnesses, diagnosed of the illness, that and are approved. I cant understand that at all. Va regulations state that if veterans have certain symptoms such as headache, fatigue, joint pain, va is supposed to presume that these symptoms are related to the Veterans Service in the gulf area yet 80 of these games are denied, 87 of these claims are denied. Fao found one ever the problems the va physicians are applying the wrong standards during the exams. Another issue that the va employees are not ordering exams when necessary. I appreciate the rise va, i appreciate recently that the va retained all of its employees on gwi claims and i am looking forward to, looking forward to hearing whether rao takenned, he retaining these employees made a difference. Im also frustrated because gao pointed out that the vas decision letters are not clear. This issue keeps coming up. As you know my appeals reform bill, hr 2288, would require va to make its decision letters more clear and useful for the veterans but it shouldnt take legislation to force the va to act. I would like to see the va change its decision letters now so that the veterans understand why va made the decisions it did. So, gao also found several other problems that may be keeping the approval rate for gwi claims low. Such as a lack of a single Case Definition for gwi. Im looking forward to an hon of the discussion about the vas need to do so and how to insure that they do. None of us want to come back here next year to find the same problems. After this hearing i intend to work with my colleagues to keep on va to make sure that these changes are made, and made this time where we wont have to do it again. I ask unanimous consent written statements provided for the record be placed into the hearing record. Without objection so ordered. I also want to take, want to thank the witnesses for being here today. With that i want to call on the oversight and investigation distinguished Ranking Member, for her opening statement. Thank you, chairman bost, and to general bergman and miss esty when she arrives and for the witnesses being here today. It has been 26 years since the beginning of the gulf war, 44 of the veterans served in that conflict suffered from gulf war illness. Sadly these veterans struggle to receive accurate diagnoses for their systems and health care and compensation for their Service Connected conditions even with the presumptions that should result in more veterans receiving benefits and not denied claims. Last year our subcommittee held a hearing as the chairman said on access to treatment for gull war illness more Research Needed to get our veterans the health care they need. Now were back here again. This is entirely bipartisan across our committee to determine why 83 of gulf war illness claims are denied by the va. What we can do to insure our gulf war veterans receive the benefits they earn. Gulf war illness is chronic, painful, often decan debilitating disease and they deserve disability compensation and have their condition recognized and treated by va providers. Just this past monday the state Veterans Advisory Committee in my home state of New Hampshire who i meet with on a quarterly basis were criticizing the va as process for adjudicating gulf war illness claims. In fact one of the members of the state advise very committee had his own claim for gulf war illness denied. In veterans in my state and across the country the vas process is poorlyrun and fail to adequately train personnel. This late of the report confirms what our constituents suffering from gulf war illness continue to tell us on a regular basis is. Their claims continue to be denied because medical examiners do not know how to diagnose gulf war illness or the va fails to apply the presumption that congress intends for to grant this serviceconnection disability. When these claims are denied, va does not communicate to veterans as the chairman said. The reasons for the denial, leading to veterans becoming frustrated, losing faith in the va, and filing appeals. The gao report found that 90 of medical examiners that the va relies upon to assess veterans disabilities have not completed the elective training on gulf war illness so they can better assess veterans disability levels. I would like to know why this train something not a mandatory requirement and when it will become mandatory. I would like also to know if this webbased train something sufficient to train medical examines and if claims processors need better training requirements as well. I wish to hear from the va on the plan to improve the way it communicates decision made on claims. When veterans are not provided the reason that the claim was denied, they become frustrated and angry and end up in our apples process which is already swamped. If they do knot know why the claim is denied they can spend years attempting to obtain benefits through a lengthy appeals process. Finally we know the va continues to conduct and support research on gulf war illness, however the va lack as single Case Definition and as i understand, it has no plan to develop one. A uniform Case Definition for gulf war illness was recommended in 2014 by the vas research Advisory Committee and the National Academy of medicine. A single Case Definition is needed to improve research, diagnosis and treatment of gulf war illness. I would like to see a plan put in place to develop a single gulf war illness definition. The number of gulf war illness claims doubled from 2010 to 2015 and we can expect that more veterans will file claims and we subsequently appeal denied claims. It is imperative the va implement the gao recommendations now so that gulf war veterans receive the treatment and disability benefits that they deserve without having to the fight the va every step of the way. Thank you, chairman bost, i yield back. Thank you, miss kuster. Im going to ask all members waive their opening remarks as per the committees custom. I understand chambering man and Ranking Member esty will give their statements at the end of the hearting. Now i would like to welcome our witnesses again. Thank you for taking time to be here today. Our first witness is bradly flohr, Senior Advisor for compensation services. He is accompanied this morning by dr. Patrick joyce, the chief Occupational Health clinics of the washington va medical center. Were joined by melissa emreyarras, is that correct . With a name like bost, where they say bost, make sure we get it right. Director of Education Workforce and income of the gao. Zachary hearn, the Deputy Director for claims for Veterans Affairs and Rehabilitation Division of the American Legion. And michael figlioli, correct . The Department Director and national Veterans Services of the vfw. Finally, Anthony Hardie National Board chair of veterans for common sense. I want to remind the witnesses your complete witness statement will be entered into the hearing record. With that, mr. Flohr, youre recognized for five minutes. Thank you, chairman bost, chambering man, Ranking Members esty and kuster, and members of the committee. Thank you for the opportunity to discuss how va processes gulf war veterans compensation claims for undiagnosed illnesses for medically unexplained multisymptom illnesses of the for purposes of my testimony i will refer to these categories as gulf war illness. Today i will provide overview of va processing of gulf war illness claims and some of our training and Quality Assurance efforts. Service connection may be awarded for gulf war illness when veteran has service in the southwest asia theater of operations after august 2nd, 1990, has a qualifying disability in according to 38cfr, 3. 187. Service connection may be awarded for gulf war illness from december 31st, 2016, to december 31st, 2021. In fest call year 201,618,681 veterans received a digs for a claim specifically for gulf war illness. From this, 4594 veterans were awarded Service Connection for one or more diagnosed illness or chronic multisymptom illness. 13 were for undiagnosed illness and 31 for medically unexplainedded multisymptom illness. Vba continues to strengthen Training Program for gulf war illness claims. Which developed 13 related courses for processors they mandated 10 hours training for rating Veterans Service representatives. Were developing a new training module which focuses on the southwest asia gulf war claims. This module scheduled to launch in fy 2018. Va simply minted number of initiatives to include improvement of the notification process, specifically to include a more thoroughly explanation when a claims issue is denied. In recent years va developed special tracking to specifically account for gulf war claims. Va also amended its gulf war general medical examination template to include Important Information for examiners when addressing undiagnosed and chronic multisymptom illnesses as well as information on various environmental exposures in the gulf war. Va constantly looking for ways to improve benefits and services it provides for veterans that served in the gulf. Va works closely with the Veterans Health administration reviewing research by offices Public Health and research of development and academy of medicines biannual updates on gulf war issues. We work with the department of defense in join work groups that Research Environmental exposures coincident with military service vba as well as medical capacity examiners. Finally have. Ba national quart review staffs as well as local quality reviewers in our regional offices continue to insure employees correctly process and decide claims for gulf war illness. As agreed upon with the National Gulf War Research Center vba conducted pox focus reviews on decisions for gulf warrelated illnesses in december 2015 and december 2016. The review in 2015 focused on fiscal year 2015 gulf war cases showed 94 accuracy rate. 2016 review expanded review from cases medically unexplained chronic multisome illnesses four year period starting from fiscal year 2011. This review showed 89 accuracy rate. Va continues to approve the efficient, timely processing of claims of service in the gulf war. Science and medical aspects of undiagnosed illnesses and chronic multisome illnesses are complex, va continues to review scientific and medical whether it literature to gain a better understanding of the impact of these ill necessaries on our gulf war veterans. This concludeses my opening statement. Im ready to address any questions you or the member of the committee may have. Thank you, mr. Flohr. Miss emreyarras are recognized for five minutes to give testimony for the gao. Thank you, chairman bost, chambering man and Ranking Members of the subcommittees. Im please to discuss our recent report on va evaluation of gulf war illness disability claims of the exact causes of gulf war illness are not always known and veterans symptoms vary widely. Veterans with gulf war illness may experience symptoms such as fatigue, headaches joint pain, indigestion, insomnia, respiratory disorders and skin problems and memory impairment. May have Infectious Diseases likes malaria or west nile virus. Va refers to claims for gulf war illness undiagnosed illness, medically unexplainedded chronic multisymptom illness and infect schusses it claims. We refer to the three types of claims as gull war illness claims. My testimony today will focus on our findings related to three key areas. One, recent trends in gulf war illness disability claims. Two, challenges va faces, and three, vas gulf war Illness Research. In terms of claims trends, we found that the number of gulf war illness claims processed increased in recent years. In fiscal year 2015 vba completed processing about 11400 claims which was more than double the 4,800 claims it processed in fiscal year 2010. Many of these claims included multiple medical issues or symptoms related to gulf war illness. On average we found that gulf war illness claims took four months longer to process than other claims. We also found that gulf war illness claims were approved at lower rates than other types of disability claims. We found that approval rates for gulf war illness medical issues were about three times lower than for all other claimed disabilities. Specifically, we found that 17 of gulf war illness medical issues were approved compared to 57 for all other types of medical issues. According to va several factors may contribute to the lower approval rates. Including that these claims are not always understood by vas staff. Additionally veterans sometimes file for gulf war illness benefit but according to some va staff we spoke with, do not provide sufficient evidence that their symptoms have existed for at least six month as generally required by va regulations. In terms of challenges va faces we found that there is inadequate training for vha million examiners. Vba claims rating staff often rely on these medical am examiners to before they make a claim. Medical examiners say conducting gulf war medical exams is challenging because of range ever symptoms that could qualify as gulf war illness. Vha offered optional 90 minute webbased gulf war illness training for its medical examines since 2015 but according to vha, Training Data only showed 10 of the examiners had taken this training as of this past february. We recommended that va require its medical examiners to campus pleat training on gulf war illness and va agreed with this recommendation. We also found that decision letters va sends to veterans denying benefits for gulf war illness claims do not always clearly explain to the veteran how their claim was decided which can leave the veteran uncertain how the claim was evaluated and potentially lead to unnecessary appeals. We remember that va require decision letters to clearly explain how the claim was evaluated and va agreed with our recommendation. In terms of gulf war Illness Research we found that. Have a does not have a plan to develop a single Case Definition of gulf war illness. Va advisory groups emphasized establishing a single definition could further improve research, diagnosis and treatment of veterans. Va advisory groups recommended in the near term that va analyze data from the existing data sets, in long term conduct Research Projects to contribute to the establishment of a single Case Definition. Va included in its 2015 Gulf War Research Strategic Plan an objective to establish a single definition but the agency has no action plan in place to achieve it. Without a plan, va risks engaging in research that is not targeted toward its goal. We recommended va prepare a plan to develop a single of anything and va agreed with this recommendation. Thank you. This concludes my remarks. Thank you, mr. Hearn, youre recognized to begin testimony for American Legion, please. Thank you. It is like deja vu all over again. Ranking member kuster, you made this assertion in our opening remarks during the march, 2016 hearing regarding gulf war illness. 486 days, one damning gao report, thousands of injured veterans and impacted dependents later were here to discussed a adjudication of gulf war illness claims by va, yes, Ranking Member kuster it feels like deja vu over again. Good morning chairman bost, Ranking Member kuster and members oversight investigation and on behalf of commander Charles Schmidt over 2 million members of the nations largest Veterans Service organization the American Legion appreciate the opportunity to testify regarding the adjudication of gulf war illness claims. Gulf war illness claims are inherently complicated. Veterans must tread murky waters for many undiagnosed illnesses. Undiagnosed illness is just as it sounds, cluster of symptoms unexplained and undefined. Veterans seeking treatment for the symptoms are often treated for years and often have multiple diagnoses before va will acknowledge that they are related to undiagnosed illness. Terribly frustrating for veterans and seen by recent gao report, overwhelmingly denied by va when Service Connection is sought. Va previously acknowledged its frustration with gulf war illness. With that in mind you would think there would be mandatory training to improve the workforces understanding of conditions. However the gao report he revealed 10 of the examiners successfully completed optional course related to gulf war illness this is pathetic. Only one in 10 taken the optional course but the other 10 are qualified to conduct gulf warrelated examinations . Lets not forget examinations are conducted by private sector contractors fva isnt providing mandatory training to the own many employees what requirements are being made of those examiners . The examiner, the American Legion has overthousand accredited representatives located throughout the nation. These dedicated individuals are the lifeblood for staff in washington. They are the souls that provide necessary feedback regarding issues our veterans face regularly. One Service Operator reported that va Regional Service employee Veterans Service organization receive more frequent and Higher Quality training than our own employees. Webbased training that results in various interpretations ultimately resulting in inconsistent decisions. Each Service Officer spoken prior to this hearing they had to accept claims, for undiagnosed illnesses will have to go to boards of veterans appeals if they expect the claim to be granted. Costing the veteran not months, but numerous years to result in positive decision. Impacts of symptoms from family members an friends. The these statements will have little if any impact on ro decisions however the Service Officers report bva decisions are much more favorable for veterans take into account those lay statements. Gao report combined with American Legion findings paint a bleak picture of development and ajudication of gulf warrelated claims. Medical providers have optional training which only 10 participate and vba personnel complain of lack of adequate training on subject. Three generations of veterans have been potentially impacted by gulf war illness. These have been swirling a quarter of a century. 20 yearold deployed troop in iraq wasnt even born when these symptoms arose and may one day suffer. We have yet to discover, a, cause and proper treatment for it, and b you how to properly ajudicate the claims associated with it. It is evident that there is need for improvement and the American Legion is willing to work toward achieving these bowls. In the last year vsos worked with va designing appeals modernization plan we collectively achieved. We have proven for substantial change to occur takes vao and va collaboration. The American Legion is eager to work with the va and vso to accomplish the feet. It will not be resolved instrumentally by fingerpointing. It is problem that will being resolved by identifying sensible solution. On behalf of National Commander charles e. Submit, members of the American Legion. We appreciate the opportunity to speak with you this morning. I will be happy to answer any questions. Thank you, mr. Figure lowell only. Members of the subcommittees on behalf of vfw i would like to thank you. As professionally trained accredited advocates vfw Service Officers work extraordinarily hard to insure our veterans and their testimonilies receive maximum benefit allowable by law for va. All too often this does not happen for myriad of reasons. For todays hearing i will focus on referred to largely across the Veterans Community as gulf war illness, more commonly in va, medically unexplained, multisymptom illness. Gulf war illness is ins strictly difficult to treat. In other words, no one distinctive set of symptoms that allow for a single unmistakable diagnosis. Gulf war illness presents itself as conglomeration of possible to thes which countless members about of the general public with no military experience can be subject. Persian gulf veterans have steeper hill to climb relating symptoms to illness most Critical Link to establishing Service Connection. None is remotely possible without benefit after va exam. As va continues to evolve on number of fronts, electronic business management, va developed Business Development questionnaires with eye toward efficiency and timeliness. Last year the vfw strongly advocated for elimination of parsing out of symptoms and placing greater concentration on clustering indicators of potentially one illness affecting mulitple body symptoms as he opposed to specific conditions related to each symptom. Put more simply the vfw feels gulf war illness claimants eliminating assignment of multivdqs and it meets criteria for gulf war illness. It remains our contention the Current System of assigning separate dbqs in association with gulf war illness promotes indirectly as signing a illness linked to gulf war illness which ultimately results in the veterans claim being denied. More than a year ago these committees met to discuss the topic to develop a single dbq for dwi. Regret iably va not reported any progress developing this dbq and veterans continue to have their claims denied. Va continues to rely on gulf war illness general medical dbq, not singular in nature for claims of gulf war illness, subjective nonmedically trimmed from a claims cisaness to determine veterans claim condition and schedule appropriate va exam. When asked about a possibility of creation of more favorable dbq, the response va would look into the issue. First we had to confirm lack after single dbq is a real problem. Mr. Chairman, lets stop mincing words. We know this is problem. Gao agrees. This continued problem has downstream affect appellate process. Boards of veterans appeals find numerous inkisses when decisions remanded to the Va Regional Office. The vfw notes that va appears to clearly favor finding a diagnosis for each reported symptom, thereby rule out gulf war illness, rather than further developing accurately applying the ratings schedule to diagnosis even minimally supported one. Vfw urges va to consider both possibilities as existential. Preponderance of evidence that shows beautiful war illness may exist the as its therefore, vas own regulations show that va should develop a claim for potential grant of gulf war illness disability. Vfw suggested in prior testimony ins is sys in the application of ratings schedule is with regard to claims for gulf war illness disabilities while we were not in in way suggesting this is deliberate, we continue to put forward that a grant for gulf war illness in michigan should be the same exactly same in New Hampshire or any other Va Regional Office based on same evidence and fact pattern. Vas office of Performance Analysis and integrity demonstrated their capability to track data nearly totzke stroke. This presents the perfect opportunity to identify and develop best practices across va properly ajudicating claims for gulf war illness around eliminate the disparities at very least with vas national war queue they could deliver specialized claims to regional offices with a proven track record of proper ajudication of gulf war illness claims as one of the nations largest vsos providing direct assistance to veterans seeking to earn benefits the va thanks the sub committee. We urge va to adopt a single dbq for all gulf war illness claims. This concludes my testimony. I will be happy to answer any questions you and members subcommittee may have. [inaudible] good morning, thank you, chambering man and bost, Ranking Members discuss sister and esty, distinguished members opportunity to speak with you today. Thank you gulf war veterans. We know youre watching live from all over count. Im Anthony Hardie. National board and chair directors veterans for common sense. Todays following hearing to try to fix these many unresolved issues. This is not how i saw my life at 47. Albright about denying the presumptive goal for claims exactly what gao writes about in the report. One from louisiana writes about having had to instruct a supervisor who had it wrong and calling the white house seeking resolution. The kentucky federal i filed for a constellation under lock symptoms i was denied. Others say the same thing. Whether sims and a tribute to diagnose conditions and can denied. Thats the crux of the problem. Its 23 since congress enacted the wellintentioned 1994 law that created a presumption for undiagnosed illness symptoms. I written statement details findings. Today gao confirming findings. We sit in the report that three times the nile rate of any other claim but the denial rates for undiagnosed illnesses are the worst of all and these trends or worsen over time and are 87 overall and get this, 90 for undiagnosed illness. We see from the claims these take 50 longer than other claims meaning veterans who are the worse off suffer the longest. The a underreported goal for claims by 57,000 issues, and bask in the true scope of this egregious problem. The fact that the va leaves door open for potential litigation but given the findings, a finding that mirrors are exasperated experiences we are glad to be a new scene be stepping up to the plate affixed gaos three basic recommendations. However everything the disability benefits question is using claims processing many if not most undiagnosed Health Conditions begin with his first basic question, does the veteran have this diagnosis . With that basic question it doesnt work for undiagnosed illness claims and quench it reports some claims examiners one never find in favor of an undiagnosed illness and will always attribute symptoms to a diagnosable illness thats most damned in showing its inevitable these claims will continue to be denied at near total writes about how much training is conducted. Collectively theres decades long evidence makes it clear. Undiagnosed illness as a to couple claim simply does not and cannot work. Its beyond clear what we need to do statutory fix along the lines of what we proposed in a written test one is needed or we will keep having these investigations. Decade after decade. We ask Congress Work in a bipartisan manner with President Trump to enact legislation to one central fix goal for illness claims and the other goal for issues we raise in this in previous testimony. The va essays about resolving these issues, and the ones of the veteran raises and last paragraph im about to read, leadership should leap of the chance to work with stakeholders and congress to craft of this legislation together. If for no other reason than the human impact of the night but not all goal for illness claims is all too real. Listen carefully to these works written by a fellow wisconsin veteran. I was told there is a twoyear wait before my p it will even be opened and that is now up to four years. Over the last ten years ive lost two jobs and my home. Weve had to move twice and change schools which is tough for my kids got feel like im on the verge of losing a job and im afraid i cant rebuild thanks again. My psychologist told me it was an awful long time to hold onto life by my fingernails. And i agreed. I put a belt around my neck twice and told my doctor wednesday that i would blow my brains out if i am denied begin. 22 per day day dont kill himself because of ptsd. Denied and called a liar by the administration that is supposed to be helping us. Veterans look alike are different than most. If have no hope i will not continue to be a burden on myself, my family and my country. I will do my best to let them know i was destroyed by the va. [inaudible] as soon as i turn on i will start. I do want to thank you all for being here and for your testimony. I do want to start with the question to mr. Hearn, do you think the vba adjudication manual provides useful guidance for the va employee employs a tr illness . When preparing for the testimony i was reviewing the manual and i think its fairly, its very clunky in the way it is written. And the question as to whether or not aspects of joint or more recent cases is applied properly and alerts the staff here i understand why the raiders and why the bsr is having difficulty understanding what to do. I think when you look at the vso configures a doesnt use the manual when advocating for a case. Do you know else who doesnt . The board of veterans appeals. So its funny that the one aspect that seems to be different is this manual and the vba rater. Thats a concern with the way that va goes about dealing with these types of cases. Mr. Flohr, how do you respond to a statement about where were at with this right now . Thank you, sir. First of all i would like to say the week before last i had my 42n42nd anniversary of working t the department of Veterans Affairs. All of them here in washington, d. C. , all kinds of jobs from a basic adjudicator to where i am now. And we used to have a very, the adjudication Procedures Manual was all in paper. Took forever to make changes, to get them to adjudication out in the field in our field station. Now its a live manual. It is live, online. We make changes easily whenever we find a change needs to be made we can do it. We have a large staff that can do that. Its very much a very to what used to have. Is a perfect . No. Nothing is going to be really always perfect because there are always changes. Theres either a Court Decision or legislation that is going to require us to make changes. But we do a lot of training. We have a very large Training Staff who works very hard to train our adjudicative and are reading specialists in making the right decisions. These claims are difficult. For example, an undiagnosed illness can any of you for you e physicians know when ephedrine presents or anyone presents to you with a constellation of symptoms, the first and give us try to diagnose it because he cant diagnose it you cant treat it. If you treated it possibly produce more if you treated with the wrong type of medication. So thats one reason why its so difficult undiagnosed illness claims. We request an examination. The examiners do all indicated test to time determine what if it has and if they cant we asked him to report to us, the veteran has an undiagnosed illness of the respiratory system, cardiovascular system, whatever body such they may be. When the kids relate to us we grant the clampett as a set of four to a diagnosis often is made and then when it is made, then the direct Service Connection criteria of statute comes into play. We must find evidence that veteran had that particular disability while they were in service, carly habit and determine how disabling it is. I dont want to interrupt but have another question on what to get to walk my time is limited. That va issued a training letter on february 2010 the details va should develop a claim go for illness. For example, 11 shocks the employs only to request disability exam for goal for illness. However gao found employees have different interpretations of vba policy. Despite vbas steps to clarify that guidance, with guidance. I think we can all agree that adequate exams come if one was requested are critical to correctly process these claims. The fast letter that was issued seven years ago, even despite the lack of additional clear guidance in the manual. So why is it that va employees still have such difficulty knowing when to request an exam for these claims . Thats a good question. As a set our live manual is pretty clear, at least in my view. But one of the other company wasnt a requisition made by gao but it was an expression that we should do perhaps consistency study on when to schedule an examination. May be, ms. Emreyarras i love messing thats fine. Melissa. Melissa, what you think the reason is . Va told us they were in fact, planning to do a consistency study to evaluate just this issue by consistency in referral for medical exams and they told us they would be doing it the Third Quarter of this fiscal year. So i think thats an excellent question to ask ivh and trends of what is the status of a consistency study. Glad to tell you that it was completed in april, which was in the Third Quarter. We gave it to allah out our vsos, our veteran Service Representatives to a lot when it was a wrong answer and with most studied defiance of edges not quite right, but after the exam was given then the people took the exam were taken to a room and provided post examination training to ensure that the new the right answer, what it is Going Forward so that would not make the same mistakes again so that was completed. Can we get results of the studies for the record, please . Yes. I would be glad to provide a. Thank you. My time has actually expired and i hate to do that to miss estes when she first walks through the door, but ms. Kuster did have to lead to another meeting. Ranking member kuster is here, if she is ready i was hoping to do that for you. Thank you all very much. Appreciate you being here. Sorry this be the fourth or fifth, i started at 6 a. M. This might so its one of those days. Its going to be long. Ndaa days are long with many different commitments. I really want to thank all of you very much for your efforts ever really partnering with us. This committee prides itself on bipartisanship and in getting things done for vendor making the va works well and where serving people the way we need to. And this Technology Changes and as the needs of veterans change, and for tha for the population,t will change over time. We will not always get it right but we will always try. We count on you doing the same thing, and giving a little nudge sometimes when we dont come figure out how we can all do this better. An issue i want to really look at because i feel about all the time in my district, and weve talked about it before in hearings here, is on decision letters and on the lack of clarity in decision letters. Im a lawyer. I read those decision letters. I cant tell what they mean. How can our veterans know what they mean . Its disrespectful, and it leads to appeals and leads to frustration and a feeling of disrespect. So if people could talk a little bit about what actually can we do. This is an incredibly high priority for me not just because im the subcommittee Ranking Member and i want us to deal with those claims, because its just wrong to be sending out letters that dont have clarity. So what can we do to get greater clarity in average people speak . This should not come use not need to have a phd to figure out what these letters mean, and to do think its disrespectful which is number one a problem. Number to come and leads to appeals and it leads people to disengage. We have to find a better way forward so would love to hear your thoughts on this as we are moving forward to make changes. Thank you. This is melissa, gao. I would say that we found a a letters did not specifically inform veterans that their claims have been considered in terms of presented eligibility. The language made it seem like only direct Service Connection had been considered. So if you are a veteran expecting a presumptive claim and you saw the letter you would think that that was not evaluated appropriately. And the a accepted that recommendation and we have plans to change our letters by the end of august to provide that information but i think we need to look at in more detail, see what we can make it even more clear. We will do that as well. This is a great concern to our organization as it is to the American Legion and the other vsos. The number one thing about these letters as you said their convoluted, they are not written in english. They are not written in plain language that the average citizen can understand. Its not just political for illness. This is for every disability, every communication with the va. Every letter has to meet certain requirements that they can outline in that letter to prefer claim you need to provide abc and the, not the standard cut and paste the evidence of record but we have to deny the claim because there is no diagnosis that this occurred or was caused by service to that tells the better nothing. We have been at the va to make them simple, straightforward and allow the better to understand the shortcoming and then correct the deficiencies so we can go ahead and approve the claimant. Thank you. Good morning, Ranking Member. One of the issues that we have noticed over time, especially the appeals inventory, is the a kind of shot themselves in the foot with these letters because a lot of veterans are appealing cases or appealing their claims but they dont know what they are appealing because they dont know why, they just know they feel like they got messed over by va. And so like mike was saying, they will sit ins a Service Connected, you must have the following. Why dont they identify, you have a diagnosis can you have an incident the service but yet we dont have a doctors note linking the two conditions. And i think thats whats creating a lot of confusion. Like you said you shouldnt have to have a phd or some sort of advanced degree just to figure this out and a fortune this is been a problem weve been calling for for years and years and years and put in the appeals modernization that was a caveat for the sole thing. We are very much looking forward to it. Can i respectfully suggest that when va has a draft letter ready they circulate it to this committee and the circulate it to vsos . I fully agree i think it ought to be broken out with a checklist with numbers so you can visibly see this criteria must be met, the following was, was not met. These would be documentations. So its really clear and its easy to do a checklist or that is the military waiter dont very get in the middle of the paragraph. Break it out so you can easily understand what that means. So i would urge that need to circulate that to us. I know i work with some behavioral economist. I want them to take a look at it and i would like to some actual veterans look at it and say this is make sense to you . If you read this what would you understand you would need to do. I think that would help us get to the objective wisher. Thanks very much and i see im over time. I apologies, chairman. Thank you. No apologies necessary. Quality, you should never put a time limit on good quality. Mr. Coffman, your recognized for five minutes. Thank you mr. Chairman. I saw to say first as a gulf war veteran how disappointed certainly i was in aftermath of the war and to this day that the department of defense i think participate in a coverup, and that coverup was the exposure to chemical weapons. And that i can remember the marine corps is limited advance in the first gulf war was kind of the northern end of kuwait on the iraqi border. And i can remember in aftermath of the fighting, and your tremendous visibility in the open desert, seeing this white cloud close to the ground not moving. I didnt think it was a question at that time, well, i knew later on, years later on what it was. And it was that combat engineers of the United States army were blowing chemical weapons in place because they did want to go through the hassle of all the decontamination stuff. So we were fortunate, the marines i were with were fortunate we were not downwind of the come that the wind patterns were moving in the other direction for none of the i served with came down with gulf war illness. But the department of defense denied for i believe about a fiveyear period in the aftermath of the war that the u. S. Troops were exposed to chemical weapons and it wasnt until they were forced to admit it later on that they in fact, that they did blow chemical weapons in place. And so i think we got a very bad start in terms of research, that that was not one of the aspects that were researched because the department of defense was so vehement in the nine, that that was, in fact, true. Vehement in denying. Certainly left a bad taste in my mouth as they go for veteran in terms of the integrity of the United States government relative to veterans. But i think my question at this point is, in the training of these disability, folks that to the processing, reviewed the claims, there doesnt seem to be any uniformity in the training, and as i understand it theres a course that is optional for them to take and i think its online. I guess let me ask the va, why isnt that mandatory training for our folks that do this claims, review these claims . Are you referring to the training for medical examiners, for medical opinions of the people who make the decisions . I think thats a good question. How is it for both . Well, for us, for vba every time we hired a new group of individuals we have a very large Training Staff and they get sent away to the baltimore or denver. We of training academies there. They go through a lot of training at least relative to to all particular claims, all types of claims. So they get an initial group of the training and then every of their required to complete training as well. Okay. Gao . The medical examiners are not required to take trainings specific to gulf war illness issues. If elective and because of their high caseloads and effective dont have a lot of time for a lecture training, only about 10 of the medical examiners have taken training on gulf war illness. American legion. Thank you, congressman. The training, that something that we have a lot of concerns about and i trusted during my remarks was that all the medical side, yet remember these are doctors come doctors a lot like mechanics. You dont take a car into the mechanic to fix my breaks a guy comes as is i dont know what it is. That goes against their dna. They naturally will create a diagnosis pic i think its how they operate. If the doctor comes back and says i dont know, thats a pretty rare circumstance. They want, the the concern is va as a department has said this is a priority of hours within only 10 have taken it, it can make you and if theres Just Lip Service been paid. Then the second aspect of it is that we started going to these contracted examinations. If they cant get right with their own employees, whats going to happen when utc or one of these other providers in the private sector having these examinations, are are they getting the proper training next which go for that it will be by the private sector physicians . My time is up. I yield back. Thank you mr. Coffman. Ms. Brownley, your recognized for five minutes. Thank you, mr. Chairman. And thank you all for being here this morning. This is a very important topic. They gao presented vba with a set of recommendations on this issue, and you had said and agreed to all of those recommendations. Can you, in a general way, can you give me an idea of when you might complete all of these recommendations and have them operating in a way that is more effective . Yes. Thank you for the question. We did accept and concur with the three recommendations. We appreciate gaos looking at this. They are always instrumental in helping us do a better job of what we do and we appreciate that. The recommendation to ensure the vha medical examiners take this 90 minute training has been accepted by vha. It is going to be made mandatory and speedy do you think 90 minutes is enough . I will let dr. Joyce answer that. I would like to address that the 90 minute Training Course described by others as being optional is a mere fraction of the training required to do a go for examination, or any other kind of exam. These physicians, Nurse Practitioners or physicians assistants are first licensed, privileged and experienced before they do go for examiners, examinations. This additional course of 90 minutes will be mandatory and completed by november. But it is supplemental to the underlying training compass Healthcare Professionals which allow them to address this very complex subject, subject that is not easy to define and is challenged even though learned colleagues at the National Academy of medicine. As far as number two, i think ill resend we had that is will and we will have our decision notification letters completed, changes made to them by the end of next month. And number three is, is the single Case Definition. We do have a plan to do that. Whats the plan . A plan is to get a lot of smart people together and try and figure it out. Whats the timeline . The timeline is march of 2018 right now. We ask the National Academy of sciences to do this several years ago. They couldnt do it, it was that difficult so they to it back to us. We are going to try and do that. Were going to get people from dod, people from Veterans Health administration, from vba, National Academies if we can, whoever we can get it was part about this. People from war related injury study send it in d. C. , follow up. They see a lot of gulf war veterans so we were really appreciate your input and try to come up with a secret Case Definition but we do have a plane and weve already started. Certainly my expectation is it that the va would be the experts when it comes to gulf war illness, and the va doesnt, should not have to look to other entities for that. The research, this is what its all about, is why the va in its nation is because they are serving our veterans with all kinds of illnesses, but there are specialty illnesses that are just not out in the world, other than within the va. And i think back to the medical training, i agree that the doctors that come to the va are welltrained doctors. I dont dispute that for a second, but a 90 minute webbased course to me seems like its really not deep enough, you know, to really understand sort of what veterans are going through and understanding of that. But certainly its a step in the right direction to require that everybody take a course so i certainly agree with that. Im in complete agreement with you. It is not sufficient to take that 90 minute course and call yourself a goal for examiner. It is a near supplemental course gulf war examiner better able answers to questions and i would be doing a disservice to my colleagues to suggest you could be certified that quickly. So with regard to the manual that has been spoken of and you talked about it being live, you can make changes as we go. The American Legion described as clunky. You described it as clear. Do you really think the manual is fundamentally absolutely clear . It is large, it is very large and it is full of a lot of information. And i have not process claims myself for many, many years so i dont necessarily always use the live manual. If i want to look u at Something Like i looked up what was on a goal for illness before eichinger, and theres a lot of information there that needs to be digested. And it may at times lead people to be confused. Im not sure about that again, but theres a lot there and when we need to change something we can do it immediately. Thats whats the best part about it, plus a bonus can see it as well. I think thats good, the transparency peace is good, but clarity is also important and i think that all goes back to the definition and other kinds of things that were talking about and i will come i know my time is up but i would just like to hear from vba, not now, but if you can get back to me. The opening of this hearing started about a deja vu, that weve had this conversation can we had it a year ago. Would really like to know what, the work that has been done since last year up until this point. Now were talking a year later, talking about meeting, some recommendations yet into the future. But i would like to the conversation offline and i apologize. I yield back. Thanks, ms. Bradley. Dr. Dunn, you are recognized for five minutes. Thank you very much. Id like to channel a comment made by mr. Hearn a little earlier where doctors dont like to say they dont know how and youre absolutely right come we dont. We dont like that, but we can be trained to say that and this is my next, is directed to dr. Joyce and mr. Flohr. I want to stipulate something just among us here. Can we agree we absolutely, we do not understand gulf war illness syndrome as a disease, none of us do and is a experts anywhere that at some comprehensive understanding of the pathology of this disease . Do you agree with that . [inaudible] you do. So now come we all agree that the claims arising, the denials are rising as well. Clearly some of our gulf war veterans are not having a conditions properly recognized and treated if we can agree on that, yes . We can agree . 30 there some of the veterans are not being recognized and treated for gulf war illness syndrome . Some, not all of them, some . Dr. Dunn, using the word some as we medical doctors do i will agree with you. Thank you. Medical technology. I have been up here long enough to use anything other than that terminology. We know the dod has been between 942016 over 172 million on research in hopes of simply clarifying the presumptive list of conditions, sort of that basket of pathologies that fit into gulf war illness syndrome. And we have made no new changes or additions in seven years, since 2010. My question is of this, the ten, can we together promptly finalize some diagnostic criteria for gulf war illness syndrome and then address the prompt rollout of administrative financial and medical action to help these deserving soldiers . Emphasis on prompt. You are talking about prompt training for medical providers . So you do listen him going back to the river, doctors dont like to say they dont know but if you go to doctor and say nobody knows, not just you, in this clinic, nobody knows gulf war illness syndrome, use this basket of symptoms that fit this criteria, use this menu of pathologies, and if your soldier cities criteria, and they were in the gulf war, then they presumptively have goal for illness syndrome and they get the financial disability, whatever and medical treatment such as we know at the time on phone and we know that will be advances. I spent my evening reading the studies on gulf war illness and unfastening stuff but not clinically relevant just yet. But its okay. I think you go to doctors. I worked in the hospitals and say nobody knows, notches you, can you make this diagnosis and help the soldier asked well, you know, the goal for illness is described in statute and regulations. If the better has a chronic multi symptom illness, which is defined in statute as, such as speedy pretty clear the system isnt working yet defining the Statute Committee getting lawyers involved was the wrong group. Maybe we need to get the doctors involved. That would be good, but if a veteran has one of those auto myalgia Chronic Fatigue syndrome, if a veteran speedy things we sort of understand speedy that is presented and we should be granted is immediately. If we are not please let me know. My charge i guess would be, and i heard you suggest to me, might do that by march of 18 to ms. Brown lays caution is to roll this out really, really promptly. No more fully around whether we been fully met with a for long, long time. We need to take some action to help these poor soldiers. And in my final 45 seconds id like to ask and i guess you, mr. Flohr, what would you have us say to our constituents who perceive that have a medical condition gulf war illness syndrome arising from their service in the gulf war, yet thats not being recognized by the va . And that happens to us on a weekly basis. Well, i all of us. I understand that i would to them that if they have a disability think resulted from the Gulf War Service and if it has been diagnosed chronic multicentric elves they need to provide that medical evidence when they filed a claim from the private provider or whoever it might be. If they only have symptoms, if they dont have a diagnosed illness then we will do what we need to do which is request an examination. Then under the law, if after all indicated tests are done the examiner cannot arrive at a diagnosis they should be cookbook, really, right . Yes, it should. Lets get the cookbook out there and its not easy. Thats the thing. Its not easy. Thats why we went to med school. Mr. Chairman, i yield back. Thanks. Thanks, dr. Dunn. Mr. Sablan, you are regular for five minutes. Thank you very much, mr. Cha. Good morning, everyone. Thank you for joining us today. I asked to join because i have seen a spike of veterans coming to the Congressional Office asking for help. They go see a doctor or a medical professional and they are told nothing is wrong with them. And here we are discovering that nobody really knows the entire story or whatever it makes off some of the illnesses from gulf war pic and in talking about gulf war veterans primarily. I had a week, two months ago, dedicated to just talking to veterans in a Group Setting in a onetoone basis, at all of the veterans have filed claims and they are still suffering. Some of them suffer in quiet. They quietly suffer because they are told nothing is wrong with them. Now, dr. Joyce mentioned that of va physician who is usually, usually examines a gulf war syndrome or unit specializes in this issue. So let me ask you, and that the gao reports that only 10 do this web service training. So let me ask you, contracted medical examiners, private doctors who are contracted it is because i dont have i va clinic in my district, what makes you determine that doctor knows what theyre doing . General, internal medicine doctor. So as a general, gulf war exams are an extension to the regular contract exams done to these nonspecialists and see if the exams. If they go see a doctor and the doctor says nothing is wrong with them, they cant get a referral to go to hawaii. You know, some of these people have no money to go to hawaii. You know it costs to go to why cant bush have to rent a car, get a hotel, lodging and everything. To make that appointment. And the doctor is saying nothing is wrong with you, so no one can, so it has to make that appointment in hawaii for them. They have to go to a doctor. I think im going to have to say that were going to have to get back to you because im not personally familiar with the referral system. Well, im sure that there are private doctors in the nation. And again, mr. Flohr, thank you, sir, for your years of service. But let me ask you, gao recommends that they should be required, a requirement that medical examiners completed Training Courses before conducting these exams for gulf war illness are complete training such as 90 minute gulf war illness with basic course and only 10 do it. What do you do to the 90 who wont do it . Do you give them a bonus bucks i heard you guys give out lots of bonuses. I can address that. When the course is now mandatory, we will be required, myself included, to demonstrate on a computerized record list because all the way to Central Office that we have completed the course and passed the test showing we took the course here no one will be exempt. Thank you, doctor im not pointing fingers, doctor. I making statements because they come from a place, i representa district where there is no va clinic, and to go to guam, to go to hawaii requires a lot of money. And these people dont have money. So they have absolutely no help and so they suffer in silence, and they come to me, especially when they are told nothing is wrong with them, they come to me and say what can they do . What can you do for me . I cant file appeal papers for them. I dont have their documents. Does it take the gao to tell you these things come here 42 years of service, sir. Do you really need the gao to tell you some of these things, that you failed to do, that we have discussed a year ago . [inaudible] but we work with vha to make sure that we get all that we need to make proper im sorry, i dont mean to be very, if i appear critical. I dont mean to be. Im just expressing, and i took the stories of veterans word for word. I added nothing. I took out nothing, and i presented them to secretary kelly, shall come, im, i mistaken. Bubut i really need help in my district and i cant, i dont know what else to do. I joined this committee trying to find help, not to be critical of anybody. I appreciate you guys are, i think gao also, but i will take him im over my time but i will tell you some of the best information i have learned over this series of parents have come from these people, the vsos. Unfortunately, i only have the vfw in my district, many of them are Vietnam Veterans,but ive put together a list of all vsos in the nation and is going on my website and im telling veterans join our go to vsos for help. I cant do your things for you, but they could be helpful. Mr. Chairman, i apologize for being out of time, general. Thank you, sir. No apologies necessary. My parents raised me to be kind. As a boy scout i was courteous, so im willing to try very hard to maintain my parents and my scoutmasters values here in my questioning. You can tell by the questions from our members there is a sense of urgency in this panel, a true sense of urgency. Im not sure i feel that throughout the room, so mr. Flohr, dr. Joyce, im going to look at you first. Do you feel a personal sense of urgency in this . Yes, and not just for gulf war veterans but all veterans. Yes, okay. So now since you do, can you give me in examples at the va or the last, pick your time, two years, ten years, that would actually show a sense of urgency from the top on down to get some results . Let me try it in a different way. Can you give me an innovative program, innovative, that was based on a sense of urgency to shrink the timeframe to develop the capabilities for the individual practitioners and necessary to begin to get a handle on this problem . Can you give me one example of innovation, other than a 90 minute optional online Training Program . I can give you an example of an innovation that is currently underway, its called underway . How about an execution phase . Underway mean were working it up or does underway mean actually being speedy working with the department of defense to achieve an electronic availability of determining someone had an exposure while there on active duty. That it . Yes, sir. I would also add in the testimony mr. Flohr so far, the increase in number of claims for gulf war illness is a demonstrable manifestation that more have been great segue, thank you very much. Because in the military we, and youve heard this term, in fact, general petraeus coined the term when you look at changing how we were looking at Operation Iraqi freedom and he talked about creating the surge. Can you give me an example of the surge operations that have been instituted within the va . Not just asking for more money and more people, but taking already existing assets that you have and that you pay every day of the week and redistribute those assets in a certain manner to begin to grab a handle on this . I dont know if this is what you are looking for, but im looking for existing assets that you refocused based upon a perceived need. Again, war fighting is real simple. The enemy is over here, bring a step over here to go after them. What weve done over the last several years that if you dont training academies for newly hired employees way to get the training they need to make proper decisions in a Group Setting. They get tested. Its working out very well for us. Is there a sense of urgency . Its urgent we get them trained for theres one urgent you feel a sense. Sensing is a feeling. Someone can write the word urgent, but unless you sense urgency, thats where im going with this. From the top down if the leaders and the people in charge do not have a sense of urgency, thats not going to filter down into the organization. It doesnt come from the bottom up. It comes from i believe secretary shulkin as a sense of urgency and he is reeling that didnt to all of us . It too bad it took the second to come if you will. And i agree with you, secretary shulkin does have a sense of urgency. Im trying to reinforce our support for his efforts to develop that sense of urgency throughout the va. Heres a question for you. I dont care who answers of this. Whats the single biggest challenge for us moving forward here . On going to give you two of my choices. Apathy or bureaucratic red tape. Mr. Chairman, anthony from veterans for common sense to i would like to suggest taking the biggest challenge that undiagnosed illness doesnt work and all the training in the world is it when you fix it. The solutions we can rewrite manuals all day long, if somebody doesnt work because these conditions are diagnosed are i had a veteran this one who context means that i was diagnosed with sleep apnea. Its one of the nine conditions listed under sleep disorders. Why cant i get this done and i explained to him it was diagnosed and, therefore, doesnt qualify under undiagnosed illness. He says that makes no sense. I said thats the point. So is it apathy or bureaucratic red tape that is causing that . Does anyone want to throw it out there . Theres a right or wrong answers answers. Its what you perceive based upon your understanding and research into this issue. Mr. Chairman, i would say its bureaucratic red tape in my opinion, too many steps, the manual is clunky, confusing. Training is not conducted in a way that they can recognize either. It is for it is not golf war illness and roadblocks abound gulf war illness. It was made more so, if it was developed to the point that said this is, in fact, gulf war illness or if we started from template goes and worked away backwards it might be less of. This is not been going on since last yupik this has been going on since 1997, mr. Kevin. Thank you very much. Question for mr. Flohr probably, and dr. Joyce. What would be the cost, dollar cost, to just presumptively assume that all, all, gulf war veterans had a baselevel of gulf war illness . What would be the cost . I have no idea. Ill tell you what, would you take it for the record . I could take it to our staff that works on those costs. Good. I think, and i dont care whether its 10 , 20 , i, i dont care. Are you talking about any disability claim by a gulf war veterans . Getting into the system, presumptively assume because they were there they were exposed. Again we are a product of our own expenses. Im agent orange. On vietnam. Okay . I can tell you that right now gulf war veterans for serviceconnected to more than 14 million disabilities. Give me a cost to presumptively assume, that you were there in that specific timeframe, because when we talk about what are we, number one, what are we providing, what is the cost of providing it, and how quickly are we going to come to some resolution . Wait time is not, wait time is of a mine, one of my squadron mates told a month ago, he is still grieving for the recent loss of his wife to cancer. And he said, and hes writing a book on our experiences in vietnam, but quote, the quote is going to use to all to know and it relates to his grieving for the loss of a spouse is you think you have time but you dont. I would suggest to you that that sense of urgency in thinking about how much time you have but you really dont, we need more. We need a lot more and we needed senator and you can do it with quality. I know you can. I have gone over my time, and and less of the other followups, were going to procedure with a closing statement. First of all id like to thank all the witnesses for participating in the hearing today. The panel is not excuse and as you heard chairman bost and Ranking Members say, that our efforts as these subcommittees on behalf of the veterans are an example of true bipartisan effort that we are all philosophically aligned, that is our job as the committee to do the right thing for the veterans. These subcommittees that we represent here will continue to set the example for our 115th congress about doing the right thing for those involved. I am very proud to be a member of this committee. For years of this committee has been working to address the root cause of the high denial rate for gulf war illness claims. In that time we have been met with a list of excuses from va for failing to improve the process for gulf war claims. Last year we held a hearing to assess the disability claims process for gulf war veterans and highlighted, just as we discussed here today, that vas approval rate for gulf war illness claims its less than 20 . Va often seems to deny these claims because it demands to know the specific cause of an illness. Yet under the law, presumptive conditions do not require causality because they are presumed to have been caused by service in the gulf war. The Government Accountability Office Report that weve discussed in detail here today further substantiated that the approval rates for gulf war illness claims are three times lower than all other claims disabilities. The critical point to understand is that veterans cannot receive appropriate va care for symptoms of gulf war illness when the majority of those claims have been denied by the va. To make matters worse the reason for claims denials are also not clearly communicated to veterans. We heard that in your testimony to its not written in english, if you will, or their representatives. Failure to communicate the reason for denials often leaves a veterans with confusing or insufficient information for a potential appeal which for the delays access to care and compensation for injuries. Gaos review of the medical examination process for gulf war illness also highlighted the vas medical staff, that vas medical staff are not adequately trained to conduct the exam, and we talked about the 90 minute optional course. Vha medical examiners inform gao it is challenging to conduct gulf war general medical exams do to the range of symptoms associated with the claims. Although their concerns are legitimate, there is limited evidence to support that vha has taken the initiative to improve the examination process. Again, that sense of urgency. Gao reported that as of februarf examiners participated in the optional Online Training for those examiners. This the cystic is troubling, very troubling, because the vba statistic cannot consistently and i can provide benefits ratings without a proper exam from vha. Furthermore, gao found that another contributing factor for claims denial was the lack of a single cause, excuse me, single Case Definition of gulf war illness. Establishing such a definition could lead to improvement in diagnosis and treatment of gulf war illness. Over the Years Congress has appropriated millions of dollars for va Research Programs and there is still strong resistance against establishing a single Case Definition for undiagnosed illness related to Gulf War Service. I am also extremely concerned that the va does not have a plan to guide, to review of the existing medical data sets, and integrated information from recent and Ongoing Research to identify areas of future research and establish a single Case Definition. Again, that sense of urgency when it comes to innovating and really coming together to move forward. I look forward to continuing to work with va, Veterans Service organizations, and other stakeholders to increase gulf war illness claims approval rates. Improve the medical examination process, Prioritize Research related to go for illness, and ensure that vba is providing straightforward information to veterans regarding their benefits decisions. With that i now yield to Ranking Member esty for any Closing Remarks that you might have. Thank you, general, thank you to all of you on the panel. I particularly want to thank mr. Hardie. I know this is been a patient of yours, and you been a forceful and persistent and sadly, necessary advocate, to put a human face on what i know from my friend who has inspired me to introduce a bill to try to move this along further, so i in particular want to thank you for your advocacy. I dont think we would be here today if it were not for your efforts, and im sorry for the reasons it has brought you here but im glad you are here. I want to thank you. As a new member of this committee, im struck by how much we need to learn, the hardearned lessons of agent orange, and not do what was done then. And i think the level of frustration your scene from this panel is a deja vu, that this is taking too long and not everybody has got time, nor should they have to wait. The most important of those lesson is that we have to be determined. We have to work together. The unwieldy and Lung Research process which again i would agree with my process, the expert on the goal for an illness is not the National Academy of sciences. It should be the va. Nobody else should know or dod or take working together nobody is going to know that other than right here, the people who supervise. The difficulty medical examiners have understanding the multi symptom Health Conditions of gulf war illness, and is a giddy in the way of identifying and quantifying toxic exposures on the front and, and providing timely fair compensation, services, and most importantly, top quality healthcare for our gulf war veterans on the back end. We owe it to them not to let this happen, as we continue to owe it to our Vietnam Veterans and the bluewater veterans who are still trying to find a way to get the care that they need and deserve. I think its very clear and want to acknowledge and thank the v for taking steps in the positive direction for veterans who have gulf war illness but it seems to me the steps are too small, too incremental. They lack the urgency and they lack the surge, the surge that we need. Its been 26 years since the first gulf war started at many of the veterans who are deployed are very sick and the been beaten down by a claims process that is confusing, it is unclear, and in almost every case they seems to deny what you know to be true in their lives. That is undermined their faith in the system as a whole. And they are disconnected and they are discouraged, and that is quite simply wrong. So i want to say for my part and i suspect im not the only one on this panel that if va doesnt use its authority on its own initiative, congress will begin to take steps. We will set time frames. We will mandate training for all examiners, whether they are in the va or whether the contractor i think that has to happen to we will mandate timelines within which we have to have a single definition that everybody can use. And most importantly we need to do better. The general and i were talking about this point about cost. Which often seems to me to be really the reason behind the red tape. The point should be to care for our veterans. And if were spending so darn much time and expense and people dedicated to making people are sick prove just how sick they are and how they got so sick, what about just taking care of the people who defended this country . What if we took the same resources that are deployed dell on saying no and deploy them to saying yes to those who were deployed in the gulf . I think its not just an academic exercise to answer the question that the general and i were talking about or a directly asked what would be the cost of a truly presumptively saying anyone who served, we will get you better and back on your feet. That is our commitment to you. And not spend our time trying to determine what percentage of where were you exactly. Time and effort that goes into this time of distinction and instead id rather see that money going to care for others so i ask you all to think seriously about that and ask everyone on this panel if the time has come to rethink, particularly at a point where were now with the volunteer force. Our methods are changing and we need to think about changing with them. Thank you for your service, thank you for working with us and we look forward to seeing those letters in august and i hope they will be shared so we can get this better and get that right, thank you very much and with that mister chairman general, i feel that thank you Ranking Member sd. I ask unanimous consent of all members by legislative days to revise and extend the remarks and include extraneous material. Without objection, so ordered. I would like to once again thank sincere thanks to all of our witnesses and audience members for joining in todays conversation. With that, this hearing is adjourned. 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