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PTSD Compensation and Military Service 2 Background—Disability Compensation Disability-compensation systems vary by myriad factors, reflecting the social, political, and economic conditions of their formative periods. The legislators who create these policies and the executives who carry them out are influenced by key stakeholders and constituents as well as by the state of the relevant science and law at the time of their actions. Thus the major disability-compensation systems that exist in the United States today—veterans’ disability compensation, Social Security disability programs, workers’ compensation, and, to some extent, private disability insurance programs—are multifactorial legacy systems. This committee was charged with addressing veterans’ compensation policy and, specifically, veterans’ compensation for posttraumatic stress disorder (PTSD), but committee members agreed that examining the intent and conduct of other compensation systems would be useful in fulfilling that task. The first part of this chapter provides a historical background on veterans’ disability compensation, focusing on the period up to and including World War II. A brief review of veterans programs in the United Kingdom and Canada is also included. The chapter’s second part presents an overview of other disability-compensation systems in the United States. Together, these sections serve as a contextual foundation for the material presented in subsequent chapters. EARLY COMPENSATION FOR MENTAL DISABILITIES Early American colonial law regarding the care and responsibility for mentally or otherwise disabled persons reflected existing English law to
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PTSD Compensation and Military Service a great extent, with the disposition of a particular case dependent upon such factors as whether a disabled person was considered to be violent or nonviolent, was mentally or intellectually disabled, was able to maintain gainful employment or had access to familial material support, and was accepted as a charge of the local community1 (Braddock and Parish, 2001). From a public welfare perspective, a great deal of overlap exists between the early support systems for the mentally and physically disabled and for the indigent and the criminal. The residents of early asylums, workhouses, almshouses, and houses of correction were a heterogeneous mixture of the criminal, the poor, the orphaned, the elderly, and the sensorily, physically, and mentally impaired (Braddock and Parish, 2001). The earliest legislation that specifically included a provision for the care and maintenance of persons with mental disabilities was authorized in 1751 in the Pennsylvania colony as part of the law establishing the first general hospital in America (Braddock and Parish, 2001). The petition associated with that legislation cited the growing number of “Lunaticks or Persons distempered in Mind and deprived of their rational Faculties” as justification for the new provision. A 1776 judicial decision in Pennsylvania established what seems to have been the first municipally mandated institutional provision for the mentally ill in the colonies. The Pennsylvania court ordered that “a small Levy be Laid to pay for the buildings of ye house and the maintaining of ye said madman according to the laws of ye government” (Braddock and Parish, 2001). Throughout the early 1800s counties often dealt with the mentally ill with a practice known as bidding out or auctioning out. When a disabled person was auctioned out, the county paid a stipend to the lowest bidder for the provision of one year of care (Breckenridge, as cited in Braddock and Parish, 2001). Auctioning out would not necessarily have been an improvement over the “beatings of the head [that] were employed to treat people with many mental diseases, including depression, paralysis, and intellectual disability” during the 1700s, as many auctioning-system-related abuses occurred with little or no official monitoring of the care of these wards (Braddock and Parish, 2001). Over time the practice of auctioning out fell out of favor, as local municipalities found its continued implementation to be cost prohibitive. Fishback, in his essay on public assistance during the American colonial period (Fishback et al., 2006), notes that the Philadelphia Almshouse, 1 Under England’s Poor Law of 1601—also known as the Elizabethan Poor Law—the local community was required to provide certain maintenance through compulsory taxation when a family was unable to provide for a mentally ill member. This provision, and its associated economic burden, often led to a person with mental disability being forcibly driven from local communities (Braddock and Parish, 2001).
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PTSD Compensation and Military Service like most almshouses of the period before the Revolutionary War, “was a miscellaneous receptacle for human distress. One almshouse could serve as a hostel, a hospice, and a home for the disabled.” Little research has been conducted on rates of receipt of public assistance during the colonial period, and any such quantitative research on that period that attempted to segregate the physically from mentally disabled—or even the disabled from the poor and criminal—would need to carefully consider the operational definitions for recipient and assistance, as the lines between penal action and welfare administration are barely distinguishable in the few early records that do exist, and “the auctioning system of the 1800s or the whippings of the 1700s … hardly deserve the word ‘assistance’” (Fishback et al., 2006). While vicissitudinous, the near-400-year history of public assistance for the disabled in the United States evolved with successive policy changes, generally shifting from a collection of disparate systems of localized administration and funding to a series of programs of increasingly uniform standards and more centralized control. An exception to this pattern is the system of public assistance for the veteran, as a centralized policy for the maintenance of disabled soldiers was established very early on, during the Revolutionary War period. VETERANS’ DISABILITY COMPENSATION The Pilgrims at Plymouth are credited with passing the first pension law in America (Burke, 1899).2 In 1636 the Pilgrims “enacted in their Court that any man who should be sent forth as a soldier and return maimed should be maintained competently by the colony during his life” (Plymouth Colony Records, as cited in Burke, 1899). This policy was retained when Massachusetts Bay and Plymouth colonies formed a union in 1691 (Burke, 1899). Virginia, Maryland, and New York passed their own colonial statutes providing compensation for disabled military members in 1678 (Burke, 1899). Maryland’s statute went beyond compensation for disabled soldiers and provided pensions for widows and dependent orphans (Rockoff, 2006). While today the compensation of those disabled through service to their country might be seen by many as an obvious social obligation,3 during the 2 In 1624 colonial legislation with provisions for the compensation of disabled soldiers was passed in Virginia. Had it not failed to receive ratification in London, it would have been the earliest compensation legislation in the colonies (Rockoff, 2006). The British had a 200-year history of compensation for disabled military veterans at the time the first pension laws were passed in the Colonies (Bradley Commission, 1956). 3 Veterans in England were maintained through the charitable support of the monastic system until 1592, when legislation providing government compensation to disabled veterans was enacted. A sense of national responsibility for the disabled veteran that was part of their British heritage remained among the early colonists of America (Bradley Commission, 1956).
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PTSD Compensation and Military Service Colonial era a major impetus for veterans’ disability compensation was actually the need to build and maintain militia strength during the first Indian Wars, most notably the Pequot War in New England (Rockoff, 2006). Revolutionary War The first federal disability-compensation program in the United States was provided to the veterans of the Revolutionary War. From the onset of the war the Continental Congress was inundated with “claims for relief” submitted by disabled servicemen. Officers in the field warned the Congress that if it did “not give better encouragement to the privates than at present is held forth to them, you will have no winter army” (Powell, as cited in Bodenger, 1971). Largely in response to growing pressure from military leaders, plans for the relief of disabled veterans were formulated and ratified, becoming what is known as the Military Pension Law of 1776 (Bradley Commission, 1956). Pursuant to the Pension Laws,4 half-pay was to be given “for life to every officer, soldier, or sailor losing a limb in any engagement or being so disabled in the service of the United States as to render him incapable of earning a livelihood,” and a portion of this was paid to the partially disabled (Bodenger, 1971). The promise of monetary compensation for war-related disability served not only to attract enlistments in the Colonies—where popular support for the war was far from unanimous (Bradley Commission, 1956)—but also to prevent desertions from an Army fighting in conditions that were abjectly cruel: [T]he emaciated, louse-infested … half-naked exhausted men, broken in spirit and discipline, crowded into the camps and hospitals … [where] sickness, suffering, and death from communicable diseases intensified the devastating effects of the ferociously cold weather upon soldiers who were short of clothes, shoes, blankets, fuel, and food, and existed in dismal, frigid, filthy huts (Bayne-Jones, 1968). Further incentives were provided for military service when land grants became a standard part of enlistment contracts, and by the War’s end more than 9.5 million acres had been awarded to veterans of the Revolution (Rockoff, 2006). These compensation policies continued to be modified in the decades following the Revolutionary War. Benefits were made increasingly comprehensive, for instance. Initially limited to members of the Continental Army, benefits were soon provided to “all disabled men who fought in 4 What is known today as disability compensation was formerly known as a pension. It was not until 1919 that all awards related to service-connected disability and death were referred to as compensation (DVA, 2006a).
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PTSD Compensation and Military Service the common defense”5 (Bradley Commission, 1956). Throughout the late eighteenth and the early nineteenth centuries, as the federal government attempted to develop acceptable disability policies for veterans, the distinction between recipients of disability compensation and of veterans’ pensions6 became less clear, as some veterans on the compensation rolls discovered they could receive greater monetary benefits by shifting to the pension rolls and many veterans received compensation and pension concurrently. During the early part of this period the locus of benefits administration, with often protracted and circuitous modification, shifted away from state-level jurisdiction to adjudication at various offices at the federal level. While Congress retained final authority over claims, the Secretary of War generally assumed the responsibilities of compensation administration in 1789 (Bradley Commission, 1956). In 1802, the Secretary of War asked the U.S. Attorney General for an interpretation of the Military Pension Law in order to clarify the issue of service connection for claimed conditions. According to the Attorney General, the connexion [sic] between the inflicting agent and consequent disability need not always be so direct and instantaneous. It will be enough if it be derivative, and the disability be plainly, though remotely, the incident and the result of the military profession…. Such are the changes and uncertainties of the military life … that the seeds of disease, which finally prostrate the constitution, may have been hidden as they were sown, and thus be in danger of not being recognized as first causes of disability in a meritorious claim [Opinion of Richard Rush (U.S. Attorney General) April 15, 1815] (DVA, 1993). This finding indicates that by early in the nineteenth century policy makers were already recognizing delayed-onset cases as pensionable. In 1808 the states’ remaining compensation responsibilities7 were transferred to the federal government. During the period when the state and federal governments had shared responsibility for administration, monetary awards had varied by the individual state’s ability to fulfill the federally mandated program. One of the results of the 1808 transfer of overall compensation administration to the newly established Bureau of Pensions8 was to establish greater consistency in awards payments (DVA, 2006a). Despite the existence of a dedicated federal bureau to oversee compen- 5 Pensions were provided to local militia, etc. 6 Refers to service pensions and not retirement pensions. 7 Claims had been qualified at the state level and awards were paid by the states and the “sums thus paid [were] … deducted from the requisitions levied on the states for the support of the Confederation government” (Bodenger, 1971). 8 The Bureau operated under the authority of the Department of War.
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PTSD Compensation and Military Service sation, a number of major issues remained that both complicated policy development and hampered the administration of veterans’ benefits programs. These included: service records that were of poor quality or nonexistent; pay that was substandard and that was provided in currency that rapidly devaluated during the course of the war; the existence of pension disparities—officers received half-pay for life, while grants for enlisted personnel were far more modest and of limited duration—which in turn led to demands by enlisted personnel for compensation later; and limited-duration enlistments, which further compromised the quality of enlistment records (Bradley Commission, 1956). In the uncertainty created by the postwar government fragility, veterans began organizing to push for timely receipt of their promised benefits. The Commutation Act of 1783 had provided government-issued securities—at 6 percent interest—equal in value to five years’ pay for officers who had served during the War of Independence. Securities were not provided to enlisted personnel; they received instead a service pension of one year’s pay (Rockoff, 2006). But the Confederation could not afford to pay the pensions that had been awarded or even to cover the interest on issued bonds (DVA, 2006a). Fears that the country would fail to fulfill its obligations to its veterans led to the formation of the Society of Cincinnati, considered to be the first veterans’ service organization in the United States (Rockoff, 2006). The Society was composed of officers of the Revolutionary War, and its express purpose in the years following the war’s end was to “pressure the government to fulfill the pledges made to the officers” (Rockoff, 2006). The Society’s early activities marked the beginning of a long history in which veterans’ service organizations have been engaged quite influentially in the development of benefits’ policy in the United States. Early compensation legislation did not specifically refer to mental disabilities, but the language of the following Continental Congress pronouncement would indicate that policy makers intended more than a simple physical-injury-driven pension program for veterans: [P]ermit not him, who, in the pride and vigor of youth, wasted his health and shed his blood in freedom’s cause, with desponding heart and palsied limbs to totter from door to door, bowing yet his untamed soul, to meet the frozen bosom of reluctant charity (Glasson, 1900, as cited in Braddock and Parish, 2001). Furthermore, eighteenth-century experts in military medicine had already recognized that the health of the soldier extended beyond infectious disease
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PTSD Compensation and Military Service and injury. Baron van Swieten, in his 1776 volume The Diseases Incident to Armies with the Method of Cure, notes that “the soldier fresh lifted, and torn at once from his family, no sooner loses sight of his village, but he becomes melancholy; and tho, [sic] a robust husbandman, finds himself scarce able to bear the fatigues and inconveniences of a military life” (Bayne-Jones, 1968). The War of 1812 Through the Civil War Period Between the Revolutionary War and the Civil War veterans’ disability policy went through a series of changes (Rockoff, 2006). At the beginning of that period, eligibility was strictly contingent upon the existence of a disability, but 1818 saw the introduction of a needs-based service pension for veterans of the Revolutionary War.9 As a result, between 1816 and 1820 the number of veterans receiving a pension increased by 805 percent from 2,200 to 17,730, and the total cost of compensation increased by 1,167 percent from $120,000 to $1,4000,000 (Bradley Commission, 1956). There was no means test associated with the 1818 act, and pensions were considered to be “an expression of gratitude and an act of charity which did not subject indigent veterans to the humiliating necessity of searching for evidence of the precise quantum of their property, or producing surgeons’ certificates of the state of their bodily strength” (DVA, 1993). In 1820, however, budgetary constraints led to the purging of all pension recipients from the rolls, pending proof of poverty. Pensions for the majority of these veterans were restored in 1823 when the economy was more robust. Veterans of the War of 1812, the Mexican-American War, and the Indian Wars were given monetary pensions similar to those provided to veterans of the Revolutionary War, with eligibility restricted to invalids and the dependents of deceased soldiers (Rockoff, 2006). Veterans of these wars did get warrants for tracts of western land, although that program was thought to have been motivated at least in part by the government’s need to secure hostile regions. By 1860 warrants for more than 73 million acres of land had been issued to veterans (Rockoff, 2006).10 By the time service pensions were established for veterans of these wars, so much time had elapsed—pensions for veterans of the War of 1812 were not established 9 While the first major study of veterans’ earnings was not reported until 1956 (President’s Commission on Veterans’ Pensions), the sharp increase in the number of veterans qualifying for pensions on a means or income basis might imply that veterans were not thriving in post-war occupational settings, assuming that the eligibility cutoff for income was derived from valid economic indices. 10 It has been estimated that roughly 40 percent of the total arable acreage in Iowa was transferred via veterans’ warrants (Rockoff, 2006).
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PTSD Compensation and Military Service until 1871, for example (Rockoff, 2006)—that they were the equivalent of old-age pensions for those veterans who had survived to receive them.11 Much as was the case with the Revolutionary War pension laws, Congress’s passage of the Civil War pension system in 1861 has been attributed in large part to the need to raise an army (Blanck, 2001). The pension program was further expanded in 1862 into the so-called General Law System. One of the changes ushered in under the General Law System was a requirement that veterans applying for disability compensation be given a medical evaluation. This evaluation would rate the disabilities found to be attributable to wartime activities according to the veteran’s relative ability to perform “manual labor requiring severe and continuous exertion.” The rating protocol was later amended to include nonmanual labor skills (Blanck, 2001). Under the new system, a veteran12 declared totally disabled was entitled to a monthly annuity of $8. Physicians were responsible for the medical screening and rating of claimed disabilities. Disabilities rated as less than total were awarded in fractions of the maximum $8 grant. Blanck (2001) notes that the “war-related lost finger or small toe was compensated by a prescribed rating of 2/8 totally disabled” or a $2 per month annuity. Amendments to the General Law System in 1862 and 1866 expanded the list of compensable conditions and “increased the rate of compensation for severe disabilities that were neither self-evident nor easily ascertainable by the existing medical practices” (Blanck, 2001). Many of the newly compensable conditions were rated based on their “equivalence” to injury or wound-related disability. The veterans’ compensation system became more complex as it continued to be amended throughout the 1870s. In 1873 the Consolidation Act was passed by Congress. Under the act, levels of severity were assigned to ratings for war-related disabilities, and compensation was for the first time linked to impairment and not to rank (Blanck, 2001; Bradley Commission, 1956). The act also allowed for the compensation of disabilities shown to have “originating causes” during military service. Thus while a veteran may not have been disabled for years following military service, if a claimed condition was etiologically related to service, then the condition was pensionable (Blanck, 2001). Due to the crude nature of many of the diagnostic techniques of the day and to changes in the national economy, controversy soon arose regarding the equitable application of medical evaluations and disability rat- 11 Rockoff (2006) also notes that in the 39-year period while Northern veterans of the Civil War were waiting for service pensions, their numbers decreased from 1,830,000 to 821,000. 12 Only Union soldiers were eligible for pensions. Some southern states provided pensions to Confederate soldiers (Rockoff, 2006). It was not until 1958, when the Confederacy was pardoned, that the single living survivor of the Civil War was awarded a pension.
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PTSD Compensation and Military Service ings (Blanck, 2001). Not long after the liberalization of eligibility criteria brought about by the General Law System, newspapers were publishing stories of alleged corruption in the veterans’ disability pension system, and the system was portrayed largely as a corrupt process in which biased surgeons were substantiating exaggerated and faked claims of disability (Glasson, 1901, as cited in Blanck, 2001). While comprehensive statistics were not recorded at the time, an 1888 report made to Congress by the Commission of Pensions indicated that between 1862 and mid-1888 a greater number of awards were granted for delayed-onset diseases than for service-incurred injuries (Blanck, 2001). Among the Commission’s reported statistics were 5,320 pensions for nervous prostration and 1,098 pensions for “disease of the brain, including insanity” (Blanck, 2001). As well, 25,994 cases of “diseases of the heart” were reported. It was during the Civil War era that military physicians first attempted to isolate the causes of an increasing number of heart disorders of unclear etiology (Meagher, 1919). Jacob Da Costa, an Army surgeon, hypothesized that the syndrome variously referred to as irritable heart, soldier’s heart, effort syndrome, neurocirculatory asthenia, and disordered action of the heart13 was actually an organic response to battle stress (Lasiuk and Hegadoren, 2006; Meagher, 1919). Da Costa’s analysis of 200 cases revealed that 38.5 percent had been exposed to “hard field service and excessive marching,” and 30.5 percent had a history of diarrhea (Meagher, 1919). Being able to attribute soldier’s heart to a physical cause provided an “honorable solution” to all vested parties, as it left the self-respect of the soldier intact and it kept military authorities from having to explain the “psychological breakdowns in previously brave soldiers” or to account for “such troublesome issues as cowardice, low unit morale, poor leadership, or the meaning of the war effort itself” (Van der Kolk et al., as cited in Lasiuk, 2006). Physicians in Britain were also grappling with “disorders of the heart” among their veteran populations. In 1865, based in large part on the studies conducted during the Crimean War by W.C. MacLean at the Army Medical School at Netley, British physicians attributed the syndrome previously investigated by Da Costa to soldiers’ equipment (Jones, 2006a; Jones and Wessely, 2005). Redesign of the equipment was recommended because government-issued rucksacks and waist-belts were thought to restrict circulation “through the heart, lungs, and great vessels,” and it was observed that in “well-disciplined regiments the practice of falling out at drill or on the line of march is discouraged, and [that] men will bear and suffer much, rather than incur the imputation of being ‘soft’” (Jones and Wessely, 2005). 13 Later, the name Da Costa’s syndrome was added to the list.
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PTSD Compensation and Military Service Throughout various British campaigns (Afghanistan, Egypt, and Sudan) between 1882 and 1902, concerns grew in the military medical community as the reengineered field gear failed to reduce incident cases of “irritable heart” (Jones and Wessely, 2005). By the time World War I approached, at least two patterns in veterans’ disability policy had emerged: benefits were established at the start of wars, despite considerable protest of many legislators and other stakeholders; and, as time passed, the amount of time between death or onset of disability and receipt of compensation awards was gradually reduced (Bradley Commission, 1956). Throughout this period, pension lawyers and veterans service organizations like the Grand Army of the Republic (GAR) became influential lobbyists for the expansion and delivery of benefits (Rockoff, 2006). President Grover Cleveland’s 1888 reelection defeat was said to be due in large part to his unpopularity with the GAR subsequent to his 1887 veto of legislation supported by the GAR that would have provided service-based pensions to “deserving” veterans (Blanck, 2001). In vetoing the bill, Cleveland had expressed concerns over the potential difficulties posed by a situation where the “establishment of facts [resting] largely within the knowledge of the claimant alone … would not only stimulate weakness and pretended incapacity for labor, but put a further premium on dishonesty and mendacity” (Blanck, 2001). The economic prosperity that the nation enjoyed in the years following the Civil War contributed to the liberalization of veterans’ benefits. Enabled by a federal budget that had for many years been in a surplus state—and following a pattern that was very similar to the evolution of Revolutionary War-era benefits—the Dependent Pension Act of 1890 broadened pension eligibility to include any veteran who was “incapable of manual labor” (Rockoff, 2006; DVA, 2006a). The lifting of the requirement that disabilities be service-connected led to a 203 percent increase in the number of veterans on the pension rolls by 1893 (DVA, 2006a), by which time veteran-related spending represented 43 percent of the total federal budget (Rockoff, 2006). The World Wars Micale and Lerner (2001) assert that by 1918 there existed “vigorous public and academic debate in the U.S. over the care and treatment of shell shocked veterans.” Shell shock was an expression used first in 1915 in the Lancet by Charles Samuel Meyers, a military psychiatrist, to describe the escalating number of psychiatric cases of unknown etiology among British soldiers (Meagher, 1919). Meyers hypothesized that the observed syndrome—seen in hospitalized combatants and characterized by anxiety and “distressing dreams of battle, bombing aeroplanes, etc.” (Meagher,
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PTSD Compensation and Military Service 1919)—was caused by cerebral concussion and rupture of the vasculature resulting from exposure to exploding shells (Lasiuk and Hegadoren, 2006). Later, Meyers recognized that there existed an analogous condition with the same set of symptoms that appeared in patients that had not been exposed to exploding shells. He then used the expression shell concussion to describe the condition associated with exposure to the physical blast from exploding ordinance and shell shock for psychological morbidity resulting from the stress of war (Lasiuk and Hegadoren, 2006). An analysis of historic data on British World War I veterans revealed that among the soldiers who were awarded disability compensation there existed a subset to whom awards had been granted for the effects of poison gas exposure who showed no signs of damage to the skin, lungs, or eyes but did demonstrate a constellation of unexplained symptoms (Jones and Wessely, 2005). Jones and Wessely note that attending physicians had recategorized these cases as “disordered action of the heart” in recognition of the emergence of a distinct second class of disability for gas-exposed veterans—psychological cases instead of organic ones. In 1917, 20 percent of the 200,000 veterans on the British pension rolls were being compensated for “war neuroses” (Bailey, 1929). This number more than doubled by 1921 but was still considered a gross underestimate due to the large numbers of veterans who were experiencing combat-related functional impairment but who had been pensioned under other diagnoses. In 1921 the British were paying 35,000 pensions for “effort syndrome” alone (Zarbriski and Brush, 1941). Among the approximately 4.7 million members of the U.S. military who served during World War I (WWI),14 60 percent entered through the Selective Service System (DVA, 2006a; SSS, 2006). This large influx of citizen soldiers was associated with several developments in veterans’ benefits policy. One of the basic principles of veterans’ compensation in the United States had always been the responsibility of the government to “mend any damage which it has inflicted as a result of calling a citizen from his usual occupation to serve with the colors” (Wolfe, 1918). Wartime service has a variety of costs for members of the armed forces: They lose the opportunity to advance in their peacetime occupations while they are serving, for instance, and they miss out on the potential financial gains afforded to other citizens during wartime economic booms (Siegel and Taylor, 1948). The War Risk Insurance Act of 1914, originally intended to insure the assets of the American shipping industry, was amended in 1917 not only to provide 14 For purposes of veterans’ benefits in the United States, WWI service is defined as service after April 5, 1917, and before November 12, 1918, except for U.S. service members serving in Russia, for whom the WWI service window is November 12, 1918, to July 1, 1920, inclusive (CRS, 2006).
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PTSD Compensation and Military Service compensation benefits: New York, Pennsylvania, and certain other states use a “wage loss” approach, paying injured workers over time, given evidence that they are unable to work; a second group of states pays according to “loss of wage-earning capacity” or “impairment” (Barth, 2003/2004), basing payments upon a disability schedule (Berkowitz and Burton, 1987; Reville et al., 2005). The permanent disability benefits provided in workers’ compensation and, in particular, the approach of paying according to the loss of wage-earning capacity is most similar to the VA approach. As a basis for disability compensation, though, the VASRD is unique to the VA. In determining workers’ compensation, most states—42 of them— use the American Medical Association (AMA) impairment-rating guides in various editions, depending upon the state (Barth, 2003/2004). The AMA system is based on “whole body impairment” and not upon occupational disability or loss of earnings capacity. The AMA impairment-rating guides do not rate psychiatric conditions. The latest edition of these guides (AMA, 2001) does include a chapter on psychiatric conditions, but the information is not converted into a whole-body impairment rating. Many states have policies that address the treatment of psychiatric injuries and illnesses in workers’ compensation, but there is no centralized data source that summarizes this information. In general, a distinction is made in workers’ compensation between psychiatric conditions that are adjunct to physical injuries (so-called physical-mental) and stand-alone psychiatric conditions (so-called mental-mental). PTSD is an example of a mental-mental claim. While it is difficult to determine exactly how the different states treat physical-mental claims, there are no states that seem to exclude them explicitly. However, many states do have explicit policies regarding “mental-mental” claims. According to Neuhauser, at least 13 states explicitly exclude all “mental-mental” claims (Connecticut, Florida, North and South Dakota, Georgia, South Carolina, Kentucky, Minnesota, Montana, New Hampshire, Washington, Wyoming, and West Virginia) and thus would not allow compensation for PTSD without attendant physical injury (Neuhauser, 2007). Conversely, a number of states (Alaska, Arizona, Colorado, Idaho, Louisiana, Massachusetts, Missouri, Nevada, New Mexico, Oregon, Rhode Island, and Utah) explicitly allow compensation for “traumatic stress claims” when they arise out of “extraordinary or unusual” events, such as robberies and other violent acts, or else meet some similar standard. An important distinction between the compensation paid to workers of private employers and the benefits paid by the VA is that veterans acquire their disabilities while taking risks on behalf of the public. In this sense, veterans have more in common with police officers, firefighters, and other public-safety employees of states, counties, and municipalities around the
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PTSD Compensation and Military Service country than they do with employees of private companies. As noted by Seabury (2002), public-safety workers’ compensation benefits are often set by statute at higher levels than the benefits required to be paid by private employers or even than the benefits paid by public employers to their employees that are not involved in public safety. In addition, many states, counties, and municipalities provide lower eligibility thresholds and higher benefits for disability retirement to public safety employees. Short- and Long-Term Disability Protection against income loss because of disability is often available to employees through their workplace. The annual U.S. Department of Labor survey that tracks employee benefits found in 2006 that 39 percent of all employees in the private sector had access to short-term disability (STD) benefits and 30 percent had access to long-term disability (LTD) benefits. By comparison, 71 percent of private-sector employees had access to health insurance through their employers (BLS, 2006). STD programs cover absences from illness and accidents that are not sustained in the course of employment and most often specifically exclude work-related accidents or injuries. Employees must typically be out of work five days before they get benefits, and this waiting period will usually be covered by a paid-absence plan. The usual disability definition is “unable to perform the required tasks of the usual and customary occupation by reason of a medically established mental or physical condition” (IOM, 1999). Wage-replacement ratios range from 50 to 70 percent of pre-disability earnings, with 50 percent replacement being the norm. STD compensation is paid for up to 26 weeks. Most plans apply specific guidelines for how long a particular impairment should prevent a person from working, given his or her age and the demands of the particular job. Return-to-work dates may be established as part of the initial award of benefits. For persons whose impairments indicate that they will be unable to work over the long term, case-management techniques such as assuring proper medical treatment, vocational rehabilitation, and job accommodation or modification may begin during the STD payment period. LTD programs cover work absences caused by illnesses and accidents that are not sustained in the course of employment. For employees in higher income brackets, LTD may supplement workers’ compensation and SSDI benefits. Before persons are eligible for LTD payments, they are required to be unable to work for 30-120 days as a result of their disability. When an employer offers both STD and LTD, the eligibility periods are coordinated. For the first 6-12 months of disability, the eligibility requirement is that a person be “unable to perform the required tasks of the usual
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PTSD Compensation and Military Service and customary occupation” by reason of a medically established mental or physical impairment. After one year, a stricter definition, inability to do “any occupation,” applies. The benefit period may be for a specific length of time or else until retirement age. Wage-replacement rates vary from 50 to 70 percent of pre-disability earnings, with 60 percent being the most common. Most LTD plans require that a person be receiving appropriate medical treatment for the disabling condition. These plans require systematic follow-up with both the person and their physician to assess ongoing disability status. LTD programs include appropriate return-to-work services. Mandatory Temporary Disability Benefits Five states—California, Hawaii, New Jersey, New York, and Rhode Island—plus the Commonwealth of Puerto Rico have mandated temporary disability compensation. Employees contribute to these plans in all five states. Employers contribute in Hawaii, New Jersey, and New York. Wage replacement is usually 50 percent of prior pay with certain dollar maximums and minimums. Most states require that a person be out of work for seven days before payment. In 2006 the maximum duration of benefits was 26 weeks in Hawaii, New York, and New Jersey, and 52 weeks in California. Rationale for Private-Sector Work Disability Programs The underlying principle for private-sector work disability programs can be traced to the ideas of social justice discussed above. In the United States, people have the responsibility to support themselves through work. There is general public acceptance that the risk of being unable to work because of a disability is legitimate. Definitions of work disability are more or less objectively defined and managed. There is an underlying presumption that persons would rather work than be unable to work because of disability. Insurance Principles Social insurance—SSDI being the prime example—spreads the risk of being unable to work because of a disability across the working population. Payroll taxes from all covered workers and their employers are pooled to create a fund for making payments to those found disabled under the established definition. Everyone pays according to a wage-related formula applicable to the entire population. A younger person with less risk of becoming disabled pays the same rate as an older person with greater risk as long as they earn the same amount.
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PTSD Compensation and Military Service A central principle of private-sector disability-compensation programs is that the risk of an insurable event can be determined by actuarial predictions. The predictability of risk makes it possible to place a price tag on risk protection that is based on projected disability incidence and duration for individuals and groups in similar risk categories. Risk categories for work disability are sorted out by individual characteristics such as age, work skills, and health as well as by the type of work performed (classified by industries and occupations). The insurance industry’s rationale is that assumption of a risk can be done profitably through proper risk assessment, risk management, and pricing. Both insurance approaches—the social and the private—assume that what economists and insurers call “moral hazard” can be managed. The term moral hazard is used to describe the effect that insurance can have on the behavior of the person being insured. Malcolm Gladwell, a noted social commentator, highlighted the relevance of moral hazard in a 2005 New Yorker public-policy article: “Insurance can have the paradoxical effect of producing risky and wasteful behavior.” Gladwell indicated that economists spend a great deal of time thinking about such moral hazards, and for good reason: Insurance is an attempt to make human life safer and more secure. But, if those efforts can backfire and produce riskier behavior, providing insurance becomes a much more complicated and problematic endeavor (Gladwell, 2005). The Perception of the Risk The risk of being unable to work for a considerable period of time because of disability is high. An often-cited figure, attributed to the 1987 Group Long-Term Disability Valuation Tables published by the Society of Actuaries, is that at some point between the ages of 35 and 65, three out of ten people are unable to work for a period of 90 days or longer because of disability (Society of Actuaries, 1987). Employees and self-employed workers are often made aware of this risk and the need for income protection by insurance companies, labor, and professional organizations. Payment Sources Part or all of the cost of disability protection may be paid by employers. Employers can pay insurance companies to cover the risk and pay benefits. Large employers may self-insure, which means that they pay the benefit costs and costs of administration themselves instead of passing them off to an insurance company. Disability protection may be offered in a benefit
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PTSD Compensation and Military Service plan that gives an employee a certain amount of money to spend on various benefit options. Insurance companies offer group coverage to employees in selected industries, and employees pay the entire cost. Professional and other associations may offer their members group coverage through insurance companies. Workers and self-employed persons may qualify to buy individual protection against the risk of earnings loss because of disability. In these cases, the risks of disability are assessed and priced based on individual characteristics such as age, occupation, and health. Program Goals Disability protection can be part of a larger menu of employment-based benefits constituting a total compensation package. Historically, such benefits have been made available in lieu of wage increases, and collective-bargaining has played a large role in making these benefits available. Employers recognize that protection from the risk of work-related disability can be an important part of an overall employee-compensation package and can help attract and retain employees. Employers often use these benefits as part of a larger absence-management program. Managed-disability programs can save costs by reducing absence and increasing productivity by returning employees to work in transitional or modified work roles. Some research suggests that managed-disability programs reduce medical costs (Chelius et al., 1992). Assessment of Work Disability Private-sector programs require the presence of a medically established condition. The inability to work is judged according to how that condition impairs work-related functions for a particular person. Functional assessments determine what a person can and cannot do because of the medical condition. Depending on the definition of work disability being used, the person’s functional assessment is then compared to the functions required for either a particular occupation or for any occupation in the economy. This means that both medical and vocational evaluations form a part of the overall disability evaluation. Disability Management Employees, employers, and insurers all bear part of the costs of private-sector disability compensation. Managing costs and assuring adequate protection are goals of a workplace disability-compensation system. Disability management is a concept that took hold in private-sector disability-
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PTSD Compensation and Military Service compensation systems in the 1990s. Disability-management programs are designed to prevent or minimize the costs of disability to both employers and employees. The goals of a disability-management program include (1) disability prevention through health promotion and health care, (2) encouraging employees to remain at work or return to work whenever possible, (3) early intervention, (4) medical and vocation rehabilitation, and (5) case management. The most successful of these programs involve employees in their design and assure a proper mix of work incentives and appropriate benefit payments (Akabas et al., 1992; Shrey, 1998). BOX 2-1 Characteristics of Best-Practice Programs On the basis of a review of the relevant literature and the expertise of its own members, the committee responsible for the report Integrating Employee Health: A Model Program for NASA derived the following characteristics that may be considered as “best practice”: Program plans are linked to organizational business objectives. Top management supports the program. Effective communication programs are implemented. Effective incentive programs are used. Evaluation is an integral part of the program and is systematic; shared with top management; shared with employees; and valued by top management. The creation of a supportive environment is strongly pursued. The program is appropriately resourced with a sufficient budget. The program design is based on best practice management and behavioral theory (APQC, 1999; also addressed in Chapter 5 of IOM, 2005), including: goal setting; stages of readiness to change, the central construct of the Transtheoretical Model of Behavior Change; define theories (Prochaska et al., 1997) self-efficacy as a recognized predictor for successful behavior change among employees; incentives to optimize program participation; social norms and social support features; programs tailored to the needs of individuals; and multi-level program design that addresses awareness, behavior change, and supportive environments. SOURCE: Adapted from Box 4-1 (IOM, 2005).
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PTSD Compensation and Military Service Integration of disability compensation with health care and health-promotion programs is an important and evolving practice. Such integration assures that all workplace health-promotion and disability programs work together under like principles to encourage a healthy workforce and reduce disability. A previous Institute of Medicine committee produced a report that addresses the characteristics of a best-practice program for an integrated health system (IOM, 2005), and a summary of their findings is reproduced here as Box 2-1. REFERENCES Akabas SH, Gates LB, Galvin DE. 1992. Disability Management: A Complete System to Reduce Cost, Increase Productivity, Meet Employee Needs, and Ensure Legal Compliance. New York: American Management Association. AMA (American Medical Association). 2001. AMA: The Guides to the Evaluation of Permanent Impairment. 5th ed. Chicago, IL: American Medical Association. Andrews H, Barker J, Pittman J, Mars L, Struening E, LaRocca N. 1992. National trends in vocational rehabilitation: a comparison of individuals with physical disabilities and individuals with psychiatric disabilities. Journal of Rehabilitation 51:7–16. Anonymous. 2005. Historical Perspectives in PTSD. [Online]. Available: https://www.1888932-2946.ws/vetscommission/e-documentmanager/gallery/Documents/August_2005/va_ptsd_8-26-2005.pdf [accessed February 1, 2007]. Bailey P. 1929. Neuropsychiatry in the American Expeditionary Forces, Detection and Elimination of Individuals with Nervous or Mental Disease. [Online]. Available: http://history.amedd.army.mil/booksdocs/wwi/Neuropsychiatry/frameindex.html [accessed December 14, 2006]. Barron BA. 2001. Disability certifications in adult workers: a practical approach. American Family Physician 64:1579–1586. Barth PS. 2003/2004. Compensating workers for permanent partial disabilities. Social Security Bulletin 65(4):16–23. Bayne-Jones S. 1968. United States Army, 1607-1939. Office of the Surgeon–Office of Medical History. [Online]. Available: http://history.amedd.army.mil/booksdocs/misc/evprev/frameindex.html [accessed November 28, 2006]. Berkowitz M. 2003. The ticket to work program: the complicated evolution of a simple idea. Background information and baseline data. In Rupp K, Bell SH, eds., Paying for Results in Vocational Rehabilitation: Will Provider Incentives Work for Ticket to Work. Washington, DC: The Urban Institute. Berkowitz M, Burton JF. 1987. Permanent Disability Benefits in Workers’ Compensation. Kalamazoo, MI: W.E. Upjohn Institute for Employment Research. Berkowitz M, Hill A. 1986. Disability and the Labor Market: Economic Problems, Policies, and Programs. Ithaca, NY: ILR Press. Blanck P. 2001. Civil War pensions and disability. Ohio State Law Journal 62:109–238. BLS (U.S. Bureau of Labor Statistics). 2006. 2006 National Compensation Survey: Employee Benefits in Private Industry in the United States, March 2006. U.S. Department of Labor, U.S. Bureau of Labor Statistics, August 2006. Summary June 2005. [Online]. Available: http://www.bls.gov/ncs/ebs/sp/ebsm0004.pdf [accessed September 20, 2006]. Bodenger RE. 1971. Soldiers’ Bonuses: A History of Veterans’ Benefits in the United States, 1776–1967. Doctoral thesis. The Pennsylvania State University.
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Representative terms from entire chapter: