Medical examiners have no training on how to conduct gulf war illness exams. Witnesses included representatives from the Veterans Affairs department, the Government Accountability office and advocates for veterans. Good morning and welcome, everyone. This is joint hearing of the subcommittee on disability assistance and Memorial Affairs and oversight and investigation. Well now come to order. I first want to take a moment to thank my colleagues, sharon burgman, Ranking Member who should be along shortly and Ranking Member custer for hold tinge hearing with me today on the important issue were facing, and thats helping gulf war veterans get the benefits that theyve earned. It should go without saying that we have a duty to take care of the men and women who is been wounded while serving in our military. Unfortunately, too many injured gulf war veterans are not being taken care of. The va estimates 44 of gulf war veterans develop gulf war illness, yet 26 of these veterans are reseefceiving bene. Something doesnt add up. On march 15th, 2016 during a similar joint hearing on gwi, claims va testified claims 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 the 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 ill unlesses diagnosed of the illness and and are approved. I cant understand that at all. Va regulations state that if veterans have certain symptoms such as headache, fatigue or joint pain, va is supposed to presume that these symptoms are related to the Veterans Service in the gulf area, yet 80 of these claims are denied. 87 of these claims are denied. Gao found that one of the problems is that the va physicians are applying the wrong standards during the exams. Another issue is that the va employees are not ordering exams when necessary. I appreciate the recent va i appreciate recently that the va retained all of its employees on gwi claims, and im looking forward to working looking forward to hearing whether the retain retaining these employees made a difference. Im also frustrated because gao point 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 rates for gwi claims low, such as lack of a single Case Definition for gwi. I am looking forward to an honest discussion about the vas need to do so and how to ensure 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 that written statements provided for 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, im going to call on the oversight and investigation district distinguished Ranking Member, ms. Cofstra for her opening statement. Thank you. Thank you to the witnesses for being here today. It has been 26 years since the beginning of the persian gulf war, and since that time 44 of veterans who served in that conflict have suffered from gulf war illness. Sadly, these veterans struggle to receive accurate diagnoses for their symptoms, access to the needed health care and compensation for their Service Connected conditions, even with the presumptions that should result in more veterans receiving benefits and deny not denied claims. Last year our subcommittee held a hearing, as the chairman said, on access to treatment for gulf war illness and how more research is needed to develop treatments and get our veterans the health care they need. Now were back here again. By the way, this is entirely bipartisan across our committee to determine why 83 pearls of gulf war illness claims are denied by the va and what we can do to ensure our gulf war veterans receive the benefits necessary have earned. Gulf war illness is a chronic, pain. Often debilitating disease, and veterans suffering from gulf war illness deserve disability compensation and to have their condition recognized and treated by va providers. Now, 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 vas process for adjudicating gulf war illness claims. In fact, one of the members of our state Advisory Committee had his own claim for gulf war illness denied, and for the veterans in my state and across the country the vas process is poorly run and fails to adequately train personnel. This latest gao report confirms what our constituents suffering from gulf war illness continue to tell us on a regular basis. 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 presumptions that congress intends to grant the 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 reports that 90 pearls pearls of medical examiners the va relies on to assess disabilities have not completed the training on gulf war illness so they can better assess veterans disability levels. I would like to know why this training is not a mandatory requirement and when it will become mandatory. I would also like to know if this webbased training is sufficient to train medical examiners and if claims processors need better training requirements as well. I also wish to hear from the va on the plan to improve the way in which it communicates decisions made on plans. When veterans are not provided that the reason that the claim was denied, they become frustrated and angry and they end up in an appeals process which is already swamped. If they do not know why the claim was denied, they can often spend years attempting to obtain their benefits through a lengthy appeals process. Finally, we know that the va continues to conduct and support research on gulf war illness, however, the va lacks a 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 of the National Academy of medicine. A single Case Definition is needed to improve research, diagnosis and treatment of gulf war illness, and 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 be subsequently appeal denied claims. It is imperative that the va implement the gaos recommendations now so that gulf war veterans receive the treatment and disability benefits that they deserve without having to fight the va every step of the way. Thank you, chairman bost. I yield back. Thank you. I am going to ask that all members waive theyre opening marks as per the committees custom. I understand chairman berman and member esty will give theres at the end. First witness is bradley form, accompanied by dr. Patrick joyce, the chief Occupational Health clinic of the washington va medical center. We are joined by Melissa Emory hess is that correct . Now, see, with a name like bost and people say boast, i want to make sure we get everybodys right. Who is director of the education workforce, income of the gao. Zackary hern, Deputy Director for claims of Veterans Affairs and Rehabilitation Division of the American Legion. Michael figlioli, correct . The department director, national Veterans Services of the vfw. Finally, anthony hardy, National Board chair and director of veterans for common sense. I want to remind the witnesses that your complete written statement will be entered into the hearing record. With that, mr. Floor, youre recognized for five minutes. Thank you, chairman bost. Chairman bergman, Ranking Members esty and cost. Thank you. For undiagnosed illnesses or medically unexplained chronic multisymptom illnesses. For purposes of my testimony i will refer to these category of illnesses as gulf war illness. I will provide an overview of vas processing of gulf war illness claims and some of our training and Quality Assurance connection. It may be awarded for Gulf War Service when a veteran has service in southwest theater of operations after august 2, 1990 and has a qualifying disability in accordance. Va recently revised the designation to extend the date for which Service Connected may be awarded to december 31st, 2021. In fiscal year 2016, 18,681 veterans received a decision for a claim specifically for gulf war illness. From this number 4,594 veterans were awarded Service Connection for one or more undiagnosed illness or chronic multisymptom illness. 13 of these awards for undiagnosed illness and 41 for medical unexplained multisymptom illness. The va continues to strengthen its Training Program for gulf war illness claims. We have developed 13 related courses for claims processors and over the last year va headquarters mandated 10 hours of training for Veterans Services representatives. In addition we are currently developing a new training module which will focus on the proper development. This is scheduled to launch in fy 2018. Va implemented a number of other initiatives to improve gulf war claims processing, to include improvement of the notification process specifically to include a more thorough explanation when a claim is denied. In recent years va has developed special tracking to specifically account for gulf war claims. Va has amended its gulf war general medical examination template to include Important Information for examiners were addressing undiagnosed and multisymptom illnesses. Va is constantly looking for ways to improve benefits and services it provides to veterans who served in the gulf. Va works closely with Veterans Health administration in reviewing Research Done by office of Public Health as well as the National Academy of medicine updates on gulf war issues. Also works with vha on department of defense and groups with research and exposures with military service. Updates training so its medical examiners as well as evas contracts with medical examiners. Finally, the National Quality review staff as well as local quality reviewers in our Regional Officers continue to ensure employees process and decide claims for gulf war illness. As agreed upon with the National Gulf war resource center, va conducted two distinct special focus groups for decisions on claims of gulf war relate willed illnesses in december 2015 and september 2016. The review in 2015 focused on fiscal year 2015 gulf war illness cases and showed a 94 accuracy rate. The 2016 review expanded the review the cases kellyanniss that involved medically unexplained multisymptom illness starting from fiscal year 2011. This reviewed showed an 89 accuracy rate. Va continues to approve the efficient, timely and accurate processing of claim involving service in the gulf war. Although the science and medical aspect of undiagnosed illness and chronic multisymptom illness are complex, va continues to review scientific and medical literature to gain a better understanding of the illnesses on our gulf war veterans. This concludes my opening statement. I am pleased to address questions you or members of the committee may have. [ inaudible ]. Thank you, mr. Floor. Im sorry, maam, you are recognized for five minutes to give testimony to the gao. Thank you, chairman bost. Chairman bergman, Ranking Member custer and members of the subcommittees. I am pleased to be here today to discuss our recent report on vas evaluation of gulf war illness disability kplams. The exact causes of gulf war illness are not always known and veterans symptoms vary widely. Veterans may experience symptoms such as fatigue, headaches, joint pain, indigestion, insomnia, respiratory disorders, skin problems and memory impairment. They may have infection diseases like malaria or west nile virus. They refers to claims for gulf war illness as undiagnosed illness, medically unexplained multisymptom illness and infection disease claims. We refer to these as gulf war illness claims. My testimony will relate to three key areas. One, recent trends in gulf war illness disability claims. Two, challenges va faces. Three, vas gulf war illness research. In terms of claims trends, we found that a number of gulf war illness claims processed has increase willed in recent years. In fiscal year 2015 bva completed processing about 11,400 claims, which is 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 va staff. Additionally, veterans sometimes file for gulf war illness benefits, but according to some va staff we spoke with do not provide sufficient evidence that their symptoms have existed for at least six months as generally required by va regulations. In terms of challenges va faces, we found that theres inadequate training for vha medical examiners. Bba claims rating staff often rely on these medical examiners to assess a veterans disability before they make a decision on a claim. Medical examiners we interviewed said that conducting gulf war medical exams is challenging because of the range of symptoms that could qualify as gulf war illness. The vha has offered an optional 90minute webbased gulf war illness training for its medical examiners in 2015, but according to vha Training Data only showed 10 of the examiners had taken the training as of this past february. We recommended that va require its medical examiners to complete training on gulf war illness and va agreed with this recommendation. We also found that decision letters va sends to letters denying benefits for gulf war illness claims do not always clearly explain to the veteran how their claim was decided, which can leave a veteran uncertain about how the claim was evaluated and potentially lead to unnecessary appeals. We recommended that va require decision letters to clear explain how the claim was evaluated, and va agreed with our recommend. In terms of gulf war illness research, we found that va does not have a plan to develop a single Case Definition of gulf war illness. Va advisory groups have emphasized establishing a single definition could further improve the research, diagnosis and treatment of veterans. Vas advisory groups recommended in the near term va analyze data from its existing data sets and in the longterm conduct Research Projects to contribute to the establishment of a single Case Definition. Va included in a 2015 Gulf War ResearchStrategic 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 towards its goal. We recommended that va prepare a plan to develop a single definition, and va agreed with this recommendation. Thank you. This concludes my remarks. Thank you. Mr. Hurn, youre recognized to begin the testimony for American Legion, please. Thank you. It is like deja vu all over again. Ranking member custer, you made this assertion in your opening remarks in the 2016 hearing regarding gulf war illness. Thousands of injured veterans and impacted later we are here again to discuss the adjudication of gulf war illness claims by va and yes, Ranking Member, it feels like deja vu all over again. Good morning, chairman bergman and bost, Ranking Member custer and distinguished members of the subcommittees on oversight investigation and disability assist answer and affairs. On behalf of National CommanderCharles Schmidt and the ove