Exploring Disparities in Awarding VA Service-Connected Disability for Post-Traumatic Stress Disorder for Active Duty Military Service Members from Recent Conflicts in Iraq and Afghanistan.

Introduction We explore disparities in awarding post-traumatic stress disorder (PTSD) service-connected disability benefits (SCDB) to veterans based on gender, race/ethnicity, and misconduct separation. Methods Department of Defense data on service members who separated from October 1, 2001 to May 2017 were linked to Veterans Administration (VA) administrative data. Using adjusted logistic regression models, we determined the odds of receiving a PTSD SCDB conditional on a VA diagnosis of PTSD. Results A total of 1,558,449 (79% of separating service members) had at least one encounter in VA during the study period (12% female, 4.5% misconduct separations). Females (OR 0.72) and Blacks (OR 0.93) were less likely to receive a PTSD award and were nearly equally likely to receive a PTSD diagnosis (OR 0.97, 1.01). Other racial/ethnic minorities were more likely to receive an award and diagnosis, as were those with misconduct separations (award OR 1.3, diagnosis 2.17). Conclusions Despite being diagnosed with PTSD at similar rates to their referent categories, females and Black veterans are less likely to receive PTSD disability awards. Other racial/ethnic minorities and those with misconduct separations were more likely to receive PTSD diagnoses and awards. Further study is merited to explore variation in awarding SCDB.

Keywords: afghanistan; awards and prizes; iraq; military personnel; post-traumatic stress disorder; veterans; diagnosis; disability; health disparity

Recent conflicts in Afghanistan and Iraq (Operations Enduring Freedom, Iraqi Freedom, New Dawn, Freedom's Sentinel, and Inherent Resolve) have become known for both physical and mental injuries, with post-traumatic stress disorder (PTSD) being a major comorbidity for which veterans receive care in the U.S. Department of Veterans Affairs (VA).[[1]] Although physical and mental health care during deployment and immediately thereafter are provided in military treatment facilities for service members (SM), the VA provides long-term care for those who became ill or injured while serving in the military or whose conditions were worsened by military service. The VA cares for nearly 6 million unique veterans annually in a network of 1,700 medical centers and clinics. The VA also adjudicates service connected (SC) disability awards for SM after separating from the military.

An important aspect of caring for veterans is a national policy that provides them with disability benefit awards for loss of function/injury or mental health conditions that are a direct result of or are aggravated by their military service.[5] These "service-connected disability benefits (SCDB)" are awarded by the VA after an application is filed by the veteran and a medical and mental health evaluation is conducted by the VA. Benefits include a tax-free monthly monetary compensation and access to free health care in VA, along with vocational rehabilitation and employment services. In 2013, nearly 3.5 million veterans were receiving compensation totaling about $54 billion per year;[6] the top three compensable conditions are tinnitus (ringing in the ear), hearing loss, and PTSD.[7]

Studies using small samples of veterans have shown that women[[8]] and Black racial/ethnic minority veterans are less likely than non-Hispanic Whites to receive SCDB for PTSD.[11] There also appear to be regional differences in awards for PTSD.[12] These studies were based on roughly 3,000 self-reported survey results from SM/veterans, all of whom had applied for disability benefits. There are no large-scale studies based on all separating SM using combined Department of Defense (DoD)-VA administrative data regardless of their disability application status. Furthermore, it is not known whether the type of separation (routine vs nonroutine) from the military affects the award. This becomes important with recent policy changes and executive orders by which all SM, regardless of their VA eligibility, will be provided mental health care in VA for 1 year after separation from the military.[13] Recent studies have noted that SM discharged for nonroutine causes such as misconduct were at higher risk for mental illness[14] and adverse social outcomes such as homelessness.[15] Thus, it is important, from a whole health and policy/planning perspective, that we determine whether those with nonroutine separations such as misconduct are appropriately receiving disability benefits for mental health conditions such as PTSD. We therefore performed this study to (1) explore disparities for PTSD SC disability awards based on gender, race/ethnicity, and time in military service and (2) test the hypothesis that active duty SM with nonroutine separations from the military (for misconduct, disability, disqualification, or early separation) were more likely to receive PTSD SC disability as compared to those with routine separations.

The study population comprised the entire cohort of active duty SM listed in the VA Defense Manpower Data Center file (VA/DoD Identity Repository [VADIR]) who were separated from the military from October 1, 2001 to May 2017. VA administrative data were accessed using the Veterans Informatics and Computing Infrastructure (VINCI),[16] and the VADIR file was imported into VINCI after appropriate regulatory approvals. Unique identifiers from VADIR were used to link the SM to VA administrative data to determine SC disability for PTSD in the VA up to March 2018 using the "VARatedDisability" file from the VA Corporate Data Warehouse. The extension of the study period to March 2018 was to allow for at least 10 months of observation after military separation for adjudication of disability benefits. We conducted this research with approval of the University of Utah Internal Review Board (IRB #00091744), the Research & Development Committee at the VA Salt Lake City Health Care System, and according to VINCI's regulatory requirements.

The primary outcome for our study was the award of SC disability benefit for PTSD. Disability ratings are in 10% increments from 0% to 100%, and a veteran's benefit level is tied to his or her rating which is determined after a medical and mental health evaluation in VA (compensation and pension examination, C&P).[17] For this study, the earliest available PTSD disability (by date, after the last date of last deployment in VADIR) listed in the "VARatedDisability" file was considered an outcome, regardless of the percent of the award. Independent variables (covariates) for our analyses were extracted from VADIR and included demographics such as sex, year of birth, race, level of education, branch of service, combat flag (whether they received hazard pay for serving in a combat zone), and marital status.

The key independent predictor variable used to test our hypothesis was type of separation. The DoD assigns each active duty SM an interservices separation code that indicates the circumstances related to discharge from service. Routine separations are those that occurred after completing a certain number of years on contract, whereas nonroutine separations could be due to misconduct, disability, disqualification, or early separations.[14] As described previously,[14] each separation category is a heterogeneous group. Examples of disqualification separations include failure to meet weight or body fat standards, character or behavior disorder, motivational problems (apathy), failure to meet minimum qualifications for retention, and erroneous enlistment or induction. Misconduct separations include alcoholism/drugs, civil court conviction/court martial, absent without leave or desertion, commission of a serious offense, and pattern of minor disciplinary infractions. If there was more than one type of separation for an SM during the study period, the separation type assigned to the SM was the one which had the greatest potential to influence subsequent PTSD (as determined by discussion among study team) in the following order: misconduct, disability, disqualified, early, or routine. As most SM who are now veterans are eligible for care in VA medical facilities, we followed the SM who had established care in VA and determined if they had had at least one diagnosis of PTSD in administrative data during the study period (ICD-9-CM code 309.81 before October 1, 2015 and ICD-10-CM codes F43.10, F43.11, and F43.12 thereafter).

To account for the possibility of a relationship of a clinical diagnosis of PTSD on the receipt of a PTSD SCDB, using logistic regression models adjusted for demographic variables listed above, we first determined the odds ratios (OR) for receiving any PTSD SC disability award and VA diagnosis of PTSD separately (marginal estimates). Then, we determined the odds of receiving a PTSD SC disability award conditional on either having a VA diagnosis of PTSD or not, using logistic regression models adjusted for covariates listed above and key predictor variables (type of separation). The coefficient for the OR was calculated for a doubling of time in service for years spent in service for both active duty and National Guard/Reservists to enable easier interpretation of the effect of the time in service. Significance was set at the P = 0.05 level or lower. Analyses were performed using R Version 3.5.1.[18]

During a nearly 16-year study period, a total of 1,969,724 SM experienced 3,472,031 separations from the military (from October 2001 to May 2017). A third of the separations were routine (33%), 17% were nonroutine (misconduct, disability, disqualified, or early), and the remainder (50%) were either null, unknown, or applicable (likely representing National Guard/Reserve SM, as only active duty SM receive an inter-services separation code). Of the total SM, 1,558,449 (79%) had at least one encounter in VA administrative data during the study period (Table I). Females comprised 12% of the total number of SM seen in the VA. The racial/ethnic distribution of the study cohort generally followed the distribution of veterans seen in the VA with non-Hispanic Whites forming the majority.

TABLE I Demographic Characteristics of Study Cohort of 1,558,449 Active Duty Service Members From Recent Conflicts in Iraq and Afghanistan

1 aExcludes 15 service members with unknown sex.

2 bExcludes 22 service members with missing combat flag status.

All examinations of group differences between those who received (Yes) and those who did not receive (No) service-connected disability award for PTSD were statistically significant by chi-square analyses.

Overall, 381,051 (24.5%) of the cohort had evidence of PTSD SCDB in VA administrative data. Similarly, one-fourth of the SM seen in VA during the study period had a diagnosis of PTSD in the VA (398,987). It was interesting to note that a majority (67%) of the group that had a diagnosis of PTSD in the VA also had a VA SCDB for PTSD.

After adjusting for covariates, female veterans were less likely to receive a PTSD award (OR 0.72) and were nearly equally likely to receive a PTSD diagnosis in the VA (OR 0.97). The disparity of less likelihood of receiving an award persisted on examining the odds of receiving an award conditional on diagnosis for females (Table II).

TABLE II Results of Models for Service Members Receiving PTSD Disability Award, Any PTSD Diagnosis Code, and Award Conditional on Diagnosis

The first two columns indicate the estimated odds ratios (OR) for awarding of a service-connected disability (SCD) award (regardless of having a PTSD diagnosis) and the OR for the presence of any ICD diagnosis code that indicates PTSD (regardless of if a SCD was awarded), respectively. The remaining two columns indicate the OR for awarding of a SCD award conditional on having received a PTSD diagnosis in the VHA, or not, respectively. The OR listed for time in service is for a doubling of time in the indicated branch/component. Asterisks indicate the significance level and are as follows: *** = P < 0.001, ** = P < 0.01, * = P < 0.05.

Racial/ethnic minorities other than Blacks (Hispanic, Asian/Native Hawaiian, and American Indian/Alaskan Natives) were more likely to receive an award (OR 1.14, 1.19, and 1.18, respectively) and diagnosis (OR 1.60, 1.51, and 1.25, respectively) as compared to non-Hispanic Whites. The increased odds of receiving an award persisted only for American Indian/Alaskan Natives conditioned on diagnosis (OR 1.15 to receive an award with no diagnosis) and to a certain extent for Asian/Native Hawaiians (OR 1.08 to receive an award with diagnosis). For Blacks, the lower likelihood of receiving an award persisted after conditioning on receiving a PTSD (OR 0.82) diagnosis.

Those with levels of education of high school equivalent were more likely than those with higher education to receive an award (OR 1.11) and diagnosis (OR 1.25); this trend persisted for an award after conditioning for no diagnosis (OR 1.11).

Though the "time in service" variable demonstrated consistency in direction and effect size across the SC disability award and the VA diagnosis models, there was variation noted among branches of service and active duty/reserve components. The Air Force and Navy behaved similarly showing reduced odds of receiving either an award (OR 0.83 and 0.78, respectively) or diagnosis (OR 0.84 and 0.83, respectively) the longer a SM served in active duty. This was in contrast to those in Air Force and Navy Reserves who had an increased odds for receiving an award with increased time in the Reserves (OR 1.05 and 1.08, respectively). The Army and Marine Corps showed either a small increase or no effect in likelihood for award (OR 1.01 and 1.00, respectively), or a slight decrease for diagnosis (OR 0.98 for both), with increased time in active duty, while also showing the same increased odds for reserve forces (OR > 1).

Those with misconduct separations had the highest odds of receiving SC disability award (OR = 1.31) and VA diagnosis (OR = 2.17). Those with disability (OR = 0.80) and disqualification (OR = 0.94) separations were less likely to have PTSD SC disability awards compared to those with routine separations while still at significantly higher odds of having PTSD diagnoses in the VA. Those with early separation were at slightly elevated odds for receiving an award (OR = 1.06) but there was no observable effect after conditioning on diagnosis.

Acknowledging disparities in the award of service-connected disability for PTSD is an important first step in understanding the complex process involved in such awards with the goal of mitigating them. To the best of our knowledge, our study is the first to demonstrate disparities in awards for PTSD based on a large sample of SM (1.5 million) who are now seeking care in VA as veterans. Studies have demonstrated that veterans file claims for tangible need as well as a belief that PTSD disability award justifies and legitimizes their condition.[19],[20] As an extension of the claim and disability award, it has also been shown that there are positive long-term benefits of receiving PTSD disability awards with regard to mental health (decreased PTSD symptoms) and social consequences such as decreased poverty and homelessness.[21]

With regard to disparities based on demographic characteristics, we confirm the gender-based disparity reported by smaller studies[9],[10] in that female veterans are less likely to be awarded PTSD SCDB. Murdoch et al.[8],[9] have previously demonstrated that this disparity may actually be related to a combat injury bias that favors male veterans, whereas Sayer et al.[10] postulated that the difference may be attributable to clinical factors such as a diagnosis of PTSD, functioning (both social and physical), and post-service life stressors. In our study, we note that despite being diagnosed with PTSD at similar rates to male veterans, female veterans were less likely to be awarded PTSD SCDB. In our study, the combat flag from VADIR that indicated receipt of hazard pay for deployment to a combat zone was positive for 96% of the cohort and thus could not be used to quantify combat exposure and injury. Our administrative data could not indicate severity of clinical symptoms for PTSD; however, conditioning for a diagnosis of PTSD in the VA did not mitigate the disparity for PTSD awards for female veterans. The other major trauma (apart from combat) among female and male veterans leading to PTSD is military sexual trauma, which is also SC to[22],[23] In this context, the finding that female veterans are being diagnosed with PTSD on par with males and still have lower rates of SCDB for PTSD merits further study. Furthermore, the role of military sexual trauma leading to PTSD in males and the relationship of these factors in awarding SCDB for PTSD should be studied to gain clarity of the role of military sexual trauma in awarding SCDB for male veterans.

We confirmed the disparity for Blacks noted by Murdoch et al.,[11] with the intriguing result of this racial/ethnic minority being significantly at lower odds for receiving an award despite being diagnosed with PTSD in the VA at rates similar to non-Hispanic Whites. For the first time, we note racial/ethnic minorities other than Blacks are more likely to receive a diagnosis and award for PTSD. The increase remained significant for awards for American Indians and Asian/Native Hawaiians after conditioning for a diagnosis.

The seemingly "protective" effect of higher education on a diagnosis of PTSD and lower odds of receiving a PTSD award is an important finding in light of a third of the study cohort having higher than high school education. This may have implications for recruiting, military occupation assignments, military-sponsored training/education, and re-enlistments at a higher grade.

The modest increase in odds of receiving awards for National Guard/Reservists as compared to active duty SM based on the time in service is also an important finding that may have implications for policy and planning, as well as recruitment/retention in the military. The apparent relationship may be explained by variation in combat theater roles and duration of deployment among SM from different branches and component (roles more proximal to combat vs. remote support).

The second set of results with regard to separation category supported our hypothesis that those with misconduct separation were at the highest risk for a diagnosis of PTSD and appropriately were receiving awards. The seemingly discordant result of these SM receiving awards at a higher rate in the absence of a diagnosis (as compared to the presence of a diagnosis) raises important questions regarding whether we are able to retain these SM in care in the VA. Regardless, these results merit mention and further study in assuring that those who are disabled by PTSD are appropriately cared for in the VA. Those with disability and disqualification separations were more likely to have a diagnosis of PTSD and less likely to receive a PTSD SCDB. One possible explanation is that these veterans may have been receiving benefits for other service-connected diagnoses. Those with "early" separations pose special challenges; these SM were separated for reasons generally related to family and social stress such as sole-surviving family member, marriage, parenthood/pregnancy, or lack of dependent support.[14] This group of SM were marginally at greater likelihood of receiving awards for PTSD, even without a diagnosis.

We acknowledge several limitations. Our study cohort is biased in favor of those who seek care in the VA, and such visits may be associated with either an increased or decreased probability of applying for SCDB that is difficult to measure. Thus, our results on disparities should be interpreted in the context of those SM who seek care in the VA, have applied for disability benefits, and have been successfully awarded SCDB for PTSD. Because of the nature of the administrative data used in our study, we are not able to determine who filed claims for disability for PTSD and those who were denied. Studies have demonstrated that those denied disability benefits are more vulnerable, likely lack social support, and generally have poorer health.[24],[25] Variations have been described in adjudicating claims for PTSD based on regional characteristics,[12] and there are likely variations based on provider characteristics.[26] Controlling for these variations in a large system, such as the VA, that processes millions of claims throughout the country poses a significant limitation and may affect our results. Even though a large proportion of veterans apply for SCDB, we are not able to identify the group of veterans who did not apply for any benefits; this affects our ability to study disparities in awarding benefits.

We used ICD codes to detect a diagnosis of PTSD; as with any administrative data, there may be variation in coding for diagnoses at the provider and facility level. However, for a diagnosis such as PTSD in the VA, administrative data are likely reliable for estimation of prevalence of the condition. Our study dataset that combined DoD (VADIR) and VA administrative data excludes those that do not seek care in the VA. The proportion of veterans who do not seek care in the VA is variable and not capturing those veterans places a limitation on our ability to determine who had a diagnosis of PTSD. It has been shown that not all veterans with PTSD seek and continue care in the VA for reasons ranging from access to care to treatment beliefs;[27] it was interesting to note observed that receipt of PTSD SCDB resulted in decreased odds of receiving either psychotherapy or pharmacotherapy for PTSD in the VA.

Although the VA has recognized disparities in the provision of health care to minorities,[28],[29] the literature on disparities in awarding SCDB to veterans has been limited. Providing appropriate disability benefits for PTSD for veterans is an integral component of our commitment to caring for those who have served the country. Although acknowledging that our study is limited to those who seek care in the VA and have been awarded SCDB, we note that despite being diagnosed with PTSD at similar rates to their referent categories, females and Black veterans are less likely to receive PTSD awards. This is in contrast to the positive finding that other racial/ethnic minorities having higher odds of receiving PTSD diagnoses and awards. The striking increase in likelihood of receiving both PTSD diagnoses and awards for those with misconduct separations is another important positive finding. Although there is room for improvement, the importance of these positive findings is the implication that vulnerable veterans are being awarded SCDB appropriately to compensate for their adverse experiences in combat. There is a need for further study to understand best practices and veteran/health care system factors leading to the positive findings noted in this study. At the same time, there is a need to identify mitigation strategies for the shortfalls resulting in the negative findings with the goal of improving the health of all veterans.

Funding for this project was provided by grant F3Z4537031GW01 (Travis Air Force Base, PIs: IJS and AVG), and VA Center of Innovation Award #I50HX001240 from the Health Services Research and Development of the Office of Research and Development of the US Department of Veterans Affairs.

Presented as an oral presentation at the 2018 Military Health System Research Symposium, August 2018, Kissimmee, FL; abstract #MHSRS-18-2069

The views expressed in this article are those of the authors and do not necessarily represent the position or policy of the US Department of Veterans Affairs, US Army, US Air Force, Department of Defense, or the US government