Health and Health Care Service Utilization Among U.S. Veterans Denied VA Service-Connected Disability Compensation: A Review of the Literature

ABSTRACT The general consensus in studies of individuals seeking federal disability compensation is that individuals "denied" disability compensation are healthier than those "awarded." In contrast, studies of military veterans seeking U.S. Department of Veterans Affairs (VA) disability compensation suggest that those "denied" ("denied applicants") may be as impaired as those "awarded" ("awarded applicants"), and likely have critical, albeit unmet health care needs. Moreover, although social isolation among U.S. Veterans has received some attention, its broad influence on health and health care consumption among veterans "denied" VA disability compensation is not well understood. Objectives: To provide a more thorough understanding of "denied" applicants' health, health care utilization, and social conditions. Methods: We reviewed published reports of health, health care utilization, and social isolation "relevant" to U.S. Veterans "denied" VA disability compensation. Among 122 research items initially reviewed, a total of 47 met our inclusion criteria and are summarized herein. Results: Compared to veterans "awarded" VA disability compensation, those "denied" have poorer health, use less VA health care, and may experience social isolation. Conclusions: Veterans "denied" VA disability compensation may comprise a vulnerable subgroup of veterans in need of supportive services. Such needs may be addressed through evidence-based targeted outreach programs.

INTRODUCTION

The U.S. Department of Veterans Affairs (VA) is the largest single provider of health care in the United States and administers the nation's second largest federal disability program.1 There are three independent administrations within VA: the National Cemetery Administration, the Veterans Benefits Administration (VBA), and the Veterans Health Administration (VHA). The latter two are critical to the administration of compensation and health care: the VBA manages disability compensation through Regional Offices, whereas the VHA provides medical care to veterans through a regionalized network of hospitals, clinics, and community veteran centers.2

VA disability compensation is intended to compensate veterans for losses in earnings resulting from service-connected diseases and injuries "and their residual conditions in civil occupations."3 "Service-connected" refers to conditions that occurred during military service or those that were aggravated by it.4

VA service-connected disability compensation is based on severity of medically evaluated disability as well as number of dependents. A combined disability rating expresses serviceconnected disability severity on a graduated scale from 10% (least disabling and least compensated) to 100% (most disabling and most compensated) in increments of 10%. Although a veteran may receive a 0% disability rating, which entitles him/her to health care benefits for the noted condition, only combined ratings of 10% or more qualifies him/her for compensation.4,5

Accessing VA Disability Compensation

A veteran seeking VA disability compensation benefits must first file a claim.6 In evaluating the claim, a review team gathers medical and military service-related evidence. In the process, the VA confirms the current disability, and subsequently determines whether the existing disability is linked to military service. If so, the VA assigns a combined disability rating (38 U.S.C. §1155) and establishes a date of award with payment based on the rating.7 For those veterans awarded service connection, the VA can grant a full award, or a partial award.8 If no service connection is found, the claim is denied.

The VA disability compensation adjudication process, which begins with an application and ends with either an initial decision or a decision in response to an appeal, can be onerous. In 2011, the average claims processing time was 197 days, whereas the average appeals processing time was 747 days.9 Veterans "denied" service connection receive no cash compensation.

Accessing VA Health Care

Access to veteran health benefits (38 CFR §17.36) begins with a VHA enrollment application, that is separate from the application for disability compensation. The VHA may also require some veterans to complete a financial assessment-"means test"-to establish eligibility for health care and to determine the individual's contribution to the costs or that of his/her private insurance company. Those veterans who, based on their gross household income, do not qualify for free care are responsible for copays.10

VA Disability Compensation Award Status

The literature suggests that the cohort of veteran compensation seekers comprise heterogeneous subgroups, which can be defined by their "award status" (e.g., denied applicant, awarded applicant) within the VA disability compensation system. These groups are differentiated by "unique" health, health care utilization, sociodemographic and psychosocial characteristics.11,12 In considering "award status," however, knowing what happens to veterans "denied" VA disability compensation may be more important than knowing what happens to those whose compensation claims have been "awarded""because the former leave the disability claims process with far fewer resources and a much thinner safety net."12

In view of the VA commitment to targeting veterans with the most need, and given emerging evidence suggesting that "denied" applicants may be at increased risks of poverty and homelessness,12 a greater focus on this particularly vulnerable subgroup seems timely and justified.

The aim of the present review is to

- Provide an overview of prior work on health and health care utilization "relevant" to U.S. Veterans "denied" VA disability compensation.

- Provide an overview of prior work on relationships between correlates of social isolation and health and health care utilization "relevant" to U.S. Veterans "denied" VA disability compensation.

- Highlight knowledge gaps, as well as key policy issues emerging from this research, and suggest avenues for future scholarship on this topic.

METHODS

Our review of prior work relating to health and health care utilization among U.S. Veterans "denied" VA disability compensation (Table I) occurred between 2012 and 2014. Electronic and nonelectronic sources were used to gather English language literature, and included peer-reviewed journal articles, government reports, Congressional testimony, federal regulations and statutes, court decisions and legal opinions, as well as information provided by authoritative websites (e.g., www.va.gov). We initially reviewed 122 research items, ultimately citing those 47 items that can be found in the reference section.

Search Strategy

Research materials cited in this review cover a period from 1983 to 2014. Internet search engines, including Google and Google Scholar, were used to identify relevant literature. We also used PubMed, a publicly available, open access database to expand our search.

A broad search began with the following individual and combined words: "veterans, deployment, service-connected, department of veterans affairs, disability compensation, federal, military, denied, awarded, compensation status, compensationseeking, application, social security, health, health care, utilization, consumption, resource use, dual use, United States, American, comparative analysis, social isolation, psychosocial determinants, social capital, and social determinants." In the process, the search widened using a "snowball search technique" where we followed up references from reviewed materials until we could no longer find any additional relevant studies.

RESULTS

Health

Studies of health status among "denied" applicants suggest that at least some of these applicants are burdened by health limitations, although the number of studies is small. An early study of psychiatrically impaired veterans conducted in 1983 found high levels of psychiatric impairment, regardless of whether these veterans were receiving full, partial, or no VA disability compensation.13 This finding was underscored by results from an analysis of Social Security disability compensation that led the author to speculate that some individuals suffering from schizophrenia or anxiety disorder may, in fact, be denied disability benefits because their psychiatric impairments are so severe that they are "not able to give a sufficiently coherent history [or] provide the necessary documentation for eligibility for disability."14 A similar contention was expressed in a subsequent study of health among recipients of "government" disability payments and nonrecipients.15

In 1989, an analysis of Social Security disability compensation by the U.S. Government Accountability Office (GAO) found, similarly, that "awarded" applicants and "denied" applicants who were unemployed had comparably poor health: specifically, 78% of "awarded" applicants and 80% of "denied" applicants reported fair or poor overall health, whereas 53% of "awarded" applicants and 51% of "denied" applicants also reported limitations in the performance of activities of daily living.16 Consistent with the GAO, Bound, in his seminal comparison of Social Security disability recipients with "denied" subjects, found that over 50% of "denied""report important health limitations on their ability to work."17

Rosenheck et al analyzed "functional health" and "quality of life" among 280 homeless mentally ill veterans seeking Social Security disability benefits as part of the SSA (Social Security Administration)-VA Joint Outreach Initiative. Overall, the study concluded that compared to "denied" applicants, "awarded" applicants "may have been no more disabled."18 Comparison of Addiction Severity Index Scores revealed no significant differences between "awarded" and "denied" in psychiatric illness (27.20 vs. 27.41, p = 0.953) or medical illness (42.79 vs. 50.31, p = 0.326), although Quality of Life Index Scores indicated that "awarded" had significantly better quality of life (2.96 vs. 2.67, p = 0.004).18

Murdoch et al examined symptom severity as well as physical functioning among veterans who had filed for VA disability compensation based on a claim of post-traumatic stress disorder (PTSD). Overall, veterans "denied" service connection were "not less disabled than those who obtained service connection."19 Thus, compared to "awarded" applicants, those "denied" had lower Penn Inventory Scores, indicating less PTSD symptom severity (43.4 vs. 39.6, p < 0.0001), but also lower Research and Development Corporation (RAND) Revised Physical Functioning Scores, indicating poorer physical functioning (29.2 vs. 28.6, p = 0.001).19

A longitudinal study subsequently reported PTSD symptoms, mental and physical functioning, and subjective wellbeing among veterans who had been "awarded" or "denied" VA disability compensation. It was found that although both "awarded" and "denied" applicants were clinically impaired, "awarded" had significantly higher PTSD Symptom Checklist Scores (60.18 vs. 52.66, p < 0.01), and were significantly more disabled (38.98 vs. 31.39, p < 0.05), as measured by the WHO Disability Assessment Schedule II.20

Finally, a recent cohort study analyzed overall health in a stratified nationally representative sample of VA disability compensation-seeking veterans with PTSD. It was found that 10 years after applying for disability benefits, both "awarded" and "denied" applicants continued to experience clinically relevant PTSD symptoms, as well as poor physical functioning.12

Access to Health Care

Poorer health is associated with increased health care consumption in studies of the general population.21 In contrast, although some veterans "denied" VA disability compensation are burdened by health limitations, studies nevertheless suggest that these individuals may consume less VA health care than comparably impaired "awarded" applicants.11

The limited number of studies that examined health care utilization among veterans "denied" VA disability compensation report equivocal findings.11,20,22,23 Two prospective cohort studies conducted in 2004 and 2005, analyzed pre- and postclaim VA health care utilization patterns among veterans with PTSD who had applied for VA disability compensation. In both studies, postclaim medical care service use rose equally among "awarded" and "denied" applicants, whereas postclaim mental health care service use increased only among the "awarded."11

A subsequent analysis examined the relationship between VA disability compensation award status and VA health care service use among a sample of veterans with PTSD who filed disability compensation claims between 1997 and 1999. It found that although "awarded" applicants did not use more postclaim "medical" health care services than "denied" applicants, they did use significantly more preclaim ( p <0.001) and postclaim ( p <0.001)"mental" health care services.23

Laffaye et al reviewed seven studies of VA health care utilization among veterans seeking VA disability compensation for PTSD. Overall, the study found that "awarded" applicants generally utilized more VA medical and mental health care services than "denied" applicants.11

Finally, a subsequent prospective study reported postclaim VA mental health care service use among a sample of veterans who had been "awarded" or "denied" VA disability compensation for PTSD. The study reported increased postclaim VA mental health care service use "only" among "awarded" applicants ( p < 0.01).20

Social Isolation

Social isolation, narrowly defined as "disengagement from social ties, institutional connections, or community participation,"24 is an important determinant of health. Studies have consistently found that individuals with few close personal relationships and limited social support tend to have poorer health outcomes, higher mortality risk,25-27 and some studies have reported greater health-related resource use.28-30 Socially isolated individuals are also more likely to be disabled,29 and to suffer anxiety and depression;30-32 and, results from several studies suggest that mental illness may mediate the effects of social isolation on health. -

Undoubtedly, the pathways by which social isolation influences health are complex, and no single variable can measure all of its dimensions.32,33 Nevertheless, prior work has cited an array of factors which when considered together, may be useful in characterizing one's social circumstances. In addition to small social networks and infrequent contacts,30,32 other oft-cited contributing factors have included rural residence, inadequate transportation, living arrangements,25,27 few family members or close friends,34 limitations in mobility,25,29 limited access to health-related information and feedback,35 and being unmarried.25,29,30,36,37 Although health challenges related to isolation may be particularly acute among the elderly,32 social isolation nevertheless

remains strongly associated with poorer health status across all age groups.32

At the same time, it is widely acknowledged that the adverse health effects of social isolation are often felt more acutely by individuals with low socioeconomic status. According to Locher et al, "poverty also is associated with other social conditions, such as lower educational levels, which contribute to social isolation and lesser ability and power to command and access community resources and services."25 Commonly cited socioeconomic measures have included gender, minority status, unemployment, low income and high debt levels, limited educational attainment,25 and lack of health insurance.35

Social Isolation Among Veterans

Studies of post deployment social structure suggest that when returning from active duty service, many veterans experience social isolation;36,39 and this increase can begin "immediately upon returning home."39 Veteran studies further suggest that social isolation can influence health through multiple pathways, such as homelessness,40 lower levels of encouragement, support and health-related feedback,41 reduced consumption of medical care and other health-related services,33,42,43 and reduced labor force participation.12

There is, unfortunately, a paucity of data on social isolation among veterans "denied" VA disability compensation. Nevertheless, results from studies of other populations lend support to our hypothesis that veterans "denied" VA disability compensation may be isolated and socioeconomically disadvantaged.

One such study analyzed a small sample of homeless veterans with mental illness who had applied for Social Security disability compensation benefits. Baseline comparisons revealed no significant differences in the proportions of "awarded" and "denied" who were unemployed (50% vs. 62%, p = 0.24), had a high school education or less (62% vs. 66%, p = 0.81), were single (28% vs. 29%, p = 0.32), or were divorced (54% vs. 62%, p = 0.32). However, compared to "awarded," those "denied" did have significantly lower monthly employment income ($306 vs. $132.71, p = 0.08), higher monthly food stamp income ($34.18 vs. $54.15, p =0.09), and spent less monthly income on housing ($196.67 vs. $99.37, p = 0.01) or health care ($6.67 vs. $0.37, p =0.04).18

Murdoch et al examined physical and social functioning among a sample of veterans who were seeking VA disability compensation for PTSD. The study used the Social Adjustment Scale (SAS) to measure social functioning across the following domains: social and family interactions, "work" role (e.g., employed, student), and economic self-sufficiency. Overall, compared to "awarded" applicants, those "denied" had significantly poorer social functioning (2.7 vs. 2.8, p < 0.0001), as indicated by higher SAS scores as well as poorer physical functioning (29.2 vs. 28.6, p = 0.001), as indicated by lower RAND Revised Physical Functioning scores. Mean social functioning scores among "denied" applicants were lower than those of individuals with schizophrenia, substance abuse, or clinical depression.19

Finally, a cohort study by Murdoch et al analyzed health and social functioning among veterans seeking VA disability compensation for PTSD. Overall, "denied" and "awarded" applicants continued to exhibit comparably poor social functioning at 6 years of follow-up. Moreover, compared to "awarded," those "denied" were more likely to have been homeless (12.0% vs. 20.0%, p = 0.02) and impoverished (15.2% vs. 44.8%, p < 0.001), and less likely to have been married (61.7% vs. 49.1%, p < 0.001), leading the authors to conclude that "denied" applicants "might represent an appropriate group for targeted outreach."12

DISCUSSION

Summary of Findings

The evidence lends support to our contention that there is a subgroup of veterans "denied" VA disability compensation who are characterized by low socioeconomic status, social isolation, and unmet medical and psychiatric health care needs. There are likely also veterans "denied" VA disability compensation who do not fit this description. Such characterizations are based primarily on comparisons with "awarded" applicants who are considered by researchers to be the least biased comparison group.12,17

Considering overall health, existing studies have consistently reported that "denied" applicants are often burdened by poor health and disability that can hamper multiple aspects of functioning. In addition to limitations in activities of daily living and instrumental activities of daily living, widely cited as valid measures of disability severity, an overwhelming number of "denied" applicants report functional impairments and deteriorating overall subjective health, mental illness, poor physical functioning, and healthrelated work limitations. Such significant health challenges, exacerbated by poverty, may make "denied" applicants especially vulnerable to additional health-compromising burdens, including substance abuse, and homelessness.

However, whether "denied" applicants are, in fact, sicker than "awarded" applicants cannot be resolved by the existing research evidence. Unfortunately, prior work is sparse and among the relatively few studies that have analyzed health among compensation-seeking veterans, many have focused exclusively on PTSD,4,12,19,20 or compared outcomes across inherently different, and therefore, potentially inappropriate comparison groups: as one example, comparative analyses of applicants with nonapplicants may be inappropriate because subjects who apply for disability compensation tend to be much sicker than those who never apply.12

At the same time, results from limited health care utilization analyses suggest that "denied" applicants utilize "less" VA health care than comparably impaired "awarded" applicants. Reduced health care service use by veterans with poor health stands in stark contrast to studies of the general population that have consistently reported an association between poorer health and increased health care resources use. "What might explain this contrast?"

Most utilization studies reviewed restricted their analysis to VA health care service use. Absent data on "dual system use" (e.g., VA and Medicare), it is conceivable that "denied" applicants may use less VA health care but not necessarily less "overall" health care. Future analyses of dual use among "denied" applicants could be useful in resolving this critical issue.

Given existing evidence suggesting that "denied" applicants are in poor health, what factors-other than service connection award, which is among the strongest predictors of VA health care service use1,19,46-might drive lower VA (and perhaps, non-VA) health care resource utilization?

Although studies have implicated a constellation of factors, the question of which determinants "most" impede access to health care among "denied" applicants remains unresolved. Undoubtedly, some "denied" applicants confront "financial barriers" to care.11 Thus, "denied" applicants who are poor, but whose income exceeds the VA's income threshold may respond to the loss of free VA health care by either foregoing any health care or, instead, by availing themselves of alternative sources of care. In addition, strongly held "beliefs" or "attitudes" may further influence health care seeking.35,47 For example, denial of a disability compensation claim may discourage VA service use.4

Finally, studies of the general population have long recognized the critical but complex role that social isolation plays in health and health care utilization. Among studies of social determinants of health, greater isolation, especially among people with low socioeconomic status, has consistently been associated with poorer health. In contrast, among studies of health resource utilization, the role of social isolation has been less clear: although some studies have reported associations between isolation and increased health care use, other studies have reported associations with decreased use. This ambiguity underscores the complex nature of social isolation. For some, it may act as a barrier to care, while serving as a driver of care for others.25,28

Unfortunately, no existing veterans study has specifically addressed the role of social isolation in the health and health care utilization patterns of veterans "denied" VA disability compensation. However, characterizations of samples of "denied" applicants suggest that veterans "denied" VA disability compensation are, indeed, socially isolated. Prior work by Sayer et al (2004)22 and Murdoch et al (2005, 2011)12,19 reveals that "denied" applicants tend to be renters rather than home owners, and are often unmarried with few if any dependents. In addition to low socioeconomic status (e.g., low income, limited education, low labor force participation), "denied" applicants exhibit dysfunction across a wide spectrum of social activities (e.g., occupational, economic selfsufficiency). Finally, they tend to use fewer VA health care services, and such reduced utilization may deprive them of an important, and reliable formal social support system.25,28

Strengths and Limitations

This is the first comprehensive review of the research literature concerned with health, health care utilization, and social isolation among American Veterans "denied" VA disability compensation. Our review was restricted to English language studies, because it focuses on U.S. military Veterans. Unfortunately, quantitative analysis was not possible due to the heterogeneity of outcomes and sampling. Thus, although it is conceivable that a meta-analysis might have produced different results, these findings were consistent across existing work and, therefore, we are confident that our conclusions would not differ significantly from such an analysis.

CONCLUSION

The broad picture of veterans "denied" VA disability compensation that emerges from available data shows them, compared to those "awarded," to have comparative poor health, lower VA health service utilization, as well as greater poverty, unemployment, and social isolation. Such burdens coupled with evidence of increased risks of homelessness and premature mortality support our hypothesis that veterans "denied" VA disability compensation are indeed a particularly vulnerable subgroup.

We emphasize that denial of VA disability compensation signifies only that a condition cannot be attributed to military service; it does not imply that a condition is not severe, or that it is not worthy of supportive services. Given this nation's obligation to serve the "neediest" veterans, future research might evaluate new initiatives (e.g., offering case management services to veterans with serious, nonserviceconnected disabilities; extending VA Vocational Rehabilitation Services, and/or Tele health Services to veterans "denied" VA disability compensation) that could be tailored to veterans who are not awarded VA disability compensation, but who, nevertheless, are burdened by health limitations.

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Dennis A. Fried, PhD, MPH, MBA*; Drew Helmer, MD, MS[dagger]; William E. Halperin, MD, MPH, DrPH[double dagger]§;

Marian Passannante, PhD[double dagger]§; Bart K. Holland, PhD, MPH[double dagger]§

*Department of Epidemiology, Rutgers, The State University of New Jersey 185 South Orange Avenue, MSB, Room F506 Newark, NJ 07101.

[dagger]War Related Illness and Injury Study Center, VA-New Jersey Healthcare System East Orange, New Jersey 85 Tremont Avenue, Mail Stop 129, 11th Floor, East Orange, NJ 07018.

[double dagger]Department of Preventive Medicine and Community Health, New Jersey Medical School, Rutgers, The State University of New Jersey 185 South Orange Avenue, MSB, Room F506, Newark, NJ 07101.

§Department of Quantitative Methods: Epidemiology and Biostatistics, School of Public Health, Rutgers, The State University of New Jersey 185 South Orange Avenue, MSB, Room F506, Newark, NJ 07101.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.

doi: 10.7205/MILMED-D-14-00435