According to VA, more than 1.1 million U.S. service members have been  deployed to the region since the start of the Persian Gulf War. Each of these categories includes many symptoms or illnesses that could  qualify a veteran for benefits (see fig. For these two categories of Gulf War Illness claims, VBA Rating  Veteran’s Service Representatives—claims raters—often rely on  information from VHA medical examiners to support their decision on  whether to grant or deny a claim. For all disability claims, VBA claim processing staff are required to explain  the reason for each claim decision in a decision letter. In Recent Years, Completed Gulf War Illness Claims Have Risen, Included More Medical Issues, and Been Approved at Lower Rates Than Other Service-related Disabilities

		The Number of Completed Gulf War Illness Claims Generally Increased from Fiscal Years 2010 - 2015

The number of Gulf War Illness claims VBA completed more than  doubled from about 4,800 in fiscal year 2010 through 2015, increasing  from to 11,400 during this time. We found that the approval rate for the group of potentially unidentified  medically unexplained chronic multisymptom illness medical issues was  nearly identical to the approval rate for those that VA had identified as  Gulf War Illness medical issues. 4). These Gulf War Illness medical issues may be denied at a higher rate, in  part, because according to VA officials, Gulf War Illness is not always well  understood by VA staff, and veterans sometimes do not have the medical  records to adequately support their claims. Accurate Processing of Gulf War Illness Claims Is Hampered by Confusion about the Gulf War General Medical Exam, and Claim Decision Letters Lack Key Information

		VA Has Improved Some of Its Gulf War Illness Guidance, but Weaknesses Remain in Training on Conducting Gulf War General Medical Exams

			Requesting a Gulf War General Medical Exam

The Gulf War general medical exam can be used to help determine a  veteran’s entitlement to VA disability benefits. According to a VHA official, as of February 2017, VHA’s training data  shows that only about 10 percent of its medical examiners had completed  this optional Gulf War Illness course. Without training, medical examiners may not be able to  reliably and consistently carry out their responsibilities with regard to  conducting and reporting on Gulf War general medical exams and provide  adequate information for decision-making to VBA’s claim rating staff. However, this effort does not include a review of  the decision letters for Gulf War Illness claims. VA Considers Research When Identifying Additional Disabilities Related to Gulf War Service, but It Lacks a Plan to Guide Its Work on Key Research Goal

		VA Has Used Research to Establish Presumptive Medical Conditions for Gulf War Veterans

VA’s research on Gulf War Illness is used in several ways including  identifying symptoms, diagnosing those with illnesses, developing  treatment, and finding methods to respond to similar illnesses that may  arise among veterans in the future. Lack of a Plan to Establish a Single Case Definition of Gulf War Illness Hinders VA’s Progress toward Achieving This Goal

VA’s progress toward its goal of establishing a single case definition of  Gulf War Illness is hindered by the lack of a plan to undertake this work. VA’s research advisory groups also noted the long-term  need for VA to plan for future research that is likely to contribute to a  single case definition. Federal internal control standards call  for agencies to have documented plans that include specific action steps  associated with their objectives. VA agreed with all of our recommendations and stated it has plans in  place to address them. Appendix I: Objectives, Scope, and Methodology

The objectives of this report were to examine (1) the trends in Gulf War  Illness disability claims in recent years, (2) challenges associated with  accurately processing and clearly communicating decisions on Gulf War  Illness disability claims, and (3) how the Department of Veterans Affairs  (VA) uses research on Gulf War Illness to inform its disability  compensation program. Analysis of VA Data on Gulf War Illness Trends

To examine recent trends in Gulf War Illness disability claims, we  obtained and analyzed administrative data from VBA’s Veterans Service  Network Corporate Database for claims completed in fiscal years 2010  through 2015 (the most recent data available at the time of our review). Review of Gulf War Illness Claims Processing

To understand challenges associated with accurately processing and  clearly communicating decisions on Gulf War Illness disability claims, we  reviewed relevant federal laws, regulations, and VBA’s procedures  manual. In  addition, we reviewed a sample of 44 Gulf War Illness files for claims  completed in fiscal year 2015 to provide illustrative examples of how VA  evaluates claims for Gulf War Illness and communicates its decisions to  veterans.
Why GAO Did This Study

VA estimates that 44 percent of veterans who served in the Persian Gulf War in 1990-91 have medical issues commonly referred to as Gulf War Illness and that those who have been deployed to Southwest Asia since then may suffer from similar medical issues. These medical issues may entitle a veteran to VA benefits. Recently, questions have been raised about whether VA is processing GWI claims correctly. GAO was asked to review VA's handling of these claims.
This report examines (1) recent trends in GWI disability claims, (2) challenges associated with accurately processing and clearly communicating decisions on GWI claims, and (3) how VA uses GWI research to inform the disability compensation program. GAO reviewed relevant federal laws, regulations, and guidance; analyzed VA data on GWI-related claim decisions from fiscal years 2010–2015 (the most recent data available); visited 4 of 58 regional offices, choosing those with high GWI caseloads; and interviewed headquarters and regional VA staff and key stakeholders. GAO also reviewed a non-generalizable sample of 44 claim files to provide illustrative examples of how VA evaluated and communicated decisions on GWI claims.

What GAO Found

The Department of Veterans Affairs (VA) completed processing about 11,400 Gulf War Illness (GWI) claims in fiscal year 2015, which was more than double the 4,800 claims processed in fiscal year 2010. GWI is a collective term for certain medical conditions among veterans who have served in Southwest Asia since 1990. Symptoms of GWI can include joint pain, gastrointestinal problems, fatigue, and neurological problems. On average, GWI claims have twice as many medical issues per claim as other disability claims, and take 4 months longer to complete. During fiscal years 2010 through 2015, the most recent data available at the time of our review, approval rates for GWI claims were about three times lower than for all other claimed disabilities. Several factors may contribute to lower approval rates, including that—according to VA—GWI claims are not always well understood by VA staff and veterans sometimes file for benefits without medical records to adequately support their claim.
VA's ability to accurately process GWI claims is hampered by inadequate training, and its decision letters for denied claims do not communicate key information to veterans. VA claims rating staff often rely on VA medical examiners to assess a veteran's disability before a decision can be made on a claim. VA medical examiners told GAO that conducting Gulf War general medical exams is challenging because of the range of symptoms that could qualify as GWI. VA has developed elective GWI training for its medical examiners, but only 10 percent of examiners had taken the training as of February 2017. Federal internal control standards call for adequate training for staff so they can correctly carry out an agency's procedures. Medical examiners who do not take this GWI-specific training may not be able to provide information to VA staff to correctly decide whether to grant a veteran's claim. Once a determination is made, VA regulations also require clear explanations to veterans regarding claim decisions. GAO found that decision letters for GWI claims do not always include key information on why the claim was denied.
VA considers research when adding to the list of conditions it associates with Gulf War service, but it does not have a plan to develop a uniformly used case definition of GWI. In 2010, VA added nine infectious diseases to the list of GWI-related conditions. VA advisory groups noted, however, that researchers face obstacles in conducting GWI research, including the lack of a single case definition of the illness for research and treatment purposes. In its 2015 Gulf War Research Strategic Plan, VA included an objective to develop a single case definition, but an official told GAO that VA had no action plan in place to achieve it. Without a plan to achieve a single case definition, research on and treatment for GWI may continue to progress slowly.

What GAO Recommends

GAO recommends that VA require GWI training for medical examiners, improve its decision letters, and develop a plan to establish a single GWI case definition. VA agreed with GAO's recommendations.