Expansion Limited by Cost, Science and Politics

VA Secretary David Shulkin suggests he favors expansion of Agent Orange-related health care and disability compensation to new categories of ailing veterans but that factors like cost, medical science and politics still stand in the way. Shulkin told the Senate Veterans Affairs Committee on 21 MAR that he made recommendations to White House budget officials last year on whether to add up to four more conditions -- bladder cancer, hypothyroidism, Parkinson-like tremors and hypertension (high blood pressure) -- to the VA list of 14 illnesses presumed caused by exposure to herbicides used during the Vietnam War.

     “I have transmitted my recommendations to the [White House’s] Office of Management and Budget. I did that by Nov. 1st”, Shulkin said. “And we are in the process right now of going through this data. In fact, we met with [OMB officials] on 19 MAR. They asked for some additional data to be able to work through the process and be able to get financial estimates for this. So, we are committed to working with OMB to get this resolved in the very near future.” Shulkin didn’t say which of the four conditions, if any, he wants added to the presumptive list, if and when cleared by the White House.

     At the same hearing, the VA chief was asked his position on Blue Water Navy veterans of the Vietnam War who also suffer from illnesses on the VA presumptive list but aren’t eligible to use it to facilitate claims for care and compensation. They “have waited too long for this,” Shulkin agreed, but then suggested the solution for these veterans is blocked by medical evidence or swings on the will of the Congress. “I would like to try to find a way where we can resolve that issue for them, rather than make them continue to wait,” Shulkin said. “I do not believe there will be scientific data [to] give us a clear answer, like we do have on the Agent Orange presumptive” list for veterans who had served in-country. “For the Blue Water Navy…epidemiologic studies just aren’t available from everything I can see. So, we’re going to have sit down and do what we think is right for these veterans.”

     Vietnam veterans who served even a day in country who have illnesses on the presumptive list can quality for VA medical care and disability compensation without having to show other evidence that their ailments are service connected. Shulkin said VA “recently” received the last report of the National Academy of Medicine (NAM), which found a stronger scientific association than earlier studies between certain ailments and herbicide exposure. In fact, however, VA has had the that report, Veterans and Agent Orange: Update 2014, for two years. It was written by a committee of medical experts that reviewed medical and scientific literature on select ailments and herbicide exposure published from Oct. 1, 2012, through Sept. 30, 2014. Released in March 2016, the report found evidence to support raising the strength of association between herbicide exposure and bladder cancer and hypothyroidism. The report upgrades the link from “inadequate or insufficient” evidence to “limited or suggestive” evidence of an association.

     In years past VA decided that for some ailments, such as Parkinson’s and ischemic heart disease, “limited or suggestive evidence” was enough to add these illnesses to the Agent Orange presumptive list. For others, including hypertension, a more common disease of aging, VA deemed it wasn’t enough. This last NAM report, however, looked again at cardiovascular conditions and herbicide exposure. It didn’t upgrade the link to heart ailments but it did affirm limited or suggestive evidence that hypertension is linked to herbicide exposure. It also studied whether Parkinson’s-like symptoms should fall into the same limited or suggestive category as Parkinson’s disease itself. The 2016 report found “no rational basis” to continue to exclude Parkinson-like symptoms from the same risk category. Parkinson’s disease itself was added to presumptive list in 2010.

     VA secretaries under both the Obama and Trump administration reacted more slowly on the last NAM perhaps, by law, they could. Congress in 2015 let a portion of the Agent Orange law expire, language that required the VA Secretary to decide on new presumptive conditions within 180 days of accepting a NAM report. The impact was immediate. Though a senior VA official tasked with reviewing this last NAM report said then-VA Secretary Bob McDonald would make his decisions within three months, it didn’t happen. McDonald left it to his successor. Shulkin waited more months and, in July 2017, vowed to decide by 1 NOV. OMB blocked an announcement, however, presumably over projected costs. Cost has been a factor too in Congress not passing legislation to extend VA benefits to Blue Water Navy veterans diagnosed with illnesses on the presumptive list. Budget analysts a few years ago estimated a cost of $1.1 billion over 10 years.

     Also, NAM did conduct a review of medical and scientific evidence regarding Blue Water Veterans’ possible exposure to herbicides and concluded in a May 2011 report that "there was not enough information…to determine whether Blue Water Navy personnel were or were not exposed to Agent Orange." Blue Water Veterans remain being ineligible to use the Agent Orange presumptive list. A lone exception is granted for veterans with non-Hodgkin's lymphoma. Vietnam veterans with this ailment may be granted service-connection without showing inland waterway service or that they set foot in country. In every session of Congress, going back years, Blue Water Navy bills have been introduced. They would, if passed, “include as part of the Republic of Vietnam its territorial seas for purposes of the presumption of service connection for diseases associated with exposure [to] herbicide agents while in Vietnam.”

     The current House version of the Blue Water Navy Vietnam Veterans Act (H.R.299), introduced in January 2017 by Rep. David Valado (R-GA) has 327 co-sponsors. Yet prospects of passage remain dim. Valado reminded Shulkin at a mid-March hearing of the House Veterans Affairs Committee that, six months ago, Shulkin said he was seeking more recommendations from “subject matter experts” on the issue and would be ready to update Congress in the coming months. Valado asked, “Have you come to a decision on Blue Water Navy veterans?” “I am aligned with you that these veterans have waited too long,” Shulkin said, “and this is a responsibility that this country has. And, as our veterans get older, it’s unfair.…I believe it is imperative upon us to resolve this issue. “I also believe,” Shulkin continued, “that there will not be strong scientific data to help resolve this,” in other words to justify benefit expansion. “This is going to be an obligation that we feel as a country, that these veterans shouldn’t be waiting any longer. And I am on the side of trying to find a way to resolve this for the Blue Water Navy veterans.”

    Shulkin said his staff is “working hard to look at offsets” which means cuts to other parts of the VA budget to pay for Blue Water Navy benefits, or to find “other ways to be able to do that. And it is a high priority for us.” Reminded by Valado that “with these types of cancers, time is of the essence,” Shulkin replied, “Absolutely.” The Senate version of Blue Water legislation, S.422, was introduced 16 FEBN 2017 by Sen. Kirsten Gillibrand (D-N.Y.), has 49 co-sponsors and, so far, equally dim prospects of passage.