Tom Temin: What’s the thesis of your book considering that the federal government and the public spends tens of billions of dollars a year on veteran care?
Daniel Gade: Yeah, the bumper sticker is that our nation spends more to keep veterans sick than it does to make them better or transition them successfully. And those lines crossed about two years ago. So right now we spend about $130 billion a year on disability benefits. And we spend less than that on health care, we spend less than that on transition assistance, we spend less than that on all other categories combined, disability benefits are the largest portion. And if you think about it, what happens is the health care side, which is supposed to make veterans better, is in direct opposition to the disability side, which is paying them to be worse off. So an individual veteran faces the choice as they’re leaving service, do I file for disability benefits or not? And every incentive is stacked to have them claim as much as they possibly can. And what it does is it causes them to adopt what’s called the sick roll, it makes them actually sicker.
Tom Temin: Well, that’s interesting, because just to frame this a little bit, we’re talking about a relatively small number of individuals, because every veteran that comes out of the military is not sick or wounded, or has some kind of condition. So it seems like a large amount of money for a relatively small amount of people. That be a fair way to characterize it?
Daniel Gade: Well, actually no. So there are about 18 and a half million living veterans, of which about 6 million are receiving disability compensation. So it’s about a third. And of the veterans who transition out this year, about half are going to apply for disability. Now, when you think of a disabled veteran, I’ll just ask the people who are listening to close your eyes for half a second unless you’re driving, and think like what is a disabled veteran, and in your mind, you’re thinking of amputations, you’re thinking of spinal cord injuries, you’re thinking of burns and blindness. But those numbers are very, very low, relative to the number of people receiving disability compensation at all. Most of its disability payments are for things that are conditions of aging or of lifestyle, not combat wounds. So for example, the total number of people wounded in action in all of the Iraq and Afghanistan involvement for 20 years is about 60,000. Last year, about 250,000 people went on disability compensation, like four times more than the total number of wounded in 20 years of war. So that just gives you a sense of the scale involved.
Tom Temin: In some ways then the disability situation, the payout for disability mirrors the larger societal payout of that disability, which as a proportion of the population has been getting larger and larger and larger for decades, even though there seems to be more health and safety catch nets in place than ever before in history.
Daniel Gade: Right. The problems that we described in wounding Warriors, available for pre order on WoundingWarriors.com if you want a signed copy, the problems we identify in Wounding Warriors are not unique to the VA, but the problem is nobody wants to say, hey, veterans respond to incentives like everybody else, if you give them a bunch of money to be sick, they’re going to be sick. If you give them a bunch of money contingent on them exiting the labor market, they’re going to exit the labor market, they respond to incentives. And what we argue in Wounding Warriors is essentially that what we need is policy that will help them reskill, transition upskill and thrive rather than policies that trap them in poverty and illness, which is what we have now.
Tom Temin: And let me ask you a personal question, because you did lose a leg in Iraq in a tour of duty – what was your journey to wholeness in some sense, in the fact that I presume you’re not on disability, or if you are, you’re still gainfully employed – right?
Daniel Gade: Sure, I’m definitely gainfully employed. So Wounding Warriors has its roots, really, in what I experienced in 2005. The book is not an autobiography. It’s not about me at all. But I observed close up in my fellow wounded warriors, that they were really embracing the idea that people owed them something because they had gotten blown up or whatever it was. And sure we do owe something to our seriously disabled veterans. Of course we do. But what we owe them is a chance to thrive. What we owe them is every conditions set so that they can thrive on their own terms rather than just giving them stuff. And I saw that going on all around me in 2005, and it horrified me because my goal was to get back on active duty and just do what I was doing. So I got hurt in 2005, in January, I spent five months in the hospital including the amputation and a bunch of other stuff. And then six months as an outpatient, and then I got back to work and went got a master’s in a PhD while I was on active duty, taught at West Point for many years and then retired from the Army finally as a lieutenant colonel in 2017, so I was able to stay on active duty, which was great. And when I left, it’s really funny because they said to me, at the VA, you have to go to all these VA appointments and they said, hey we need you to claim everything that’s wrong with you, claim every condition that you have. And I think it’s a moral question for every veteran, every veteran has to face this, is what are you willing to point to your fellow citizen and say you owe me for this? And so what I did was I claimed the conditions that were combat caused. So when they said, hey, do you want to claim disability payments for the amputation? Yes, I do. And I’m a hip level amputee, I use crutches to get around, it’s a significant issue. And I’m comfortable saying to my fellow citizen, hey, for my life, you’re going to pay me for this disability. I’m comfortable saying that, from a moral perspective, I don’t think there’s anybody, probably very few people in the country who would claim that that’s an immoral stance. But also the VA claims guy was literally telling me to claim a bunch of stuff that was not true, because he said, I can get you paid for it. He wanted me to claim a brain injury, I don’t have a brain injury. He wanted me to claim hearing loss, I don’t have hearing loss. He wanted me to claim all this stuff, because he knew that he could get me paid for it. And I just saw that as totally immoral, and I’m not going to do it. And I didn’t claim conditions of aging, either. I just claimed combat caused conditions.
Tom Temin: We’re speaking with retired Army Lieutenant Colonel Daniel Gade, who is co-author along with Daniel Huang, of Wounding Warriors, How Bad Policy is Making Veterans Sicker and Poorer. And so then what would a better policy look like, do you think? And I think we’re talking about Veterans Health Administration and the VA benefits.
Daniel Gade: Yeah, so basically, what we need is an entire reset. And in the epilogue of Wounding Warriors, WoundingWarriors.com, preorder, I’ll send you a signed copy — and in the epilogue, I described basically six or seven principles that our society should use. But the first one is, we ought to prioritize reskilling, transitioning and upskilling before we ever label somebody as disabled. The disability determination should come well after the rehabilitation determination is made. In other words, what we ought to do before we label somebody with a permanent disability label, we ought to give them every chance and every incentive to thrive. That’s sort of part one. Part two is we need to take incentives into account if we want certain things, we ought to pay for those certain things. So an easy example is this. We know that obesity is a major problem in veterans and everybody else, causes diabetes, causes sleep apnea, causes all kinds of other things. What if Congress was willing to put in place, let’s say $1,000 bonus at the end of every year for veterans who keep their body mass index within a certain healthy range? Right? No problem. We’re incentivizing what we want and it actually would save money in the long run, because you’re getting away from a bunch of those obesity related conditions. That’s just one simple example of how do we take incentives into account and help our veterans thrive in a healthy way?
Tom Temin: And how could that apply to some of the mental illnesses, such as PTSD from traumatic brain injury, or even without traumatic brain injury, you can have post traumatic stress disorder, that’s a much subtler thing to get at than, say, whether someone has a limb or not. How do you see that working in that area, which is also a growing area?
Daniel Gade: It’s absolutely a growing area. And what’s interesting about that is once you get 100% disability determination from the VA, for post traumatic stress disorder, you are no longer required to go to any mental health appointments at all. In other words, people are able to, in Wounding Warriors we talk about this explicitly, people are able to demonstrate symptoms up to a certain point, and then they are free to go and they take their money with them. And the way to do that is if we tied receipt of compensation with treatment, then we get people in treatment, we keep them in treatment, so that their conditions can get better and so they can thrive. Because right now what happens is those people with PTSD take that money, and they can go sit on the couch, they don’t need to seek mental health treatment at all. And this is at the same time as we have a suicide crisis. Suicide is a disease of despair. And we have all these people who are despairing, and we’re making no effort as a country to catch them, and to help them be healthier. And so we talked about that in Wounding Warriors at some length. And PTSD is a tough one, because it’s a real condition. That is easily fain, you can fake it. And people do, there are guidebooks about how to do it and it’s very lucrative to do so. So it’s a real problem.
Tom Temin: And then changing some of these policies, you’re running up against a Congress, which in both parties is highly invested in the system as it is now, to say nothing of the Veterans Affairs Department, which is not ill motivated in any way. But nevertheless, these incentives are built into what they do. So how can this change in a realistic sense?
Daniel Gade: It’s all about incentives. And it’s all about telling the truth. So the incentive of the political left, they believe that every veteran is a broken toy, victims of a patriarchal system that sends them to build empires overseas. And on the political right, they believe that anybody who ever even looks at a uniform, whether you’re a generator mechanic and the Coast Guard or a medal of honor Marine, they say you’re hero, and therefore both sides agree that veterans deserve everything. And once they agree on that, then there’s this whole disability entitlement ecosystem of organizations and people who say, because veterans deserve everything, the way we express that is with dollars. I think the way we should express that is in opportunities to thrive and less so in direct cash payments.
Tom Temin: And a follow up question on that whole idea of enabling people to thrive. Very often the culture surrounding this dictates that only other veterans are capable of helping veterans. And I’ve asked many people this question, well can’t people that are not veterans that just might be sympathetic to the cause be trained to be able to help veterans or veterans instilled with the idea that only another veteran can help them understand their situation?
Daniel Gade: Yeah, as a matter of fact, for sure non veterans can help veterans. But one thing that’s funny, and I haven’t talked about this in years, but my dissertation showed that veterans were actually harsher towards other veterans in the disability claims process than were non veteran claims processors. And it was a stark finding. And so yeah, non veterans can certainly be helpful to veterans. And remember, there are 18 million veterans, that means there are 312 million Americans who are not veterans, right? And of course, they can be helpful to their fellow citizens who chose to wear uniform at one point or another.
Tom Temin: Retired Army Lieutenant Colonel Daniel Gade is co-author, along with Daniel Huang, of Wounding Warriors, How Bad Policy is Making Veterans Sicker and Poorer. Thanks so much for joining me.