After 9/11 – New Trends for Health Care for Service Members With PTSD and TBI

Between 2002 and 2017, more than 200,000 active duty U.S. military personnel were diagnosed with post-traumatic stress disorder (PTSD) and nearly 300,000 with traumatic brain injury (TBI). These conditions became famous with the wars in Afghanistan and Iraq, where more than 3 million soldiers were deployed to support combat operations.

The physical and psychological stress of these conflicts has strained the U.S. Department of Defense (DoD) disability evaluation system, raising concerns about the consistency and timeliness of the disability evaluation process and the quality of care injured soldiers receive. In response, the DoD has introduced several changes to the way service members are treated and evaluated for potentially career-ending conditions and injuries.

The U.S. Department of Veterans Affairs (VA) disability rating scale is used as the basis for determining the degree of disability for each condition from 0% to 100% and for determining the overall disability rating. Soldiers declared disabled are medically retired or discharged from military service, depending on the degree of disability and years of service:

• If the member has a total disability rating of 30% or more or has 20 or more years of service, he or she may be medically retired with a lifetime disability award and health benefits. In some cases, a retired member may be temporarily medically retired and reevaluated within a specified period of time or until his or her health status stabilizes.
• If the combined disability rating is 0%, 10% or 20% and the length of service is less than 20 years, the active participant may be medically retired and receive health benefits and a lump sum for six months.

Those released from service for illness unrelated to or aggravated by service, or for misconduct, may be released without pay or benefits.

Main results

• Between 2002 and 2017, the military health system reported more than 200,000 active duty service members with post-traumatic stress disorder (PTSD) and nearly 300,000 with traumatic brain injury (TBI).
• The proportion of service members diagnosed with PTSD and medically discharged has increased significantly, from 16% in 2002 to 34% in 2015. The sick leave rate for service members diagnosed with TBI increased from 7% in 2002 to 18% in 2015.
• Disability rates for medically discharged soldiers with PTSD have increased over time. In 2008, 57% of soldiers with a disability rating due to PTSD were between 0% and 40%. In 2009, nearly all had an overall rating of 50% or greater. Soldiers with a disability rating of 30% or greater receive lifetime financial and medical benefits.
• A better understanding of disability evaluation trends and outcomes may help the U.S. Department of Defense set targets for the diagnosis, treatment and evaluation of disability of wounded and ill service members in future conflicts.

Military personnel diagnosed with PTSD or TBI have received increasing numbers of medical discharges between 2002 and 2015

For both PTSD and TBI, the number of service members receiving a first diagnosis increased steadily between 2002 and 2008, before leveling off and beginning to decline around 2012. This trend is consistent with the proportion of military personnel who were deployed during this period. Over time, the proportion of soldiers diagnosed with PTSD or TBI who were subsequently medically discharged has steadily increased.

Beginning in 2009, the overall definition of disability changed

In 2008, the Ministry of Defense issued policy guidelines requiring military departments to apply the VASRD system consistently, so that soldiers deemed disabled by “traumatic stress disorder” (e.g., PTSD) would receive a disability rating of at least 50%.

The percentage of soldiers with PTSD VASRD with a rating of less than 50% dropped to almost zero. A similar pattern emerged for service members who were discharged with a disability rating for TBI, likely due to the overlap between the two cohorts.

Higher disability rates offer greater financial benefits to separated soldiers. Better financial well-being for these individuals may be associated with better health and socioeconomic outcomes, thus easing the transition to civilian life.

There may also be drawbacks, such as higher costs to the Department of Defense and possible different incentives for hiring veterans. DOD has not conducted analyses of the positive and negative effects of classification changes for these broad service groups, but should do so before implementing future changes.

Recommendations and Effects

Evaluate the impact of changes to the disability rating system soon after implementation

This study provides important information on policy changes affecting the disability rating system and the military health system. However, these analyses were conducted several years after the implementation of the policy changes and examined changes over a 16-year period.

As the military and services implement future policies and practices to improve the performance of the military health and disability system, the impact of these changes should be evaluated soon after implementation and periodically to ensure that the desired results are being achieved.

For example, the military has significantly reduced the disability evaluation process (from 295 days in 2011 to 180 days in 2019). You should assess the positive and potential negative impacts of these changes.

Formally evaluate soldiers' performance after medical discharge

Soldiers medically retired will receive lifetime health benefits under TRICARE. Linking health data during and after service can reveal important results about health care use and outcomes for this population.

The same could be done with VA data. Despite active VA data collection initiatives, veterans' data on their service time may not be linked to their data on health care utilization and post-release health outcomes. There are several models that can be used to track veterans' longitudinal outcomes after military service ends, such as models developed to examine the effects of the 9/11 GI Bill, veterans' mortgages, and veterans' civilian retirement programs.