Deserving Veterans’ Disability Compensation: A Qualitative Study of Veterans’ Perceptions

Abstract

Veterans recently returned from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) experience many health and mental health problems after deployment. These OEF/OIF veterans are applying and appealing for veterans’ disability compensation (VDC) at rapidly increasing rates, often for “invisible conditions” such as posttraumatic stress disorder. Little is known about how veterans experience the process of applying and receiving VDC. In-depth qualitative interviews were conducted with OEF/OIF veterans ages 35 and younger (N = 18). This article addresses how veterans perceive themselves, and other veterans, of being deserving and undeserving of VDC. Veterans’ rationales can be categorized into four primary areas: (1) risking and suffering, (2) the cause of the condition, (3) intentions to become self-sufficient, and (4) putting VDC to “good use.”

benefits, disabilities, military, qualitative study, veterans

Social welfare programs and policies are created and maintained for intended categories of individuals and groups (for example, domestic violence survivors, veterans, and refugees) (DiNitto & McNeece, 2008). Eligibility requirements for these programs and policies range widely, as does the effort expected to prove eligibility. Historically, the United States has enacted social welfare policies that require extensive verification processes—especially for programs and policies targeting low-income individuals and families (Handler, 1972; Pavetti & Bloom, 2001). At various times, certain categories of individuals have been identified as more deserving of social aid than others; children, those with severe disabilities, and the elderly typically have been considered more deserving, while the “able-bodied” are considered less deserving of social aid (Katz, 1989; Midgley, 1995).

Veterans in the United States were one of the first categories of citizens to receive social welfare benefits from the government (Skocpol, 1992). Veterans’ benefits have often been considered distinct and separate from other social welfare benefits (Gerber, 2000; Skocpol, 1992). The philosophy underlying benefits to veterans has held that veterans earn benefits as rewards for service to their country through participation in the military; benefits are not charity (Gerber, 2000; Woloch, 2000). Benefits have also historically functioned to discourage desertion and later served to promote recruitment in a volunteer system (Gerber, 2000).

Veterans’ disability compensation (VDC) is a benefit that provides monthly cash payments to disabled veterans; the amounts vary, with veterans receiving a percentage of a maximum payment based on the extent of their disability (Institute of Medicine [IOM], 2007). The program in its current iteration is not means tested and, according to the IOM (2007), intends to compensate veterans for their average impairment in earning capacity as well as “non-economic losses, such as loss or loss of use of a limb or organ that may not affect ability to work, but reduces the quality of life of the Veteran” (IOM, 2007, p. 28).

First-time applications for VDC have approximately doubled from 2000 to 2006; this is assumed to be due, in part, to Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans (IOM, 2007). Close to 45 percent of OEF/OIF veterans from recent conflicts in the Middle East are seeking VDC, according to recent estimates from data collected by the Associated Press (Marchione, 2012). In fiscal year 2013, VDC expenditures were approximately $49 billion (Autor, Duggan, Greenberg, & Lyle, 2016). Eligibility for VDC involves a determination of the presence of a disability or disabling condition that is connected to military service; thus, it is referred to as having “service connection.” To verify service connection, veterans who apply for VDC after they are discharged from the military submit medical records and undergo compensation and pension exams by clinicians contracted with the U.S. Department of Veterans Affairs (VA).

The process of establishing a connection between a condition and military service for the purposes of VDC can occur in several ways. The first way is called direct service connection, in which evidence establishes a condition as being directly related to something that occurred while the veteran was in service. The second way involves a secondary disability caused by a direct service-connected disability. One example could be a veteran developing heart disease years after a leg was amputated while engaged in military service (Panangala, Shedd, & Moulta-Ali, 2010). The third way is when a condition is aggravated by military service. In this case, the veteran must have documentation of the condition by the military before he or she entered service to establish a “baseline” for the condition (Panangala et al., 2010). The fourth way of establishing service connection occurs when a condition fits the presumptive category: Several illnesses and conditions that automatically qualify for VDC are dependent on the war era served, such as certain cancers linked to Agent Orange exposure; these apply to Vietnam War–era veterans (Panangala et al., 2010). Finally, veterans can be approved to receive VDC when a disability occurs during active duty even if it is not combat related. Despite these criteria, veterans are rarely satisfied with the initial decision made on their applications: Nearly 80 percent of veterans appeal or resubmit their applications for VDC because they are denied any compensation or receive ratings they are not satisfied with (IOM, 2007). Thus, when a decision is made on their applications, veterans are left to deal with the aftermath.

Recipients of certain social welfare programs tend to be perceived as more or less deserving by program staff and the public (Katz, 1989). In the only study done on the topic of perceptions of VDC, clinicians serving veterans were queried, and results showed that they generally held negative perceptions about veterans who sought VDC compared to those who did not (Sayer & Thuras, 2002). Negative perceptions of health professionals and others have the potential to alienate veterans in need, enhancing their vulnerability. How veterans themselves perceive other veterans also matters. Insofar as veterans may influence each other, greater understanding of how VDC is perceived by veterans in relation to themselves and others may provide useful insights that can equip social welfare professionals in clinical practice and policy. However, little is known about the experience of the recent cohort of veterans receiving dissatisfactory ratings. Therefore, the purpose of this study was to explore, describe, and analyze how a sample of OEF/OIF veterans who received dissatisfactory VDC decisions perceived themselves and others.

Method

Recruitment and Sample

This analysis was part of a larger study that considered the decision-making process of veterans related to reapplying for VDC. The study was approved by the University of California, Los Angeles, institutional review board. OEF/OIF veterans ages 35 and younger were recruited by representatives of college veteran organizations and veteran service organizations in Southern California who distributed flyers to eligible and interested candidates. For our study, only veterans who had applied for VDC but had had their applications denied or received a rating with which they were dissatisfied were eligible.

Interested veterans were prescreened over the telephone, and arrangements were made to hold an in-person interview in a private room at a public place (for example, a library's private room) at a mutually agreeable time between February and July of 2013. After written informed consent was obtained, a validated tool to screen for cognitive impairment called the Mini-Mental Status Examination-2: Brief Version (MMSE-2:BV) (Mungas, 1991) was administered before the interview; no participants were excluded due to cognitive impairment. A $50 gift card to a local retailer was provided to participants after completion of the interview. The MMSE-2:BV administration and interviews were conducted by the first author and averaged 67 minutes. Interviews were semistructured and explored several aspects related to VDC, including the decision to apply, the process of applying, and the experience of receiving a decision about an application. Interview questions were developed with input from other social welfare researchers, a qualitative research expert, two OEF/OIF veterans, and a VDC legal advocate. All interviews were recorded and transcribed professionally.

Analysis

Guided by grounded theory methodology (Bryant & Charmaz, 2007; Charmaz, 2006), data collection and analysis were done concurrently. Atlas.ti software version 7 (ATLAS.ti Scientific Software Development, Berlin, Germany) was used to help manage the data. Initial coding began after the first transcription was produced (Charmaz, 2006); this involved a close textual reading followed by identification of multiple topics and processes within lines of data in codes. As such, initial coding involved coding idea by idea; codes were created using gerunds that reflected the action of the participant in any given situation (Charmaz, 2006). The next step in the analysis, “focused coding,” involved the identification of initial codes that were frequent in the data or that we found to be significant in relation to the focus of our study (Charmaz, 2006). Initial and focused coding was done by the first author in consultation with the second author. Constant comparison, memo writing, diagrams, and dialogue between both authors allowed for exploration of focused codes, which led to the development of one primary category. Analysis continued until we gained a robust understanding of the category and its properties as well as the relationships of the properties within the category; this is known as “saturation” in grounded theory (Glaser & Strauss, 1967). This category allowed an analytic understanding of the perceptions of OEF/OIF veterans who received dissatisfactory VDC decisions in relation to themselves and others. Pseudonyms are used in the following presentation of results.

Results

Sample Characteristics

Whereas the majority of respondents heard about the study through veteran student organization recruitment efforts, four learned of the study through the case manager of the transitional homeless residence where they lived. A total of 18 veterans participated in this study; 11 veterans were interviewed once, and seven were interviewed twice because at the end of their first interview, they needed and desired more time to talk about their experiences. Thirteen veterans from the sample had been deployed overseas, and five did not deploy. The average age of the sample was 24 years (range: 22 to 35 years). Most participants were male (n = 16). Nine were Marines, five were from the Army, and four were from the Navy or Coast Guard. Most applied for compensation for both physical and mental health conditions. However, four participants reported no mental health conditions; they only reported physical health problems such as back pain and knee injuries.

Delineating Deservingness to Pursue VDC

In the context of discussing their own pursuit of VDC, veteran participants of this study often shared their perceptions of other veterans. They frequently made judgments about the legitimacy of other veterans applying for and receiving VDC. They explained that some veterans were more deserving and some were less deserving than others to pursue VDC. Analysis led to the development of one primary category that we called “Delineating Deservingness to Pursue VDC” (see Appendix  1). The characteristics that factored into participants’ judgments about delineating deservingness involved four areas, which were the four properties of this category: (1) the level of risk and suffering that a veteran experienced, (2) the cause of the veteran's condition, (3) the intentions of the veteran to become self-sufficient, and (4) motives to put VDC compensation to “good use.” Participants applied these to themselves and to other veterans.

Delineating Deservingness Based on Level of Risk and Suffering

Feelings about deservingness of VDC were strongest around concepts of risking and suffering while in the military, which were raised as overlapping ideas. Whether someone risked or suffered, and the extent of the risk and suffering, shaped how deserving a veteran was in pursuing VDC, as perceived by participants. Most participants considered limb loss the ultimate example of suffering, deserving of 100 percent payment from the government. For example, Pedro compared himself to veterans who lost limbs, suggesting that his mental health conditions from combat were not as severe as those who had suffered limb loss:

Guys that are losing their legs, losing their arms. It's not just the fact that they have to learn to live without them. It's just the fact that they have to psychologically go through that also. It's like a double whammy on them, so it's hard for me to put myself on the same breath as them or to say that I deserve 100 percent. I'm thankful I came back a lot healthier than a lot of guys that I know.

He suggested that losing a limb results in two injuries: the loss of the limb and the psychological consequences of such a loss. The “double whammy” they suffer results in deserving 100 percent, in Pedro's estimation.

Roberto believed that he would be trading “money for pride” by pursuing VDC because he was undeserving. He explained that he experienced psychological conflict between people affirming his decision to apply and telling him that the money would be “compensating you for your pain” on the one hand and an idea that he should not “take advantage” because his disability is not as extreme as those of others.

Sometimes I'm conflicted. Like, you're asking for money. Well, this money could . . . you actually are in pain. But, you're not in constant pain. And then also I'll see other veterans and I'll see them missing a leg. Or missing something. Where I start thinking, like, “Oh, man. That's disabled. Not me.”

According to Roberto, his own deservingness was less than those who suffer more than he does, as defined by limb loss and being in constant pain.

Johnny put missing limbs and extreme hearing problems as the more deserving conditions compared with his own, echoing other participants who compared conditions: “I have 10 percent disability. It's probably not the highest I can get, but there are guys that have a lot worse than me. Guys that are missing arms or missing all their hearing.”

Finally, participants expressed personal theories regarding finite resources of the VDC program. Some participants were deeply concerned about compensation resources bypassing veterans who needed it the most and instead going to those who needed it less or not at all. Many veterans who had been in combat themselves believed that other combat veterans were suffering more at the expense of those who had not been in combat “taking advantage.” Participants identified an injustice occurring in that the wrong veterans were receiving VDC, whereas those who needed it should be receiving it.

Delineating Deservingness Based on the Cause of the Condition

Participants knew that the VA will award VDC to an individual injured during his or her military service, even if that condition or injury developed outside of a combat zone or military operation. Despite this policy, participants believed that conditions and illnesses should be connected to a military operation for an individual to deserve VDC. Although participants identified others as having legitimate conditions deserving of VDC, they also questioned certain conditions that seemed disconnected from military service and thus less deserving. For example, Eric shared a story about a veteran he felt was less deserving because of how he became injured:

One of the Marines I used to work with broke his leg on a . . . trailer. And then he kind of just went crazy and then got kicked out. And he was only in for maybe two years. And he's rated 70 percent and, like, he's undeserving. Like, he didn't do anything. He was in the communication shop the whole time. Never deployed. Always in trouble. And I felt like he shouldn't apply, because he doesn't deserve it.

Marcus delineated “paper pusher guys” from friends who had been in multiple instances of combat. He suggested that the “paper pushers” had “psychological problems” before they entered the military—in other words, that the source of their conditions stemmed from the individual rather than as an effect of military operations:

I have just seen a lot of paper pushers get more disability compensation than some of my friends that have been blown up multiple, multiple times. . . . It upsets me tremendously. The reason why some of those paper pusher guys got it is because the military has let them into the military and they already had psychological problems when coming in. It either made worse or kept [them] the same. Just because they let them in, now they are responsible.

Lance believed that a veteran friend had “milked the system” and received VDC for chronic back pain; the cause of the condition, according to Lance, was being overweight. He compared this overweight friend to veterans who “need” VDC but are “turned down.”

If the cause of the condition was not connected to military participation, it was not deemed by participants as worthy of VDC. Participants expressed the view that other veterans had internal personal deficits (for example, obesity or psychological problems), which were to be distinguished from external factors and events that occurred by virtue of participation in the military.

Delineating Deservingness Based on Intentions to Become Self-Sufficient

Participants generally believed that veterans should be working hard toward employment and self-sufficiency if they were pursuing VDC. A few veterans suggested that older veterans from other eras were cautionary tales of how they did not want to end up themselves. According to the participants, these older veterans did not work and had lives they considered unsuccessful. Sergio described other veterans he had encountered at the VA pursuing VDC as “lifers”—those receiving VDC for the duration of their lives. Sergio stated that they were “not doing anything with [their] lives,” did not work, and instead “worked the system.” These were veterans he did not want to become.

Marcus compared two types of veterans: those interested in “sucking on the government tit” and those trying to “move forward.”.

There's a whole part of me . . . I hate saying this and I mean, this goes to Social Security and everything else. There are guys who just want to suck on the government tit. . . . And I almost think that there should be rewarding of people who constantly try to move forward and do better in their lives versus the guys who sit around doing nothing, and they just want 100 percent compensation and all this other stuff.

Marcus believed that he himself was trying to move forward. Many of the participants did not believe that they were currently self-sufficient; Marcus, for example, resided in a transitional housing program. However, participants explicated the intention toward self-sufficiency as important and a characteristic of deserving VDC.

Delineating Deservingness Based on Motives to Put VDC to “Good Use.”

Many participants shared their intentions of how the monetary compensation that they were seeking would be used, suggesting that the compensation would be spent on worthy items and services. Peter described his motivations in pursuing VDC, suggesting that he did not want any “materialistic things,” and that the monies would go toward rent and doctors’ bills. Ken shared a similar idea about how he intended to use the money from compensation, expressing that he would like to save the money for future surgeries he anticipated needing. Marcus went as far as suggesting he would donate the monetary compensation once his outstanding medical bills were paid.

I just want all of the bills that have stacked and have gained interest. I just want those things to be covered. I don't care for the monthly. I'm going to figure out a way to make it myself. But at the same time, if I don't appeal and protect my future, who knows where I'll end up being? So I mean, ultimately what my ideal future would look like is that I have a nice career and I take the VA disability and donate it.

Although not explicitly about deserving VDC, we analyzed the intention for a “good use” of VDC as connected to the delineation of deservingness to pursue VDC. Participants’ intentions for putting VDC to “good use” can be contrasted with the concern that others misuse the program, as described in the previous section.

Discussion

Veterans perceived the applicants and recipients of VDC as deserving or undeserving based on four main properties that made sense to them within the context of their lives. Their assumptions of deservingness focused on certain aspects and qualities of an individual. It is useful to consider the question of why veterans would make any distinctions or judgments about other veterans in the first place. As illustrated earlier, veterans’ benefits were developed as distinct from other benefit systems. Thus, it may be that veterans in this sample felt the need to be protective about a program that was distinctly and uniquely intended for them. In relation to this, the veterans in our sample perceived a sense of finite resources and expressed concern about this. For example, participants worried that VDC might be wasted on the wrong recipients and that this could potentially take away from those who truly need it. Whereas many social programs have formal gatekeeping qualities, informal gatekeeping involves recipients and potential recipients policing each other (Shildrick & MacDonald, 2013; van den Berk-Clark, 2016). In this way, applicants in our sample seemed to be doing a kind of policing that involved assigning a moralizing code not only to others, but to themselves as well.

The emotions around who deserved VDC were expressed strongly by our participants, suggesting deep concern. The familiar psychological theory of projection may be appropriate to consider (Baumeister, Dale, & Sommer, 1998), where one projects his or her own undesirable feelings or thoughts on someone else. Participants seemed to have internalized feelings and thoughts about their own sense of deservingness or the lack thereof and applied such feelings to others. Participants frequently moved from discussing the perceptions of their own right to VDC to the rights of other veterans, suggesting that self-reflection of deservingness could not be disentangled from assumptions about the deservingness of others. It may be that taking the steps to apply for VDC is contingent on the ability to identify one's position on the continuum of deservingness, but determining one's position can only be done in relation to the situation of other veterans.

We considered possibilities about why certain aspects and qualities of veterans, in particular, were salient to our participants. It is likely that our participants’ perceptions were influenced by dominant cultural values and the specific context of military culture. The concept of individuals internalizing dominant cultural values has been applied to sexist and racist ideologies (for example, women putting down other women for perceived gender transgressions) (Foster, 1993). For our sample, combat participation was assumed to indicate risking more and making a bigger sacrifice. Limb loss and other visible injuries have historically been considered signature injuries of combat veterans—implying sacrifice. As Gerber (2000) suggested, “visible injuries have tended to become the primary way in which the general population of disabled Veterans often seems to have been conceived in the minds of experts, artists, and the general citizenry” (p. 2).

Veterans in our sample used the cause of the condition to help determine who was and was not deserving of VDC. Getting hurt while serving in the military versus becoming injured as part of daily life on base (that is, breaking a leg on non-combat-related equipment such as a trailer) represented two distinct types of sacrifices. These distinctions seemed to help our sample make sense of deservingness. If the measurement or definition of disability in society is imprecise, the lack of clarity may provoke discomfort and confusion in the public (Stone, 1986). Such imprecision may have been present among our sample, causing discomfort for the participants related to their own disability status. For example, internalized assumptions may exist that visible wounds have more legitimacy than invisible ones; this is pertinent because most participants in our sample did not have visible injuries that we were made aware of, but they may have had invisible injuries. If so, this may have contributed to our sample's processes of delineating deservingness, not only for others, but also for themselves.

The focus on individual behavior and motivation toward self-sufficiency is a familiar one in American social welfare policy (Popple & Leighninger, 2005) and represents a value that veterans may have also internalized. Beliefs about motivation and self-sufficiency related to VDC resemble findings from studies of other benefit systems, primarily welfare and means-tested programs. Recipients of other social welfare programs often identify and delineate deserving and undeserving groups based on one's motivation and work ethic. In one study, Temporary Aid to Needy Families (TANF) recipients maintained negative views of those receiving TANF while considering themselves to be exceptional or distinct from others they considered to be taking advantage of the system (Seccombe, James, & Walters, 1998). Many participants we interviewed believed that there were appropriate and inappropriate motivations for seeking VDC. The appropriate motivations included the notion of getting “back on one's feet” and moving forward. A few participants went as far as not wanting to keep the monetary compensation from the VDC, suggesting that they would donate it or return it when they no longer needed it. VDC is not determined based on whether a veteran can work. Unlike programs such as Social Security Disability Insurance and Supplemental Security Income, a veteran can work a full-time job and receive VDC at 100 percent based on injuries. Despite this policy structure, veterans maintained their own perspectives about the importance of motivation toward employment to be deserving of VDC.

These interviews also suggested a factor that may be unique to veterans: the influence of military culture. Military culture, like all cultures, is complex and cannot be summarized easily. Various theorists have identified that military culture includes the notion that health and mental health needs should be suppressed and stigmatized (Barrett, 1996; Green, Emslie, O'Neill, Hunt, & Walker, 2010). Veterans in our sample may have been strongly influenced by the institutional logics (Thornton & Ocasio, 2008) of military culture, which expects suppression of vulnerability and need. Participants in our study frequently reported their experiences with conflicting expectations to suppress their health needs while in the military but then to later acknowledge problems and disabling conditions after leaving active duty. Pursuing VDC was connected to both acknowledging their health needs and identifying vulnerability. They projected this conflict when assessing the deservingness of others while also applying it to themselves. Pursuing and receiving VDC may hold a stigma because of its connection to vulnerability. Indeed, our participants’ expressions of judgment about themselves and others seem to reflect the stigma of vulnerability. Overall, the expectation to suppress need but later acknowledge it is inherently connected to perceptions of VDC applicants and recipients.

Limitations

All participants recruited for this study were not satisfied with their disability ratings. However, the experience of dissatisfaction with a compensation rating is a common experience. Another limitation of this study is related to the issue of recall bias and selective memory. Veterans may have shared stories that made their decisions and perceptions seem more favorable during an interview.

Conclusion

This study has implications for the important role of military culture in shaping veterans’ perspectives, years after they separate from the military. Despite the institutional logics undergirding military culture, the Department of Defense and other governmental bodies have undertaken significant efforts to remove stigma from help seeking within the military (National Center for PTSD, 2014). Many of these efforts are recent and may not have affected the veterans in this study. Future studies might consider how the military maintains one set of institutional logics discouraging help seeking while the VA system may employ a conflicting set that encourages help seeking (Thornton & Ocasio, 2008).

This study offers numerous implications for social workers and veterans’ advocates. Perhaps most saliently, the data suggest that VDC is not a neutral program for veterans. Veterans in this study carried ambivalence about pursuing VDC. Thus, the complex feelings veterans have about VDC should be considered. The strong opinions expressed by our sample about deserving VDC also raise questions about how other individuals connected to the veteran experience perceive applicants and recipients of the program. The perceptions of other important individuals in the lives of veterans about VDC should be examined to gain a deeper understanding of the pressures and influences on veterans. The only study to date on the topic identified negative perceptions of clinicians regarding veterans seeking VDC (Sayer & Thuras, 2002). Compared with other beneficiaries of other social programs, veterans arguably enjoy a high political status and have significant lobbying power, with powerful representative groups (Hamilton, 2014). How veterans consider themselves and other veterans in relation to a costly social program is important to maintaining its political viability.

Veterans and other representatives have publicly criticized other veterans for malingering and for not being deserving of VDC or other benefits (House Committee on Veterans’ Affairs, 2011). The stigmatizing of the program has implications for those working on the macro level as veteran advocates: When veterans become fragmented among themselves, they have less of a unified front, which could threaten their strength as a lobby group and could undermine their interests. From a clinical perspective, veterans have internalized notions around who deserves VDC and who does not. Their beliefs and attitudes may have a powerful negative impact on their own willingness to pursue other types of assistance—including medical and mental health care—further endangering an already vulnerable group.

Appendix 1

Sample Interview Questions

• How did you first learn about veterans’ disability compensation (VDC) and being service connected? Tell me about that.

• When did you first consider applying for VDC? How did that unfold?

• Do you have a sense of how the decision on your VDC application was made?

• How did you feel when you found out about the decision? How do you feel about it now?

• What do you know about why your application was denied (or not rated highly)? What do you think about that?

Analysis Process

Initial coding → focused coding → development of the category of “Delineating Deservingness to Pursue VDC”

Properties of “Delineating Deservingness to Pursue VDC”:

• Level of risk and suffering

• Cause of the condition

• Intentions to become self-sufficient

• Motives to put VDC to “good use”