On March 9, I had sent a message to every man and woman in the U.S. armed forces on the Walter Reed situation. I described the actions taken so far, including establishment of the two outside review panels. I told them we would not wait on those reports before tackling the problems. I told them I had directed a comprehensive, department-wide review of military medical care programs, facilities, and procedures, and that I had told the senior civilian and military leadership that in dealing with this challenge, “Money will not be an issue.” I went on: “After the war itself, we have no higher priority than caring properly for our wounded.” It was a sentiment and an admonition I would repeat often over the next four years.
Shortly thereafter I created the Wounded Warrior Task Force, charged with reporting to me every two weeks actions that were being taken across the Defense Department to address the needs of wounded warriors and their families. The goals of the task force were ambitious: (1) to completely redesign the disability evaluation system; (2) to focus on traumatic brain injury and post-traumatic stress; (3) to correct the flaws in case management of wounded warriors and their support; (4) to expedite Defense–Veterans Affairs data sharing; (5) to ensure proper facilities for wounded warriors; and (6) to reexamine the entire process for transitioning wounded warriors to Veterans Affairs. These were also the primary issues addressed by the West-Marsh independent review I had appointed and by the presidential Dole-Shalala commission. I was in a hurry and was not concerned about the three efforts stumbling over one another; each had a somewhat different mandate.
I wanted to ensure that good ideas were being shared across the services and around the Defense Department. As with MRAPs and ISR, I intended to make clear from my personal engagement the priority I attached to this endeavor, and that I was going to make sure everyone was moving aggressively to fix any problems we found. Gordon England and I also reenergized a joint Department of Defense–Veterans Affairs oversight group—the Senior Operations Committee—cochaired by each department’s deputy secretary in an effort to make significant improvements in the process of transitioning from active duty to retired or veteran status.
I believe that at the outset of the Afghan and Iraq wars, neither Defense nor VA ever conceived of, much less planned for, the huge number of wounded young men and women (overwhelmingly men) who would come pouring into the system in the years ahead. Many of our troops would not have survived their wounds in previous wars, but extraordinary medical advances and the skills of those treating the wounded meant that a large number with complex injuries—including traumatic brain injuries and multiple amputations—faced prolonged treatment, years of rehabilitation, or a lifetime of disability. The Defense and VA bureaucracies, accustomed to dealing with older vets from Vietnam and earlier wars or retirees with all the ordinary problems of aging, seemed incapable of adjusting to wartime circumstances, just like the rest of Defense and the rest of government. There were three areas where I fought the military and civilian bureaucracy on behalf of the wounded, and all three stemmed from my strong belief that those wounded in combat or training for combat should be dealt with as a group by themselves and be afforded what I referred to as “platinum” treatment in terms of priority for appointments, for housing, for administrative assistance, and for anything else. I wanted them to have administrative staff for whom they were the sole “customers.” The Defense and VA health care bureaucracies just could not or would not differentiate the wounded in combat from all others needing care.
Wounded Warrior Transition Units were being created by all the services at posts and bases throughout the United States so the wounded would have a home unit to watch over them. The first fight was over who should be allowed into them. I was shocked to learn, only months into the program, that the Army units of this kind were nearly filled to capacity. My intent in approving these units had been that they be reserved for those wounded or injured in battle or training, but the Army had allowed in those with noncombat injuries and illnesses as well. So a transition unit berth that I had hoped would go to a soldier wounded in Iraq might instead go to a soldier who had broken his leg stateside in a motorcycle accident. I obviously wanted the latter to get first-class medical care, but that was not why we created these units. In talking to wounded warriors at various Army posts around the country, I was told that deploying units would often transfer soldiers with behavioral or drug problems to these units. Eventually I persuaded the new Army secretary, Pete Geren, to be more faithful to my original intent but agreed it could be done through attrition, so that no soldier was forced to leave a transition unit.
The second fight was over bureaucratic delays in making disability decisions. In the case of those severely and catastrophically wounded, there was no need to take months to determine if they were entitled to full disability benefits. Similarly, a decision to transition wounded troops unable to remain on active duty to the VA ought not take nearly as much time as it took. I called this approach “tiering.” President Bush was supportive of giving wounded warriors the benefit of the doubt on disability evaluations, erring on the side of the soldier initially and then making adjustments later if needed. Because the number of wounded warriors in the system was such a small subset of all those needing medical care and evaluation, I believed even more strongly that the system should be tilted in their favor. “We need to look at this from the perspective of the soldier, not the perspective of the government,” I told a group of West Point cadets in September. We were able to get a pilot program going in the Washington, D.C., area to expedite the disability evaluation process, but it was always limited by legislation and bureaucracy. I pushed for these changes for years, but the unified opposition of the military and civilian bureaucracies—and the lack of support for my efforts from their leaders—largely defeated me. Any new approach, anything different from what they had always done, anything that might require congressional approval, and any differentiation between troops wounded in combat and others who were ill or injured was anathema to most officials in Defense and VA.
The third fight was over the disability evaluation system itself. To be considered for a disability retirement, a wounded warrior had to be evaluated as at least 30 percent disabled. This seemed to me to involve a ridiculous level of precision. How can you quantify whether a person is 28 percent disabled or 32 percent? I knew there were rules and guidelines, and I knew some veterans tried hard to game the system to get more money. But when it came to wounded warriors, when it was a close call or there was doubt, I wanted to err on the side of the soldier, and generously. I argued that we could institute a five-year review process to reevaluate the level of disability and correct any egregious errors made initially. I had no luck.
I also pressed for more support of families of the fallen and severely wounded, in addition to advancing state-of-the-art medical care for the signature injuries of the current conflicts—post-traumatic stress, traumatic brain injury, lost limbs, and eye problems and sight restoration. I predicted that these injuries would “continue to be the signature military medical challenge facing the Department for years to come.”