Aging Veterans with Disabilities [1 ed.] 0367335905, 9780367335908

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Aging Veterans with Disabilities

The number of older war veterans receiving disability benefits is steadily growing and is predicted to rise in the next decade. This book provides comprehensive knowledge about health and psychosocial concerns of veterans aging with disabilities and unmet needs and compares policy in three countries that have been involved in massive warfare in the 20th century – the United Kingdom (UK), the United States (US), and Israel. Using a cross-national comparative study of the policies, legislation, and services provided by these three countries, which have significant numbers of aging disabled military veterans, this book provides evidence-based knowledge on the trajectories and attendant mental health and psychosocial problems this sub-group faces when aging with a disability. It sheds light on the paradox in which most veterans with disabilities in the UK, US, and Israel are older, while the current legislation and budget target younger veterans with disabilities. The book reflects the current debate regarding the desired policy toward older veterans with disabilities in these countries and whether to provide them with proactive health services prior to retirement to prevent “accelerated aging.” It also evaluates the dilemma of whether to serve aging veterans separately as a unique population or to provide them with the same services used by the general population. This book will be of interest to all academics and students working in disability studies, rehabilitation studies, gerontology, psychology, sociology, social work, social policy, and law more broadly. Arie Rimmerman is Richard Crossman Professor of Social Welfare and Social Planning and founder Dean of Social Welfare and Health Sciences and head of School of Social Work at the University of Haifa, Israel. His research focuses on comparative disability policies, particularly in areas of employment, civic society, family support, and aging with disability.

Routledge Advances in Health and Social Policy

Planning Later Life Bioethics and Public Health in Ageing Societies Edited by Mark Schweda, Larissa Pfaller, Kai Brauer, Frank Adloff and Silke Schicktanz Effective Interventions for Unemployed Young People in Europe Social Innovation or Paradigm Shift? Edited by Tomas Sirovatka and Henk Spies Social Research in Health and Illness Case-Based Approaches Constantinos N. Phellas and Costas S. Constantinou Ethnic Identity and US Immigration Policy Reform American Citizenship and Belonging amongst Hispanic Immigrants Maria del Mar Farina Research and Evaluation in Community, Health and Social Care Settings Experiences from Practice Edited by Suzanne Guerin, Nóirín Hayes and Sinead McNally Critical Discourses of Old Age and Telecare Technologies Gizdem Akdur Aging Veterans with Disabilities A Cross-National Study of Policies and Challenges Arie Rimmerman For more information about this series, please visit: www.routledge.com/ Routledge-Advances-in-Health-and-Social-Policy/book-series/RAHSP

Aging Veterans with Disabilities A Cross-National Study of Policies and Challenges Arie Rimmerman

First published 2021 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 52 Vanderbilt Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2021 Arie Rimmerman The right of Arie Rimmerman to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Names: Rimmerman, Arie, author. Title: Aging veterans with disabilities : a cross-national study of policies and challenges / Arie Rimmerman. Description: Abingdon, Oxon ; New York, NY : Routledge, [2021] | Series: Routledge advances in health and social policy | Includes bibliographical references and index. Identifiers: LCCN 2020020585 (print) | LCCN 2020020586 (ebook) | ISBN 9780367335908 (hardback) | ISBN 9780429323805 (ebook) Subjects: LCSH: Disabled veterans—Government policy—Case studies. | Older people with disabilities—Government policy—Case studies. | Disabled veterans—Great Britain. | Disabled veterans—United States. | Disabled veterans—Israel. Classification: LCC UB360 .R67 2021 (print) | LCC UB360 (ebook) | DDC 362.4086/97—dc23 LC record available at https://lccn.loc.gov/2020020585 LC ebook record available at https://lccn.loc.gov/2020020586 ISBN: 978-0-367-33590-8 (hbk) ISBN: 978-0-429-32380-5 (ebk) Typeset in Times New Roman by Apex CoVantage, LLC

To my mother, Raya Rimerman

Contents

List of figures and tables Preface Acknowledgment

1

viii ix xi

Introduction

1

Welfare and warfare and policies toward veterans with disabilities in the United Kingdom, the United States, and Israel

4

2

Aging with disability

33

3

Health and psychosocial concerns of aging veterans with disabilities

55

4

Government policies towards aging veterans with disabilities

76

5

Proposed policy to address unmet needs of older veterans with disabilities in Israel

100

Closing remarks: insights regarding cross-national policies towards aging veterans with disabilities

117

Index

123

6

Figures and tables

Figures 1.1 20th-Century Veterans Spending in the United States from 1900 to 2020 3.1 Number of Recipients of Disablement Pensioners and War Widow(er)s from 2008–9 to 2018–9 4.1 VHA Geriatrics and Extended Care Programs 5.1 Monitoring Flow Chart

14 59 87 113

Tables 3.1 Recipients of War Pensions Scheme (WPS) by Age Band and Percentage of Disablement, March 31, 2019 3.2 All Recipients of Disability Benefits by Disablement Percentage 3.3 The Five Most Prevalent SC Disabilities of All Compensation Recipients (2014 to 2018) 3.4 Distribution of IDF Veterans with Disabilities by Age (N = 51,454) 3.5 Distribution of Aging Veterans with Disabilities by Medical Disablement Percentages 3.6 Veterans Reported Secondary Conditions by Age Group (in %) (2011) 4.1 Benefit Programs Available to Ex-servicemen and Women and Veterans with Disabilities 4.2 Benefits Provided to Israeli Mid-life and Aging Veterans with Disabilities 5.1 The Status of the MoD’s Current Services

58 60 61 62 62 67 81 94 108

Preface

The number of veterans with disabilities in Western countries is steadily declining and will probably continue to decrease, assuming there is no war or major warfare. However, the number of older war veterans receiving disability benefits is steadily growing and is predicted to rise in the next decade (Fletcher et al., 2016). This is evident in three countries that have been involved in massive warfare in the 20th century – the United Kingdom, the United States, and Israel. More than half of those receiving benefits for their military disabilities are senior citizens, and the number is expected to reach about two-thirds of the total number of recipients in 2030. These countries have different approaches to warfare and welfare spending and have therefore been selected for comparison of their policies toward aging veterans with disabilities. The book sheds light on the paradox of the 21st century as most of the veterans with disabilities in these countries are older, while the current budget targets younger veterans with disabilities (Shay & Yoshikawa, 2010). Furthermore, most of the legislation is still aimed at handling the health needs of young veterans with disabilities and integrating them into the labor market. My interest in writing this book began in 2006, when I was asked by the Division of Rehabilitation in the Ministry of Defense (MoD) to examine and assist them in revising their rehabilitation model, which – at that time – leaned toward the medical model, and to align it with international standards of the functional-social model of rehabilitation (Tal-Katz, Araten-Bergman, & Rimmerman, 2011). At the same time, my doctoral student, Patricia Tal-Katz (2010), wrote her dissertation on “Attachment, acceptance of disability, hope and social networking as predictors of activities among Israel Defense Forces (IDF) veterans with disabilities.” She studied a large sample of IDF veterans with disabilities in northern Israel, revealing that older veterans with psychiatric and cognitive disabilities reported lack of social support in comparison to those with physical disabilities, indicating their vulnerability and unmet needs. My next research engagement with older veterans with disabilities was while advising Yitschak Shnoor in his dissertation. In his doctoral thesis, completed in 2016, he provided a secondary analysis of his data collected in 2011 as a researcher at the Myers-JDC Brookdale Institute on behalf of the MoD. The study shifted

x Preface attention to aging veterans with disabilities and to their decline in health functioning and lack of social support, in particular among those with post-traumatic stress disorder (PTSD). However, the most important catalyst for writing the book was my appointment in 2018 by the MoD as head of the Committee of Experts regarding the unmet needs of aging IDF veterans (Committee of Experts’ Recommendations to MoD, 2019). One of the byproducts of my contribution was a quasibenchmark study of cross-national policies of Western countries toward aging veterans with disabilities. The study was expanded substantially and served as the basis for this book. In recent months, I had the opportunity to share the concept of the book with academics as well as policymakers in the United Kingdom and the United States. The book reflects the current debate regarding the desired policy toward older veterans with disabilities in these countries and whether to provide them with proactive health services prior to retirement to prevent “accelerated aging.” An additional policy dilemma is whether to serve them separately as a unique population or to provide them with the same services used by the general population. Arie Rimmerman Haifa

References Committee of Experts’ Recommendations to MoD. (2019). Responding to unmet needs of aging IDF veterans. (In Hebrew) Fletcher, K. L., Albright, D. L., Rorie, K. A., & Lewis, A. M. (2016). Older veterans. In J. Beder (Ed.), Caring for the military: A guide for helping professionals (pp. 54–71). Routledge. Shay, K., & Yoshikawa, T. (2010). Overview of VA healthcare for older veterans: Lessons learned and policy implications. Generations, 34(2), 20–8. Shnoor, Y. (2016). Well-being of aging IDF veterans. (Unpublished PhD dissertation). University of Haifa. Tal-Katz, P. (2010). Attachment, acceptance of disability, hope and social networking as predictors of activities among IDF veterans with disabilities (Unpublished PhD dissertation). University of Haifa. Tal-Katz, P., Araten-Bergman, T., & Rimmerman, A. (2011). Israeli policy toward veterans with disabilities: A snapshot and insights of the proposed reform. Journal of Social Work in Disability & Rehabilitation, 10(4), 232–46.

Acknowledgment

This book was made possible by generous support from my research staff at the Richard Crossman Chair of Social Welfare and Social Planning at the University of Haifa. I am grateful to Prof. Yaacov Gindin, a leading geriatrician in Israel, for his thoughtful clinical suggestions regarding geriatric assessment and monitoring of older veterans with disabilities. I want to thank Prof. Tuvia Horev, from BenGurion University of the Negev, for his assistance in formulating the Committee of Expert’s recommendations regarding the unmet needs of aging IDF veterans. Special appreciation for my former doctoral student Dr. Yitschak Shnoor for sharing data from his doctoral study on the wellbeing of aging veterans with disabilities. Finally, I want to thank colleagues in the Division of Rehabilitation of the Ministry of Defense and veterans with disabilities for sharing with me their thoughts on aging with disability.

Introduction

The number of older populations with long-standing disabilities is rising due to significant advances in civil rights, medicine, rehabilitation, and technology (Myhill & Blanck, 2009). Some are people who are aging into disability, but there is a growing number of those who are aging with disability (Verbrugge & Yang, 2002). Unfortunately, there is scarce knowledge on how persons aging with disability differ from those who acquire a disability in their senior years. There is growing evidence in the United States that adults with work limitations are more vulnerable to eroding health and loss of independence as they age compared to those without a disability. They may also be at an even greater risk of poorer mental health in later life due to the potential synergistic nature of disability and secondary conditions over their life course (Latham & Peek, 2012). One of the fastest growing populations aging with disability is that of veterans with disabilities. Most of them were wounded in the most recognized wars of the 20th century (e.g., World War 2, the Korean War, and the Vietnam War) and other warfare events around the globe. This population has been prioritized in obtaining education, career development programs, benefits and medical services more than civilian populations have been. Most of them express specific health, mental health, and psychosocial concerns as they get older. The introduction to the book will provide the reader with guidelines and the structure of the book by filling in the gaps in veterans’ disability and aging research and policy. It provides a thorough and insightful view of three representative countries – the United States (US), the United Kingdom (UK), and Israel – which have addressed unique policies, legislation, and services for veterans with disabilities. The 20th century was hugely violent; while its first half was characterized by full-scale war, the second half witnessed, at least in the Western world, a massive expansion of the modern welfare state. There is a debate in the literature about the nexus between warfare and welfare and the status of legislation and policy toward veterans with disabilities. Chapter 1 introduces three selected countries – the United States, the United Kingdom, and Israel – primarily because they represent a strong commitment to war veterans and a recognition of their contribution to their nations. These countries have also invested significant efforts and budgets in integrating young veterans with disabilities into the labor market.

2 Introduction The chapter reviews and analyzes the links between warfare and welfare in the 20th and 21st centuries in the United Kingdom, the United States, and Israel and analyzes the development of welfare policies related to warfare. There is a historical review of policies for each country toward veterans with disabilities, including the current status of legislation and core benefits and services. The chapter ends with a brief cross-national comparison of the policies toward veterans with disabilities. Chapter 2 highlights the aging process of persons with acquired disability through two core concepts: “successful aging” and “accelerated aging.” “Successful aging” emphasizes the importance of reducing the secondary conditions associated with the core disability, not only through health behavior practices but also by preserving social life and social support. “Accelerated aging” is a challenging concept often used by clinicians, but it lacks substantial evidence-based justification. The gap between clinical and empirical perspectives of “accelerated aging” is demonstrated by the two most common war-related disabilities, spinal cord injuries (SCI) and PTSD. The discussion provides insights into the lack of recognition of the term “accelerated aging” in policy and legislation aimed at veterans with disabilities earlier than retirement age (Lafortune et al., 2016). Chapter 3 introduces the current demographics and profiles of aging veterans with disabilities in the United Kingdom, the United States, and Israel. It introduces common physical and mental disabilities including secondary conditions and frequent psychosocial problems. Furthermore, it discusses recent studies, particularly longitudinal, focusing on current concerns of veterans with disabilities in these countries. The chapter concludes with a description of the unmet health and psychosocial challenges of aging veterans with disabilities. Most of veterans with disabilities in Western countries, including the United Kingdom, the United States, and Israel were injured in the massive wars of the 20th century. Unfortunately, most of the policies aimed at veterans with military disabilities target young veterans in order to improve their health functioning and their integration into the labor market. Some efforts to construct services toward aging populations were initiated in the early 1970s to respond to World War 2 veterans’ needs (Wilmoth, London, & Heflin, 2015), but most of them were established in the 21st century (Fletcher et al., 2016). Chapter 4 reviews policies toward aging veterans with disabilities in the United Kingdom, the United States, and Israel and discusses the changes that have been made, primarily in the 21st century, to respond to their health and psychosocial needs. It also provides insights into similarities and differences in policies toward aging veterans in these countries. Chapter 5 provides a comprehensive insight into how to respond to the growing number of aging Israel Defense Forces (IDF) veterans with disabilities. The chapter reviews their needs based primarily on Shnoor et al.’s (2017) study of reported unmet needs of a large sample of 2,011 IDF veterans with disabilities. The policy analysis is supported by the Committee of Experts (2019), headed by the author of the book, which found that the most serious concerns are centered in the gray area

Introduction 3 between the recognized disability and other secondary conditions related to other impairments or illnesses, including decline in functioning associated with aging. The committee therefore recommended a pilot project of proactive monitoring of aging veterans with disabilities in two regions, as well as providing coordination between Ministry of Defense (MoD) services and other services that veterans are entitled to as senior citizens. The project enables the MoD to gradually study the matter and establish the most desirable policy. In Chapter 6’s closing remarks, the author provides insights into the paradox of the 21st century: while most of the veterans with disabilities in the United Kingdom, the United States, and Israel are beyond retirement age, current legislation and policies are aimed at the integration of young ex-service people with disabilities, creating a need to adopt new conceptualizations related to aging sideby-side with the classic, work-related rehabilitation perspective. Furthermore, it discusses the challenges these governments need to cope with, including whether there is a need for separate warfare/welfare systems in serving older veterans with disabilities.

References Committee of Experts’ Recommendations to MoD. (2019). Responding to unmet needs of aging IDF veterans. (In Hebrew) Fletcher, K. L., Albright, D. L., Rorie, K. A., & Lewis, A. M. (2016). Older veterans. In J. Beder (Ed.), Caring for the military: A guide for helping professionals (pp. 54–71). Routledge, New York. Lafortune, L., Martin, S., Kelly, S., Kuhn, I., Remes, O., Cowan, A., & Brayne, C. (2016). Behavioural risk factors in mid-life associated with successful ageing, disability, dementia and frailty in later life: A rapid systematic review. PLoS One, 11(2), e0144405. Latham, K., & Peek, C. W. (2012). Self-rated health and morbidity onset among late midlife US adults. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 68(1), 107–16. Myhill, W. N., & Blanck, P. (2009). Disability and aging: Historical and contemporary challenges. Marquette Elder’s Advisor, 11, 47. Shnoor, Y., Ziv, A., Brodsky, J., & Naon, D. (2017). Research report: Aging IDF disabled veterans: Implications for service delivery. Myers-JDC Brookdale, Jerusalem. Verbrugge, L. M., & Yang, L. S. (2002). Aging with disability and disability with aging. Journal of Disability Policy Studies, 12(4), 253–67. Wilmoth, J. M., London, A. S., & Heflin, C. M. (2015). Economic well-being among olderadult households: Variation by veteran and disability status. Journal of Gerontological Social Work, 58(4), 399–419.

1

Welfare and warfare and policies toward veterans with disabilities in the United Kingdom, the United States, and Israel

The 20th century saw large-scale wars with millions of casualties resulting in numerous veterans with disabilities, but it also saw the establishment and development of the modern welfare state which offers social protection policies and services (Obinger, Petersen, & Starke, 2018). Post-World War 1 is considered the initial period of the construction of social insurance and protection programs, particularly in Europe. However, the major expansion of social insurance programs began to dominate national budgets only after World War 2. Social insurance programs in the United States rose from 5% of GDP in the early post war years to about 13% in 1985; in the United Kingdom they grew from 7% to 14% of GDP (Congleton & Bose, 2010). The chapter reviews and analyzes the links between warfare and welfare in the 20th and 21st centuries in the United Kingdom, the United States, and Israel and analyzes the development of welfare policies related to warfare. In each country, there is a historical review of policies and core legislation toward veterans with disabilities, followed by a review of the current status. The chapter ends with a comparative analysis of the policies toward veterans with disabilities in these countries.

The warfare-welfare nexus: introduction Scholars of social policy explore the nexus between mass warfare and the development of the modern welfare state (Gal, 2007; Obinger, Petersen, & Starke, 2018; Titmuss, 1976). The search for a possible connection is perplexing mainly because wars are considered the antithesis of welfare. Warfare is associated with destruction, brutality, and violations of human rights, whereas the modern welfare state is with promoting social protection policies and equality. However, it is clear that the birth of the welfare state was related to the World War 2 and post-war period, particularly in Britain. Some scholars believe that war is the pacemaker of the welfare state and the implementation of social protection services (Castles, 2010; Kasza, 2002; Skocpol, 1992). This positive approach is based on Titmuss’s (1976) belief that wars stimulate the economy and challenge the political and social institutions (Yamamoto, 2007). The rationale is that governments need to respond to the

Welfare, warfare, policies toward veterans 5 employment needs of veterans (including the disabled) returning from the battleground, and to compensate families that have lost their loved ones. In his work “War and Social Policy” (1955), Titmuss provides a historical view of World War 2 as promoting the development of universal social services, including national health insurance. This approach is based on a so-called guns vs. butter trade-off logic, suggesting a negative relationship between changes in military and social spending. Excessive purchasing of war machines and military infrastructure lead to stagnation and cutbacks in social welfare and health spending (Edwards et al., 1972). In addition, the expectation that the state is under external threat is one of the main reasons for the limited funding on social welfare and health (Melman, 1975). Obinger and Schmitt (2011) expressed doubt that a single factor (war) could explain the development of welfare states. Welfare policies are related to political forces, economic growth, and ideology, and not necessarily war or external threat. Similarly, Gal (2007) thinks that the relationship between military and welfare spending is weak or non-existent because the two types of expenditure are driven by different determinants. Therefore, it is important to examine war and post-war welfare policies in each country separately.

Warfare and social welfare policies in the United Kingdom The creation of the modern British social welfare state is associated with warfare and particularly with World War 2 (Edgerton, 2018; Marwick, 1988). Historically, military service in the UK armed forces played a vital role in the government’s compensation policy, reflecting commitment to those who were killed and wounded. The roots of the welfare state date to 1906 with the introduction of welfare reforms by Herbert Asquith after the Liberal Party of 1908 offered non-contributory means-tested pensions for people over the age of 70, as well as modest health insurance based on the Insurance Act of 1911 (Harris, 1992). The policy of the time was centered on voluntary contributions, but the government coordinated the payments in and out. The inter-war period saw scattered reforms, among them the Widows, Orphans, and Old Age Contributory Pensions of 1925 (Roebuck & Slaughter, 1979). According to John Dryzek and Robert Goodin (1986), World War 2 demonstrated the need to develop risk-sharing and social justice policies. A pivotal blueprint of the welfare state was the Beveridge Commission, established in 1941 to investigate how to rebuild the nation after the war. The commission was led by William Beveridge, a liberal politician and the director of the London School of Economics (1919–37). The Beveridge Report, submitted on December 1, 1942 and known as “Social Insurance and Allied Services,” is regarded as the milestone of the post-war British welfare state. The report offered all British citizens protection as a right “from cradle to the grave,” a departure from the means tests of pre-war policy. The report was received favorably by the public, and a short version was sent to the British troops to boost morale after the first victory in El Alamein in North Africa.

6 Welfare, warfare, policies toward veterans In short, the plan included the following main strategies: extending the existing modest social insurance schemes to provide coverage to all citizens, providing comprehensive national health insurance, issuing tax-financed family allowances, and ensuring stable employment. The source of funding for these schemes was supposed to come from workers, employers, and the government. The Beveridge Report is the basis for establishing universal social insurance and the National Health Insurance (NHS). It inspired T. H. Marshall to argue that the Beveridge Report represented the key to social citizenship rights in Western Europe (Baldwin, 1992). Beveridgean welfare is associated with providing taxfunded benefits as a right to all contributors, redistribution of social protection policies, and flat rate schemes (Whiteside, 2014). The idea of getting rid of means testing appealed widely to the public and was actually the reason for Labour’s victory in the 1945 British general election. However, the report was criticized by Left-wing politicians as it failed to prevent poverty among low-paid workers, people with disabilities incapable of working, and married women who were entitled to only 75% of unemployment or sickness benefits. Right-wing historians criticized the Beveridge Report as failing to recognize Britain’s post-war economic decline and the need to invest in modern infrastructure and industry (Ashford, 1987; Barnett, 1986). The impact of the Beveridge Report and post-war welfare legislation is significant in Britain, but its principles had limited impact on other European countries (Hills, Ditch, & Glennerster, 1994). Interestingly, recent examination of the report’s recommendations revealed that there were doubts whether they were feasible. Most of the reservations were ideological and related to the role of central government regulating tax-funded and universal benefits (Macnicol, 2002). However, the Beveridge Report’s recommendations are the product of war time, based on solidarity, and were centrally planned to ensure social protection for British citizens who has undergone great sacrifices to win this devastating war. The Beveridge Report was implemented gradually following World War 2 with the introduction of the National Insurance Act 1946, the National Insurance (Industrial Injuries) Act 1946, and the National Assistance Act 1948. The National Insurance Act of 1946 was a comprehensive social security system covering Guardian’s (Orphan’s) Allowances, Death Grants, Unemployment Benefits (for six months), Widow’s Benefits, Sickness Benefits, and Retirement Pensions. The National Insurance (Industrial Injuries) Act of 1946 made industrial injury insurance compulsory for employees. Finally, the National Assistance Act of 1948 provides benefits for citizens whose resources were insufficient to meet their needs and who were not covered by the Act of 1946. However, there is no doubt that the most important piece of legislation was the National Health Service Act of 1946 which allows all citizens to receive free medical, dental, and optical services. The 1950s and 1960s are considered the golden age of the welfare state because it was a time of full employment, and worker’s contributions under the flat rate scheme more or less covered the benefits. However, some changes were made to NHS coverage because of the need to restrain government spending. For example,

Welfare, warfare, policies toward veterans 7 in 1951 charges were set for dentures and glasses, while in 1952 prescription charges were put into effect to reduce the burden on the state budget. During the 1970s, the stringent economy brought economic and political changes that created difficulties in sustaining the welfare system. Beveridge’s vision of full employment to maintain social protection policies was shattered. The election of Margaret Thatcher’s conservative government in 1979 challenged the role of the welfare state for the first time since its creation in the 1940s. The conservative government reduced the value of benefits in relation to wages. For the first time, unemployment benefits did not rise to keep pace with wage increases, and in 1980 both unemployment and sickness benefits became liable to taxation. The welfare state dream surrendered to a conservative political ideology of free market policies and reduced government intervention. Thatcherism departed from the concept of the safety net and encouraged the adoption of charity for assisting the truly needy (Carstensen & Matthijs, 2018). The 1990s welfare policy was characterized by two changes. The first was the restructuring of the civil service under new public management and privatization. The NHS was transformed to the NHS Trusts, and other government agencies were run by outsourcing business firms (Allsop, 2018). The second change was in the welfare recipients’ perception of their social right to be supported after Beveridge blamed them for their dependency on government welfare rolls (George, 2018). The Welfare Reforms Acts of 2012 and 2016 are actually continuations of the 1980s and 1990s attrition in the provision of welfare programs since Beveridge. The current scene includes government spending cut measures such as the Removal of Spare Bedroom Subsidy (RSBS or the Bedroom Tax), the adoption of the Universal Credit scheme to replace other benefits, the benefit cap, and the regular assessment of claimants for the disability allowance and the Personal Independence Payment.

Policy toward veterans with disabilities in the United Kingdom The United Kingdom’s policy toward veterans reflects a mix of collaboration between the state and numerous military charities. The impression is that the government gradually reduces its contribution and charities step in to fill the gap; however, most of the military charities that support veterans are substantially funded by government. The current approach to veterans was set by the Armed Forces Covenant of 2011 and the MoD’s “New Strategy” of 2018. The latter is based on three principles: (a) veterans are defined as civilians who need to contribute to wider society; (b) veterans are expected to maximize their potential as civilians; and (c) veterans are not seen as special recipients of services, but in certain circumstances may receive supplemental services from public and voluntary sources. Veterans with disabilities receive most of their services like the rest of the population, including health care, employment, and housing. The only exceptions are the pensions allocated to veterans and in particular war veterans with disabilities that were established after World War 2 but existed earlier in British history.

8 Welfare, warfare, policies toward veterans The creation of a pension scheme for ex-servicemen and women can be traced to 1593 (Hudson, 2000). Prior to this time the responsibility for veterans with disabilities was local and based on charities to provide shelter and emergency funds. The first legislation that was enacted (1593 Act for Relief of Soldiers) provided statutory, county-based pensions for thousands of veterans (Kent, 1971). The system was administered by county justices and covered by local taxes. In 1679, the responsibility was transferred to the central government. The status of veterans was achieved through struggle, with numerous local protests being held between 1589 and 1592. The 1593 act was amended in 1598 and again in 1601; in 1647 the Long Parliament passed three ordinances that supplemented the 1601 act. The distinction between veterans with disabilities and the poor was made in 1601 by Secretary of State Sir Robert Cecil, who claimed that they deserved compensation because of their good service. Aside from being the first recognized legislation for veterans with disabilities, it also established the criteria for compensation – the need to demonstrate an incapacity to work. After 1679, the central government took over this responsibility because of serious funding problems in most localities. Evidence of the government taking charge was the establishment of the Royal Hospital at Chelsea, which administered daily allowances for noncommissioned officers and soldiers with disabilities who had served for at least 20 years (Dean, 1950). Officers with war-related disabilities were entitled to a pension according to their degree of injury. One of the most important legislations of the 19th century was The Pension Act of 1806, which provided pensions based on the recipient’s rank, length of service, character, and the context of army service, but not on medical assessment or the veteran’s incapacity to work. Those with some mental problems were not denied because the only criterion was a good conduct record in army service (Jones, Palmer, & Wessely, 2002). The 20th century saw large-scale warfare, including the two world wars, internal conflict in Northern Ireland, and frequent international operations. World War 1 marked the future of disabled veteran’s policy for years to come, in particular in establishing the Ministry of Pensions in 1916 to determine compensation scheme and measures (Koven, 1994). By 1918, about 400,000 ex-servicemen and women received disability pensions. Pensions were calculated by percentage and related to classification of impairment and were higher for those disabled in World War 1 than in previous military conflicts. World War 1 saw 750,000 ex-servicemen and women returning home with permanent disabilities (Kowalsky, 2007). The government was forced to deal with the subsequent increasing unemployment and to reassess and change its previous policies. The National Scheme for Disabled Ex-Servicemen of 1919 (known as the King’s Roll) was a memorandum encouraging every employer to hire exservicemen with disabilities, with a minimum of 5% of total manpower (Mantin, 2016). The quota scheme became one of the markers of government goals to boast hiring, but it was poorly implemented. Most of the World War 1 veterans with severe disabilities were rarely provided with substantial work, or had to face long delays (Anderson, 2011). However, ex-servicemen and women with disabilities like their civilian colleagues felt that they deserved proper employment

Welfare, warfare, policies toward veterans 9 rather than charity. The period after World War 1 was characterized by widespread social disruption and protests that were not seen before in Britain. In 1921, the British Legion was founded as a merger of three organizations: the Comrades of Great War, the National Association of Discharged Sailors and Soldiers, and the National Federation of Discharged and Demobilized Sailors and Soldiers. This civic organization became the core representative of disabled ex-servicemen and women (Wootton, 1956). World War 2 shifted attention to two previous concerns that had already been recognized following World War 1 – unemployment and mental illness, particularly PTSD. During World War 2, the government introduced the first comprehensive legislation known as the Disabled Persons (Employment) Act 1944, which followed the recommendations of an interdepartmental committee – the Tomlinson Committee of 1943 – for the rehabilitation of disabled people. The legislation promised sheltered employment and employment quotas, an obligation on employers of 20 or more workers to employ a 3% quota of registered disabled people. However, these strategies failed to improve gainful employment (Thornton & Lunt, 1995). While there was recognition of PTSD and the need to compensate those exposed to shell shock, pension authorities were cautious in approving these claims. However, veterans civic organizations pressed to ease procedures and increase the number of recipients. The debate intensified and was tested after the Falklands, Gulf, and Northern Ireland conflicts (Jones & Wessely, 2001). To reflect the difficulty in handling new claims, the administration had to make decisions whether to compensate ex-servicemen and women who reported that they suffered from “Gulf War Syndrome,” a phrase coined after the 1991 Gulf War to group together disparate, unexplained health symptoms in Gulf veterans. The decision was to handle it as a psychiatric disorder without determining direct causality (Greenberg & Wessely, 2008). Aside from the changes in substance, the pension system underwent numerous changes during and after World War 2 to reflect the workload and increased claims (The War Pensions Records). The first change occurred in 1953 when the pension functions of the Ministry of Pensions were combined with the pensions and insurance duties of the Ministry of National Insurance to form a new Ministry of Pensions and National Insurance. In 1966, the Ministry of Pensions and National Insurance was transferred to the Ministry of Social Security and the Supplementary Benefits Commission. In 1968, the divisions of the short-lived Ministry of Social Security were absorbed into the new Department of Health and Social Security (DHSS) with little evident change. The War Pensions Department existed until 1971 before evolving into the War Pensions and Industrial Injuries Division. After 1973, the war pension’s functions were split between branches of the Social Security Policy Group.

UK current schemes for veterans and veterans with disabilities Veterans in the United Kingdom are diversified and reflect participation in various warfare activities. The oldest veterans in the United Kingdom are those who served in World War 2 and subsequent conflicts up until the early 1960s as

10 Welfare, warfare, policies toward veterans conscripts, volunteers, and as part of National Service. Nearly half of the current veterans in the United Kingdom are over 75 years old. A second cohort consists of veterans who served voluntarily post-early 1960s until the early 1990s. The newer cohort consists of veterans who served from the early 1990s after the end of the Cold War, again joining voluntarily. Pension and compensation schemes were established and modified over the years to respond to the needs of veterans and veterans with disabilities. However, it was only in the 21st century that the government shaped the policy toward veterans based on the Armed Forces Covenant – a statement of the moral obligation which exists between the nation, the government and the Armed Forces – published in May 2011. Its core principles were enshrined in law for the first time in the Armed Forces Act of 2011 (AFA, 2011). Specifically, the covenant outlines two core principles: 1 2

No disadvantage: no current or former member of the armed forces, or their families, should be at a disadvantage compared to other citizens in the provision of public and commercial services. Special consideration: particular attention is appropriate in some cases, particularly for those who have been injured or bereaved.

Although the covenant does not create new rights, it calls on the government to report to parliament each year on the progress made with respect to the covenant, and specifically in relation to four core areas specified in the Act – health care, education, housing, and the operation of inquests. The most recent effort was the promotion of “Veterans Strategy” in November 2018, which was intended to create collective and tangible outcomes for veteran’s services (Ministry of Defense November 14, 2018). The strategy is for a ten-year period, to 2028, and will be reviewed in 2023. All retired members of the armed forces are entitled to the Armed Forces Pension Scheme (AFPS). The scheme reflects the unique sacrifice the armed forces and their families make for the country. It is a generous public service occupational pension scheme. The scheme is non-contributory for members (Armed Forces Pension Scheme annual accounts 2016–17, HC 33, July 13, 2017). There are three pensions schemes depending on the date of joining: AFPS 75, for members of the Armed Forces between April 1975 and April 2005 (and who did not opt to transfer to AFPS 05 at April 6, 2005); AFPS 05, for new entrants between April 6, 2005 and April 1, 2015; and AFPS 15, for new entrants from April 1, 2015, and active scheme members on that date, unless covered by transitional protection. The 1975 and 2005 schemes are closed to new members. The 2015 scheme was introduced to adjust the rates to rising life expectancy. There are two occupational pension schemes for members of the Reserve Armed Forces: Full Time Reserve Forces Pension Scheme (FTRSPS 97) and Reserve Forces Pension Scheme (RFPS 05). These provide benefits that are broadly similar to AFPS 75 and AFPS 05 respectively. From April 1, 2015, all active members were transferred to AFPS 15 unless covered by transitional protection (Armed Forces Pension Scheme annual accounts 2015–16, HC 365, July 12, 2016).

Welfare, warfare, policies toward veterans 11

Compensation schemes for veterans with disabilities The compensation schemes are provided only to current or ex-servicemen and women with disabilities. The current Armed Forces Compensation Scheme (AFCS) makes payments to current and former service personnel and their families for ill health, injury, or death caused by service on or after April 6, 2005. However, those who served prior to April 6, 2005 might receive benefits paid by the War Pension Scheme of 1975, which is intended to provide benefits for disablement caused or made worse by service in the armed forces. The condition has to be attributable to a person’s military service, but it does not have to be related to war or military conflict. It is a “no fault” scheme, meaning that the compensation is paid by the MoD without having to establish causation or fault (Rates of War Pensions and allowances 2017–18). The rates depend on the degree of disability, assessed on a percentage basis as in the Industrial Injuries Scheme. The rates from April 2017 range from £36 a week for 20% disablement to £180 a week for 100% disablement. A range of allowances and supplements are available for the unemployed or those who need mobility or attendance allowances. While there is no statutory requirement to uprate the benefits available through the War Pensions Scheme, successive governments have honored the commitment made in 1971 by then Secretary of State for Social Services Sir Keith Joseph to review the level of War Pensions on an annual basis to protect their purchasing power. The number of ex-service veterans who received War Disablement Pension was 11,228 as of March 31, 2016. However, since the introduction of the Armed Forces Compensation there has been a steady decrease in the number of registered first claims by ex-service personnel: between 2006–7 and 2015–16 the number of new disablement claims registered each year fell by 34% from 7,404 to 4,868. The AFCS was enacted as part of the Armed Forces (Pensions and Compensation) Act of 2004, and the detailed rules are in the Armed Forces and Reserve Forces (Compensation Scheme) order 2005 (SI 2005/439). The scheme was criticized and finally revised in 2010, particularly with respect to increased benefits for mental health conditions. There are two main types of AFCS benefits: (a) lump sum payments, ranging from £1,200 to £570,000, for pain and suffering depending on the severity of the injury or illness; and (b) Guaranteed Income Payments (GIPs), a tax-free, indexlinked monthly payment for those with the most serious injuries and illnesses which would cause a significant loss of earning capacity. Various factors are taken into account when calculating GIP including the effect of an injury on future promotion prospects. The GIP may be subject to adjustment due to payments made under the Armed Forces Pension Schemes. The Armed Forces Independence Payment (AFIP) was introduced on April 8, 2013 as an alternative to the DWP benefit Personal Independence Payment (PIP) for serving or former service personnel who have been seriously injured as a result of service. As with the PIP, the AFIP is intended to help with the extra costs incurred by people as a result of their disability.

12 Welfare, warfare, policies toward veterans Individuals are eligible for the AFIP if they receive an AFCS Guaranteed Income Payment of 50% or more. Eligible individuals are not required to undergo an initial assessment, nor is there any future reassessment. Once approved, the AFIP continues for life, unless the GIP is reduced below the 50% level. The AFIP is administered by Veterans UK as part of the AFCS, but payments to individuals are made by the DWP. The AFIP is currently worth £141.10 per week – the same amount a person entitled to the enhanced rates of the PIP mobility and daily living components would receive. The government recently proposed a new compensation scheme for those who were injured or killed in military conflict or war and their dependents (Ministry of Defense, Armed Forces Compensation Scheme statistics: financial year 2015– 2016, June 2, 2016). The new proposal, the Enhanced Compensation Scheme, was tied to 2015–2017 and worked in parallel with the AFCS. It was intended to prevent individuals from seeking financial compensation for injuries (or their families in the event of death) through the courts. However, the proposed scheme was criticized by the Law Society for lacking transparency and for impugning the impartiality of the courts by denying the ability to pursue legal action (The Law Society, February 2017).

War and welfare policy in the United States Compared to the United Kingdom, the United States is marked by the development of an “idiosyncratic strong warfare/weak welfare governance paradigm” (Waddell, 2001). It maintained strong spending on military infrastructure following World War 2 which intensified during the Cold War era. This was particularly evident during President Ronald Reagan’s administration and was associated with a tremendous reduction in welfare spending. The 1990s saw increased warfare spending and levels of poverty (Henderson, 1998), with the same pattern repeated under George W. Bush’s presidency. MacLeavy and Peoples (2009) argue that the United States has turned into the “workfare state,” in which social protection is related to paid labor input. The reduction of welfare expenditures has been replaced by welfare-to-work programs, but with a steady commitment to military spending. In other words, “workfarism” and “warfarism” have become the two mechanisms that keep welfare spending as low as possible. US social welfare policy is capitalistic, focusing on free-market ideology as well as conservative ideology that believes in self-reliance and warns against dependency on public money (Tait, 2002). However, the connection between warfare and welfare is much more complicated and is also associated with public support of military policy. The best example for warfare stimulating the welfare policy is the Civil War pensions that paved the way for civilian retirement pensions. Other examples are the impact of World War 1 on health provision and the role of World War 2 as a catalyst for education and housing for all Americans. However, when the public is divided politically about the country’s military activities abroad, it is impossible to see expansion of welfare programs.

Welfare, warfare, policies toward veterans 13 From the 1970s to the early 1990s, investment in welfare and employment programs declined, and the military expanded its welfare functions. The Reagan era witnessed a preference for work-based programs, a reduction of federal and state funding of social services, and the increased importance of the voluntary and for-profit sectors (President’s Commission on Privatization, 1988). The George Bush and Clinton years marked a softening of Reagan’s policy and a slight improvement in welfare programs. Bush’s most notable social policy developments were the passage of the Americans with Disabilities Act of 1990, which dramatically increased protection from discrimination in housing, work, and public accommodation for people with disabilities (Gostin, 2015). The Clinton administration supported a major expansion of the Earned Income Tax Credit, which allowed lower income workers to credit selected work-related expenses against federal tax obligations (Hoynes, Rothstein, & Ruffini, 2017). Both the Obama and the Trump administrations expanded the defense budget, but differences between the two are related to welfare and health policy. The main difference was in health care policy as the Trump administration’s efforts were designed to eliminate Obamacare (the Affordable Care Act of 2010) and to lower the budget on welfare spending (Thompson, Gusmano, & Shinohara, 2018). Warfare is not only linked to welfare spending but also to the veteran’s budget. An overview of 20th century spending (see Figure 1.1) demonstrates that it peaked after World Wars 1 and 2. After World War 1, veterans spending climbed back from 0.6% to 1.6% of the GDP. In 1936, veterans spending peaked at 2% of GDP. Immediately after World War 2, US spending on veterans climbed to 2% of GDP in 1950. Veterans spending declined slowly in the 1980s and 1990s and reached 0.42% of GDP in the early 2000s. It increased in the late 2000s, hitting 0.82% of GDP in 2011 and is expected to approach 1% of GDP in 2020.

Policies toward veterans with disabilities in the United States: historical review United States policy toward veterans with disabilities reflects a strong commitment to those who were injured in protecting the nation. The first pensions began early in the 17th century in the English colonies of North America. The first law was enacted in 1636 by the Plymouth General Court, compensating those who were injured in the defense against the Indians (Gilman & O’Hara, 2018). However, the first national pension law was enacted on August 26, 1776 and set the rules for compensating officers, soldiers, and sailors with physical disability and incapacity by mandating a stipend of half of their regular income. Since the date of this first national law, thousands of public and special acts providing pensions, compensation, and disability allowances to veterans and their survivors were passed by Congress (Aaronson, 1942). However, these were limited in scope and provided relatively small benefits. The commitment to disabled veterans continued when Congress passed the first federal pension legislation in 1789. The new Bureau of Pensions was administered

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US: 20th-Century Veterans Spending

Figure 1.1 20th-Century Veterans Spending in the United States from 1900 to 2020

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14 Welfare, warfare, policies toward veterans

Welfare, warfare, policies toward veterans 15 from 1833 to 1840 as part of the Department of War, and from 1840 to 1849 as the Office of Pensions under the Navy Secretary. The office was then assigned to the new Department of the Interior. The first national effort to provide medical care for disabled veterans was the Naval Home, established in Philadelphia in 1812. This was followed by two facilities in Washington, DC – the Soldier’s Home in 1853 and St. Elizabeth’s Hospital in 1855 (Butts, 2019). The Civil War was a turning point in veteran’s care because it left thousands of wounded soldiers without adequate medical services. The General Pension Act of 1862 provided disability payments based on rank and degree of disability, and liberalized benefits for widows, children, and dependent relatives (Rothbard, 2019). The act included, for the first time, compensation for diseases such as tuberculosis contracted while in service. In 1865, Congress established the National Home for Disabled Volunteer Soldiers (NHDVS). Admission was free, and soldiers could choose when they wanted to leave. The system, which included 11 branches and stayed open until the mid1930s, influenced the development of national veteran health care in the United States (Julin, 2007). The Consolidation Act in 1873 revised pension legislation, paying on the degree of disability rather than service rank. Until 1890, Civil War pensions were granted only to veterans discharged because of illness or disability attributable to military service. The Dependent Pension Act of 1890 broadened the scope of eligibility, providing pensions to veterans who were incapable of manual labor (Eli, 2015). Although World War 1 was recognized as marginal in American history, it is considered as central with respect to provision of benefits, i.e., medical services as well as vocational rehabilitation programs (Carden-Coyne, 2007). The War Risk law was amended in mid-1917 to provide insurance against loss of life, personal injury, or capture by the enemy of personnel on board American merchant ships. The legislation also provided vocational rehabilitation and training for veterans with permanent disabilities. However, the first consolidation of veterans’ programs took place when Congress combined all World War 1 veterans’ programs to create the Veterans Bureau (Mix, 2016). The second consolidation of federal veterans’ programs took place on July 21, 1930 when president Herbert Hoover signed Executive Order 5398 and elevated the Veterans Bureau to a federal administration – creating the Veterans Administration (VA) (Ridgway, 2013). As the Depression worsened, veterans began protesting for immediate payment of their pensions. In March 1932, a small group of veterans from Oregon began marching to Washington, DC, to demand payment. The protest was expanded nationally as more unemployed veterans from across the country began descending on the nation’s capital. Veterans thus became a very visible and effective interest group because they were recognized as a legitimate group that could demand their rights. They knew how to exercise their political power and preserve their pensions. In fact, they became a model for others on how to mobilize federal government economic interests (Holcombe, 1999).

16 Welfare, warfare, policies toward veterans In 1940, prior to America’s entry into World War 2, Congress created a new insurance program for servicemen and women and veterans. National Service Life Insurance was designed to eliminate any inequities in premiums that would have resulted if the young men had been grouped with the older World War 1 veterans covered by US government life insurance (Manske, 2013). After the attack on Pearl Harbor on December 7, 1941, Congress liberalized service-connected disability policies including aid to families of servicemen and women who were killed or disabled before they had an opportunity to take out insurance. The Disabled Veteran’s Rehabilitation Act of 1943 established a vocational rehabilitation program for disabled World War 2 veterans who served after December 6, 1941. However, the most important legislation was the Servicemen’s Readjustment Act, known as the “GI Bill of Rights,” signed by President Roosevelt on June 22, 1944 (Mettler, 2005). The legislation consisted of three provisions. The first was educational and included four years of education or training (tuition, fees, books, and supplies, plus a monthly subsistence allowance). The second benefit provided veterans with federally guaranteed home, farm, and business loans with no down payment. This feature was designed to generate jobs in the housing industry while providing housing and assistance for veterans and their families. The third was an unemployment package that paid veterans who had served at least 90 days a weekly payment of $20 per week for 52 weeks. Although the GI Bill was for all veterans and not particularly for veterans with disabilities, it boosted millions of veterans and their families. There is no doubt that it is considered the most progressive welfare program in America. In addition, the Veteran’s Preference Act of 1944 gave veterans hiring preference where federal funds were spent. The president was authorized to set aside government jobs for veterans for the duration of the war and for five years afterward (Eiler, 2012). However, in practice both the executive and legislative branches failed to undertake meaningful steps to maximize the federal government’s role as a model employer. Post-World War 2 policies were overshadowed by the Korean and Vietnam wars and by the expansion of claims and VA health facilities. Following the outbreak of the Korean War in June 1950, Congress passed the Vocational Rehabilitation Act of 1950. The act intended to help Korean War veterans find employment after losing their pre-war jobs due to disabilities caused by war. The Veteran’s Readjustment Assistance Act of 1952, called the Korean GI Bill, provided unemployment insurance, job placement, home loans, and mustering-out benefits similar to those offered to World War 2 veterans. However, the Korean GI Bill was less generous than the original GI Bill as it reduced financial benefits and imposed new restrictions on funding of educational programs (Bound & Turner, 2002). The expansion of the VA was remarkable, serving millions of veterans with respect to medical care, financial assistance, and insurance. At that time, the ExServicemen’s Unemployment Compensation Act of 1958 provided unemployment insurance to veterans and for the first time included peacetime veterans (Whittaker & Isaacs, 2008). In 1959, the VA changed the sliding scale of pension payments based on the recipient’s income (including spouse’s income) rather than a flat rate-rate pension.

Welfare, warfare, policies toward veterans 17 The Vietnam War challenged federal government policies primarily because of the high number of veterans with disabilities resulting from this war. By 1972, there were 308,000 veterans with disabilities connected to military service. The anti-war climate made the struggle of returning veterans more difficult, with many reporting that they were isolated and abandoned by society. In addition, it was a time of economic recession with a high rate of unemployment (Figley & Leventman, 1980). Government response was the passage of the Veteran’s Readjustment Benefits Act (1966), called the Vietnam GI Bill, which restored educational benefits to veterans. Under this act, veterans who had been on active duty for more than 180 consecutive days were entitled to one month of educational assistance for each month of service. This was later increased to one and one-half months for each month of service (Ridgway, 2011). An additional provision for Vietnam veterans was the Servicemen’s Group Life Insurance. The program began with $10,000 maximum coverage, which was increased over the years to the December 1992 maximum of $200,000. Congress initiated a program of mortgage life insurance for veterans with severe disability to assist those in need of specially adapted housing. The insurance covered mortgages up to a maximum of $30,000. By 1992, coverage had increased to $90,000 (Vigdor, 2006). In 1980, Congress changed vocational rehabilitation training, so that veterans with disabilities who trained were guaranteed job placement as well as independent living assistance (Bordieri & Drehmer, 1984). A special concern emanating from the Vietnam War was the exposure to Agent Orange. Since 1978, the VA has been offering special access to medical care, including physical exams, to Vietnam veterans with Agent Orange health concerns (Palmer, 2005). In 1981, the VA established a special eligibility program which provides free follow-on hospital care to Vietnam veterans with any health problems whose cause is unclear. The Agent Orange Act of 1991 provided for presumptive service connection for disabilities resulting from exposure to herbicides used in Vietnam. In July 1993, the VA announced that Vietnam veterans suffering from Hodgkin’s disease and the liver disease porphyria cutanea tarda would be entitled to disability payments based on their presumed exposure to Agent Orange and other herbicides (Young, 2002). The Radiation-Exposed Veterans Compensation Act of 1988 authorized disability compensation for veterans suffering from a number of diseases associated with radiation. The gradual political influence of veterans is reflected in Reagan’s decision to elevate the VA to cabinet status in 1988. In March 15, 1989, the VA became the Department of Veterans Affairs. Edward J. Derwinski, VA administrator at the time, was appointed the first Secretary of Veterans Affairs. The most remarkable legislation thereafter was the Omnibus Budget Reconciliation Act of 1990 related to eligibility to file claims after October 1990. The legislation required that to be determined totally disabled, a veteran of any age had to be considered unemployable as a result of a disability reasonably certain to continue throughout his or her life. However, that year marked the beginning of Operation Desert Shield which became Operation Desert Storm in January 1991.

18 Welfare, warfare, policies toward veterans In March 1991, Congress passed the Persian Gulf Conflict Supplement Authorization and Personnel Benefits Act which determined eligibility for veterans benefits (Rumann & Hamrick, 2009). The legislation extended eligibility to Persian Gulf War veterans for wartime-only pensions, medical treatment, educational benefits, housing loans, and unemployment payments. The Gulf Act contained a provision authorizing increases in the monthly educational benefits provided by the Montgomery GI Bill. Veterans who were injured in this war presented symptoms that were not recognized before, among them fatigue, skin rash, headache, muscle and joint pain, memory loss and difficulty concentrating, shortness of breath, sleep problems, gastrointestinal problems, and chest pain. Consequently, in 1993 Congress had to authorize medical care for Gulf War veterans for conditions possibly related to exposure to toxic substances or environmental hazards. Veterans who could not be diagnosed at a local VA medical center were referred to one of four VA Gulf War referral centers located across the country. In 1994, Congress, on the VA’s recommendation, authorized compensation to veterans with chronic disabilities resulting from undiagnosed illnesses, if the illness appeared during active duty in the Gulf or within a presumptive period after Gulf service. Ridgway (2011), who reviewed veterans’ histories from before the nation was founded up until the millennium, believes that they provide insights into current policies. In his opinion, the fluctuations from the Civil War and its aftermath until the current time reflect the changes in veterans’ recognition and political power. They shaped the spirit of America during the Civil War and emerged as a powerful political power that could mobilize their own rights. World War 1 and thereafter marked a decrease in their status as the nation struggled for economic survival. The World War 2 era demonstrated their reconnection with American society and improvement of their benefits and services. However, these achievements were challenged again with military wars and conflicts in Korea, Vietnam, Iraq, and Afghanistan. There is no doubt that current policy toward veterans with disabilities is the result of these fluctuations.

US current benefits and services for veterans with disabilities The two pivotal provisions of the Department of Veterans Affairs are compensation and health care. Service-connected conditions are illnesses or injuries incurred or aggravated during military service. Eligibility for compensation from the VBA of the VA is determined by examination and is rated on a scale of 0 to 100% according to the average impairment in earning capacity that the serviceconnected condition typically causes (Meshberg-Cohen, DeViva, & Rosen, 2017). Health care is another cornerstone of the foundation of benefits provided to veterans, including those with service-connected conditions, who are eligible for health care at little or no cost. More than half of veterans with service-connected disabilities used VA health care in 2015 (Maynard et al., 2017). Veterans with a 50% or greater rating are eligible for free health care, and those with a 100% rating are provided cost-free medical care, including medications for treatment of any disability. Additional services provided include dental work, prosthetic devices, hearing aids, eyeglasses, and institutional nursing home care.

Welfare, warfare, policies toward veterans 19 Veterans with disabilities are considered a unique population in different periods of warfare. Most veterans with disabilities differ from civilian populations in their health needs, particularly with respect to mental health disorders, post-traumatic stress, and traumatic brain injury (Olenick, Flowers, & Diaz, 2015). There are special health concerns associated with certain military operations. For example, veterans of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) are younger than those of earlier wars and include more female soldiers and officers than in earlier wars or military activities. They appear to be more socially integrated, less often diagnosed with substance abuse disorders, and require less VA disability compensation for PTSD when compared to their Persian Gulf and Vietnam veteran counterparts (Fontana & Rosenheck, 2008). Therefore, it is important to examine the broad range of benefits and services provided in the context of these unique characteristics of this population. The current provisions are listed next. Compensation Disability Compensation – a monthly monetary benefit paid to veterans who are disabled by an injury or disease that was incurred in or aggravated by active military service. On December 31, 2018, there were about 4.8 million veterans with disabilities who received disability compensation (National Center for Veteran Analysis and Statistics, 2019). Automobile Allowance – financial assistance provided to help eligible severely disabled veterans to purchase or adapt an automobile to accommodate their disabilities. Clothing Allowance – annual stipend(s) provided to disabled veterans who have unique clothing needs as a result of a service-connected disability or injury. Pension The VA Pension is a monthly cash benefit that assists disabled or retired veterans. Eligibility includes low income and assets, 90 days of service (including at least one day of service during wartime), total and permanent disability (or being deemed disabled by the Social Security Administration) or being aged 65 or older. Some veterans can qualify for Housebound Benefits and Aid and Attendance (A&A) and improved pension programs. Concurrent Retirement and Disability Payments (CRDP) is a program allowing certain military retirees to receive retirement benefits and disability payments at the same time. Eligibility requires a military retiree to have service of 20 or more years, and a service-connected disability rated 50% or more. Combat-Related Special Compensation (CRSP) is a special program providing compensation to certain military retirees for combat-related injuries and illnesses. Eligibility requires military retirees to have at least 20 years of service or a medical retirement combat-related service-connected disability, and a disability rating of 10% or higher.

20 Welfare, warfare, policies toward veterans VA health care Health care service is provided regardless of having disability or serving in combat operations or during wartime, though in some cases there are copays for medical treatment depending on the type of service. For those veterans who enlisted after September 7, 1980 or entered active duty after October 16, 1981, eligibility for VA health care requires continuous service for at least two years. Veterans who were discharged for a service-connected disability or due to hardship may not have to meet this minimum service requirement. Also, veterans who served prior to September 7, 1980 do not have to meet a minimum service requirement. VA nursing home care While priority for VA nursing home care is given to veterans with serviceconnected disabilities rated at 60% or higher, any veteran who meets the basic eligibility requirements for VA benefits can be eligible for VA nursing home care.

Other VA benefits Education and training The VA pays benefits to eligible veterans pursuing an approved education or training program. There are four primary VA education benefit programs that cover active duty, National Guard and Reserve Service members, and veterans: 1 2 3 4

Post-9/11 GI Bill (Chapter 33) Montgomery GI Bill-Active Duty (Chapter 30) Montgomery GI Bill-Selected Reserve (Chapter 1606) Reserve Educational Assistance Program (REAP)

The Post-9/11 GI Bill program provides financial assistance toward tuition and fees, books and supplies, and a monthly housing allowance. Eligible service members may transfer unused Post-9/11 GI Bill benefits to an eligible spouse or child. The VA pays a monthly allowance under the other benefit programs to help offset educational costs. On December 31, 2018 there were 903,806 beneficiaries of VA education and training. Vocational Rehabilitation and Employment (VR&E) provides educational and training services to veterans with service-connected illnesses and injuries to prepare for, obtain, and maintain suitable employment. On December 31, 2018, 125,513 veterans participated in vocational rehabilitation and employment programs. Life insurance Service-Disabled Veteran’s Insurance (S-DVI) provides life insurance coverage to veterans who have been given a VA rating for a new service-connected disability

Welfare, warfare, policies toward veterans 21 in the last two years. Totally disabled veterans are eligible for free insurance premiums and are able to purchase additional insurance. Veteran’s Mortgage Life Insurance (VMLI) provides mortgage life insurance protection to disabled veterans who have been approved for a VA Specially Adapted Housing (SAH) Grant.

Other federal benefits Veterans with disabilities who receive disability payments are also entitled to receive other federal benefits, including those from the Social Security Disability Insurance (SSDI) Program and from the Supplemental Security Income (SSI) program. SSDI recipients qualify for Medicare after a two-year period, and SSI recipients in most states qualify for Medicaid. The rules for those programs are connected to employment and are much stricter than those of VA disability benefits. Some veterans with disabilities may qualify for Department of Defense (DoD) retirement pay. Until 2003, these veterans were asked to choose between receiving a full retirement annuity from the DoD with no VA disability pay, or an annuity reduced by the amount they received in disability benefits from the VA (the reduction is also known as “VA offset”). Since 2003, some retired military personnel who receive VA disability compensation have obtained payments that make up for part or all of the VA offset.

Policy concerns and future direction Compensation for service-connected conditions is considered the main income support for veterans whose earning capacity has been reduced by events that occurred during their military service. Health care is another important provision, in particular mental health services for those who have reported PTSD, major depression, or anxiety. This is a concern since these individuals are more likely to die prematurely from suicide or accidental causes. A policy document released by the Congressional Budget Office in 2014 proposed the consideration of possible steps related to the disability compensations, among them structural and procedural actions. Among the structural changes were restriction of individual unemployability benefits to veterans who are younger than the full retirement age for social security, Tax VA disability payment, and supplemental payments to veterans who have mental disorders. The procedural suggestions include a time limit on initial applications and expansion of VA use of reexaminations. The VA’s current strategic planning for 2018–24 issued in 2019 and intended to set priorities for responding better to veterans’ concerns. They include suicide prevention, improving provisions to veterans in rural areas, replacing the aging electronic health record system, better coordination between the DoD and the VA, and increased accountability and transparency. Other areas of concern that need improvement are women’s health and quality of community living centers.

22 Welfare, warfare, policies toward veterans

Warfare and welfare policy in Israel The development of Israel’s welfare state was crystalized during the pre-state era. There are a few forces that shaped the essence and spirit of the new state, among them the Zionist Labor movement’s ideology, the War of Independence, ongoing military conflicts with Palestinian and Arab countries, and immigration waves from 101 countries (Mor, 2006; Rosenheck, 2004). In fact, throughout the 72 years since the establishment of the state, Israelis have experienced persistent violence in the form of border conflicts, violence by and against Palestinians in the “occupied territories,” terrorist actions against Israeli civilians, and small- and large-scale Israeli military activity in the Palestinian territories. Aside from the fact that the state has to be prepared for military conflicts that can erupt at any time, the state has other missions including absorbing Jewish immigrants and building solid economic and labor infrastructure (Razin, 2018). Israel’s social welfare policy is unique because it reflects ongoing military conflicts and post-war periods of changes in the economy and social and political processes. According to Gal (2007), who studied the nexus between warfare and welfare in depth, the state was successful in creating a modest social welfare infrastructure that qualified it to be considered a welfare state. The milestones of a welfare state are the creation of a social security system, known in Israel as the National Insurance Institute (NII), and the development of universal social welfare legislation in the early 1970s. The state had to cope with ongoing wars and military conflicts until the mid-1970s including the War of Independence, the Reprisal Operations of the 1950s and 1960s, the Suez Crisis of 1956, the 1967 Six Day War, the War of Attrition between 1967 and 1970, and the Yom Kippur War of 1973. However, at the same time there were additional challenges such as massive immigration between 1948 and 1952 and a doubling of the existing population in 1948. In fact, most of the citizens in the 1970 were immigrants who required jobs and resources, including housing. Does the need to expand military spending take its toll in terms of welfare policy? While two Israeli studies have shown the economic effects of defense spending (Mintz & Ward, 1989; Cohen et al., 1996), none has examined its impact on social welfare policy. Shalev and Gal (2018), who remarked on the tradeoffs between guns and butter, found no evidence that military and public spending since the mid-1980s was inter-related. In fact, while military spending has increased, domestic expenditure has remained stable. Except for a slight change in the early 1990s – due to absorption of one million immigrants from the former Soviet Union – transfer payments have been valued at between 11% and 13% of GDP. Civilian public services have also accounted for a stable share of GDP, typically around 17%. The centrality of warfare in welfare legislation is reflected in the first social security legislation of the Knesset (parliament) just after the War of Independence and prior to any social insurance law. The Invalid’s Law (Benefits and Rehabilitation), enacted in 1949, provided disabled IDF veterans of the War of Independence with non-means-tested benefits. In addition, it included a variety of medical

Welfare, warfare, policies toward veterans 23 and occupational rehabilitation services, business and home loans, and access to personal social services and counselling (Gal & Bar, 2000). The impact of warfare on welfare legislation is seen in the enacting of the Victim of Hostile Acts (Compensation) Law (5730–1970). This law and its ancillary regulations were meant to equate the rights of civilian victims with those extended to bereaved families that were handled by the MoD under the Disability (Compensation and Rehabilitation) Law 5719–1959 (Rimmerman & Araten-Bergman, 2010).

The development of policy toward veterans with disabilities in Israel Until 1948, known as the pre-state phase, the state was dominated by the British Mandate.1 After the end of the British Mandate and the United Nations’ decision to partition Palestine and recognize the State of Israel, the neighboring Arab states declared war on the new Jewish state, known as the War of Independence. The first veterans with disabilities and families of the bereaved were cared for by the IDF, but the responsibility was soon transferred to the MoD. The latter provided veterans with disability cash allowances depending upon the availability of resources (Nadav, 2008). The Invalids Law (1949) was the first welfare law passed by the Knesset to provide compensation allowances to recognized veterans with disabilities (TalKatz, Araten-Bergman, & Rimmerman, 2011). When introducing the new law, Prime Minister David Ben-Gurion expressed the State of Israel’s deep obligation to compensate the wounded as follows: The War of Independence fought by the Israel Defense Forces was not only studded with satisfaction, triumph, and conquest. There was a different side to the coin. A heavy price was paid . . . happily, many remained alive, but they, too, paid a heavy price, through the loss of limbs. On behalf of the government, I present you with a law to pay the debt, or more precisely, part of the debt that we owe those whose bodies helped liberate the homeland. A law for compensation and rehabilitation of the war wounded. (Divrei HaKnesset, 1949, p. 1572) The law also provided a variety of medical and occupational rehabilitation services, business and home loans, and access to personal social services and counselling. Finally, it granted special assistance to disabled veterans with no additional source of income (Nacht & Kleyff, 1955, pp. 17–25). The legislation also recognized the “Zahal Disabled Veterans Organization” (ZDVO) as the official representative organization of veterans with disabilities. Less than a year later, legislation stipulating the rights of families of fallen soldiers was also passed (Gal & Bar, 2000). The mid-1950s saw the expansion of the Rehabilitation Department, which managed the provisions of the Invalids Law of 1949, in particular the establishment of compensation procedures and medical and social welfare services (Gal &

24 Welfare, warfare, policies toward veterans Bar, 2000). In 1959, revised legislation was enacted incorporating the changes that had occurred since the enactment of the original Invalid’s Law of 1949. Over the next 70 years, there have been 30 revisions of the law, and just recently the Welfare and Health Committee of the Knesset intended to approve a version that accommodated all the internal changes agreed by the MoD and the ZDVO in 2016. The intended changes are supposed to arrange for the following benefits: vocational rehabilitation, housing, economic welfare, psychosocial provisions, and a mobility allowance, as well as medical services and benefits. According to Gal and Bar (2000), the generous benefits secured by war-related beneficiary groups received broad consensus from the general public, which holds the soldiers of Israel’s citizen army in high regard, believing that a strong military is essential to Israel’s survival. These beliefs, expectations, and values peaked during and after wars and periods when perceived security threats were high. The most important changes in the MoD’s policies were made after the 1967 and 1973 wars which resulted in massive casualties and injured soldiers. For instance, the 1973 Yom Kippur War significantly changed the protocols of care of PTSD. In 1988, the population covered by the law was extended to include those injured in the other branches of security such as the Israel Police Force and the Israel Prison Service. The most important call for re-examination of MoD rehabilitation conceptualization and practice was offered by Generals Vardi, Greenberk, and Erlich in February 2002. In the first decade of the 21st century, the MoD hired professional consultants, among them Prof. Arie Rimmerman (the author), who offered a transition from the medical to the social-functional model and evidence-based practice. In 2005, there was an administrative change to separate the services of veterans with disabilities from those of bereaved families. After the end of the Second Lebanon War, the government established in 2006 a Committee of Experts headed by David Brodet to assess the defense budget. The committee released its recommendation in May 2007, suggesting that the war exposed serious budgetary problems and recommended that any future expansion of the budget required transparency and efficiency. The establishment of Judge Goren’s committee in November 2009 was intended to restrain the expansion of the budget allocated to disabled IDF veterans by re-examining provision eligibility. The Goren Committee’s report, released in 2010, suggested that eligibility benefits would be granted only for those injured in military-related activity, while others would be served by the NII as are civilians. The government formally decided to adopt the recommendations, and the new regulations were introduced in 2017. The decision to change the eligibility criteria marked a significant change in the status of veterans with disabilities from non-restricted to restricted and provided for those who could prove that their disability was caused by military-related activity.

Current provisions for veterans with disabilities and core issues Israeli policy toward veterans with disabilities is based on the previously mentioned Invalids Law of 1949. The law was revised in 1959 and through the years

Welfare, warfare, policies toward veterans 25 there have been about 30 revisions, including the recent changes recommended by the Goren Committee (2010). Eligibility is determined by military-related activity and according to the severity of the medical impairment (“percentage of medical disability”). The determination process is handled by physicians who examine the level of difficulty in the veteran’s physical or psychiatric functioning in comparison with the norm. The degree of medical disability ranges from 0 to 100%. Defense forces veterans with a recognized permanent medical disability of 20% or more are entitled to a monthly pension for the rest of their lives (Tal-Katz, Araten-Bergman, & Rimmerman, 2011). All veterans with disabilities with 20% of medical disability are entitled to a basic allowance (with the exception of veterans who were entitled to receive a monthly allowance from 10% medical disability (until January 1, 1996) and separate medical services related only to their recognized disability (the exception is those with 100% “medical disability” which provided them with all their medical needs at the MoD. Veterans with disabilities are also entitled also to other benefits, among them a mobility allowance for those with orthopedic disability, home-making services for those who need home care, and tax-exemption and tax discount benefits when they apply. The main goal is to engage disabled IDF veterans in career development as close as possible to their injury. Therefore, the Rehabilitation Division offers a wide range of comprehensive rehabilitation services designed to assist the individuals in developing their career development goals (Rehabilitation Division Report, 2010). More than half of the budget is spent on cash benefits, approximately a quarter is allocated to medical services, and a sixth to the various rehabilitation services, with special focus on vocational rehabilitation and career development counseling (Tal-Katz, Araten-Bergman, & Rimmerman, 2011). IDF veterans with disabilities who are engaged in vocational rehabilitation and studies receive an additional allowance until they complete their training period. Those who are determined as being unemployed receive a supplement allowance. The Rehabilitation Division also provides financial support to veterans with disabilities who decide to start a business. Historically, the Division of Rehabilitation Employment Unit is responsible for protecting the employment rights of veterans with disabilities, based on the Invalids (Pension and Rehabilitation) Law, 1959 and the Discharged Soldiers (Reinstatement in Employment) Law, 1949 and its amendments of 1951. The unit monitors and intervenes to ensure that public employers with more than 20 employees are required to employ at least 5% of veterans with disabilities and protect them from being fired. This quota scheme, which was a very important strategy in the 1950s and 1960s, lost its appeal as employers preferred to pay fines instead of hiring veterans with disabilities.

Conclusion The United Kingdom, the United States, and Israel have developed three different models of social welfare policies as related to warfare. The United

26 Welfare, warfare, policies toward veterans Kingdom’s policy was crystalized during and after World War 2 and leaned toward “social citizenship,” as civilians participated substantially in the defense and military efforts pre-war, during and after wartime. The policy reflects a comprehensive, universal welfare state that was shared by all citizens (Marshall, 1950; Titmuss, 1976). However, this consensual approach was eroded toward the end of the 20th century and moved toward a less universal approach due to the shift toward more conservative governments and economic crises. World War 2 veterans frequently complain that the government has neglected them and is pushing them to be dependent on the support of military charities (Dandeker et al., 2006). The United States’ social policy has developed a “targeted compensation” policy as a response to the Civil War and World War 2 (Campbell, 2004). It is basically a segmented military social welfare compensation scheme reflecting appreciation and tribute to soldiers for sacrificing their lives or bodies for the nation (Gifford, 2006). This approach changed after World War 2 and is reflected in the debate about the Vietnam War and the lack of consensus regarding US warfare policy. Public support of veterans’ policies has gradually shrunk, and is evident today in the number of veterans in American society (Scott, 2017). Israel is a new state that was established after World War 2 and has experienced a bloody War of Independence and ongoing warfare and terror attacks that continue to this day (Shalev & Gal, 2018). Its social policy demonstrates the need to compensate soldiers with disabilities and bereaved families, but by the same token has a commitment to build a social welfare state which can also respond to growing waves of immigration (Rosenheck, 2004). There is an ongoing struggle to maintain war readiness and to respond to domestic social needs with a stringent budget. Warfare has had a significant impact on the creation of distinct administrations to handle the psychosocial and medical needs of veterans with disabilities in these countries. In the United Kingdom, the Veterans Scheme was administered initially as a separate Ministry of Pensions. However, in 1953, it amalgamated with the Ministry of National Insurance (Brown, 1984) and in 1992 the program was transferred to the War Pensions Agency within the Department of Social Security. In the United States and Israel, there are separate administrations for caring for veterans and civilians. In the United States, the VA is a federal cabinet-level agency which provides health care and several non-health care benefits, including disability compensation, vocational rehabilitation, education assistance, home loans, and life insurance. In Israel, the Rehabilitation Division operates within the MoD, and is known to have provided more generous benefits in the past as compared to other countries, including the United Kingdom and the United States (Gal & Bar, 2000). The Goren Committee (2010) marked a significant change by separating the compensation and provisions for soldiers who were injured in military activity from others. The 21st century has seen gradual changes in veterans’ needs and has demonstrated problems. On the one hand, there is a call to respond to the special aging needs of veterans with disabilities, while on the other hand there is a requirement by government to restrain spending and to make the system more efficient.

Welfare, warfare, policies toward veterans 27 In the United Kingdom, the MoD recognizes the need to respond to the growing number of aging veterans with serious geriatric illnesses and to provide special services to those diagnosed with PTSD and those vulnerable to depression and suicide (Kapur et al., 2009). The VA in the United States has to deal with veterans with disabilities from Operation Enduring Freedom and Operation Iraqi Freedom. Both have produced more survivors with severe injuries, including devastating emotional problems, than previous wars (Owens et al., 2007). Two additional challenges that the VA has to deal with in the 21st century are the growing number of aging veterans with disabilities who require geriatric services, among whom is a high percentage of veterans with PTSD, and an increased suicide rate which is triple that of the civilian population (Tsai & Rosenheck, 2016). Israel’s MoD shares the same concern about the growing number of older veterans with disabilities. A Committee of Experts established by the MoD found that about half are above the age of 53 and close to 22% are over 70. A recent selfreporting survey carried out by the Myers-JDC Brookdale Institute and funded by the MoD identifies a greater percentage of veterans reporting of cancer, diabetes, cardiovascular illnesses, and psychosocial problems as compared to the matched civilian population (Shnoor et al., 2017).

Note 1 The British ruled Palestine from 1920 to 1948. This period is known as the British Mandate.

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32 Welfare, warfare, policies toward veterans War Pensions Records. The National Archives United Kingdom. https://discovery.national archives.gov.uk/details/r/C982 The Welfare Reforms Acts of 2012 and 2016. www.legislation.gov.uk/ukpga/2012/5/ pdfs/ukpga_20120005_en.pdf and www.legislation.gov.uk/ukpga/2016/7/pdfs/ukpga_ 20160007_en.pdf Whiteside, N. (2014). The Beveridge report and its implementation: A revolutionary project? Histoire & Politique, 24(3), 24–37. Whittaker, J. M., & Isaacs, K. P. (2008). Extending unemployment compensation benefits during recessions. Congressional Research Service, Library of Congress. Wootton, G. (1956). The official history of the British legion. Macdonald & Evans. Yamamoto, T. (2007). RM Titmuss and warfare-welfare. The Annuals of Japanese Political Science Association, 58(1), 1119–42. Young, A. L. (2002). Vietnam and agent orange revisited. Environmental Science and Pollution Research, 9(3), 158–61.

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Aging with disability

Most of the veterans in the United Kingdom, the United States, and Israel are senior citizens, and as such need to cope not only with the long-term outcomes of their military experiences during early adulthood but also with their own aging (Settersten, 2006). One of the core factors in predicting their wellbeing is their type and severity of physical and mental disabilities and the degree of exposure to traumatic combat events. Additional influences are their health behavior and social support network and whether they live a proactive life with sufficient social contacts or a passive and inadequate lifestyle lacking social connectedness (Wilmoth, Landes, & London, 2018). Aging with a disability refers to individuals who age with a physical, mental, or cognitive disability acquired in early or mid-life. Over the past half century, we have witnessed a gradual increase in the number of individuals with disabilities who are transitioning to aging (Molton & Yorkston, 2017). This trend is probably related to increased longevity as well as advancements in medicine (Leray et al. , 2016). As they grow older, they are merging with formerly ablebodied adults who are aging into new impairments. Reaching old age is perceived as success, while acquiring impairments or disability is seen as a failure in reaching “successful aging” (Ansello, 2004). The overall belief among clinicians is that individuals who age with disabling conditions cannot reach “successful aging” (Berkman et al., 1993). There is growing evidence that individuals with disabilities develop secondary medical comorbidities prior to reaching aging (Jensen et al., 2013) such as pain and fatigue (Cook, Molton, & Jensen, 2011) and additional health and psychosocial problems (Denton, Plenderleith, & Chowhan, 2013). These conditions threaten the life course of “successful aging.” This chapter focuses on aging of persons who acquired physical and mental disabilities during adulthood and discusses their health and psychosocial conditions by using the framework of “successful aging” and whether they experience “accelerated aging.” It introduces two acquired disabilities relevant to veterans with disabilities who have been studied in depth – SCI and PTSD. In the conclusion, we discuss the centrality of “successful aging” and “accelerated aging” and the relevance to veterans with disabilities.

34 Aging with disability

“Successful aging”: core selective theories The phrase “successful aging” has entered gerontology over the past few decades (Wykle, Whitehouse, & Morris, 2005). It is often cited as a parallel term to life satisfaction, longevity, freedom from disability, mastery and growth, active engagement with life, and independence (Moody, 2005). It is also used interchangeably with “active aging,” “productive aging,” or “vital aging” to differentiate the term from poor health or dependency (Achenbaum, 2001).

Activity, disengagement, and continuity theories Activity, disengagement, and continuity theories are three major historical theories of “successful aging” (Bengtson et al., 2009; Vander Zyl, 1979). Activity theory is a psychosocial process of conceptualization suggesting the importance of ongoing social engagement to improve subjective wellbeing and to avoid age-related losses (Diggs, 2008). The theory strengthens the importance of a positive sense of self and the need to substitute new roles for those that are lost because of age. However, the theory was criticized for missing socioeconomic and health disparities that determine whether or not the person can be socially active in old age (Bengtson et al., 2009). Disengagement theory is the first formal theory that attempted to explain the process of growing old. It refers to the inevitable withdrawal of persons who age (Achenbaum & Bengtson, 1994). They are often less involved in life and experience greater distance from society, which requires changing their relationship to society and recognizes that society expects that they adjust their social role. The theory was criticized as focusing primarily on the personal component of agerelated loss and does not explain the large number of older people who do not withdraw from society. It also does not pay attention to societal forces that are responsible for decline, such as poverty and a lack of available provisions and allowances. Continuity theory is an extension of activity theory and claims that most of the aging population can maintain the same activity, behaviors, and social contacts as in earlier life stages despite changes in their physical health and social role (Atchley, 1971). The internal continuity of cognition, affect, and skills – together with the continuity of role performance, activities, and social ties – ensure “successful aging.” Similar to activity and disengagement theories, continuity theory has been criticized for neglecting the impact of social environment and resources. In addition, it neglects the fact that many adults age with physical disability and chronic illness.

Lifespan theories on successful aging The lifespan approach to successful aging examines the entire life course from childhood to old age. Baltes and Baltes (1993) and Baltes’s (1997) selection, optimization, and compensation model primarily focuses on maintaining basic functions of daily activities above retirement age. In this model, “selection”

Aging with disability 35 refers to the person’s process of prioritizing goals as he or she ages. “Optimization” means maximizing the resources people currently have, while “compensation” adds new resources needed beyond the existing ones. An additional lifespan theory is called motivational theory, proposing two mechanisms to achieve successful aging (Heckhausen, 2006). The primary control mechanism involves attempts to shape the person’s immediate environment. The secondary control mechanism tries to adapt to the existing environment rather than to control it. Both lifespan theories have been criticized for failing to understand the contextual interaction (Rudolph & Zacher, 2017).

Rowe and Kahn’s model of successful aging The most cited theory of “successful aging” was offered by John Wallis Rowe and Robert Kahn. Their conceptualization made the distinction within the range of normal aging between usual aging and successful aging. They refined their early definition of “successful aging” to include three important factors: low probability of disease and disease-related disability, high cognitive and physical functional capacity, and active engagement with life (Rowe & Kahn, 1987). The combination of the three components ensured the achievement of “successful aging.” Their model was tested by assessing to what extent older persons were able to fulfil one, two, or three components. Their model merges physical, cognitive, and lifestyle factors with measurable indicators of disease and disability. They hypothesized that an appropriate lifestyle could result in successful aging, which they defined as (a) forestalling disease and disability; (b) maintaining physical and mental function; and (c) social engagement (Rowe & Kahn, 1998, p. 38). 1

2

Forestalling disease and disability is measured by the low probability of disease and disease-related disability. This component of successful aging is wholly under our control; we can partially improve our health condition by choosing healthy behavior practices such as diet and exercise. It is true that a high incidence of conditions such as diabetes and hypertension in the aging population is partially related to earlier lifestyle and environmental factors, rather than age-related changes. The same applies to people with disabilities who can do better in terms of engaging environmental support and services and enhance their functioning while aging. However, it is clear that an overemphasis of extrinsic factors cannot change the role of biological factors and those related to impairment or disability. Maintaining physical and mental function reflects the person’s ability to preserve his or her physical or cognitive abilities. The process needs adjustment, and there are periods during which the person requires support and assistance. In persons with chronic or progressive illness or disability, the goals are stability and maintaining their quality of life by obtaining assistance and accommodation, by developing proactive practices, or by engaging resources to prevent deterioration of physical or cognitive functioning.

36 Aging with disability 3

Social engagement is the third factor of successful aging, which includes two missions of relating to and being connected with others through social contacts and being creative and productive. It is clear that without social networks the person cannot create a social life and obtain social support. However, it is equally important to create a productive and meaningful life or to be engaged in paid or unpaid activities. This is particularly crucial for those with a disability or chronic illness in their transition to aging.

Rowe and Kahn’s model is widely used, probably because it changes the conceptualization of aging from health preservation to health promotion. However, it has been criticized for lacking life course perspective and the ability to develop preventive interventions to improve late-age outcomes (Berkman, Ertel, & Glymour, 2011). Furthermore, their model lacks socially constructed categories of race, gender, social class, and space which have been considered influential as institutional structures and policies that might regulate behavior and provide resources when individuals encounter risks across the life course (Leisering & Schumann, 2003).

‘Successful aging’ of persons with disabilities Rowe and Kahn’s model of successful aging is the most popular in the gerontology literature. It posits that successful aging is equivalent to having a low risk of disease and disease-related disability, maintaining high mental and physical functioning, and active engagement with life. However, the model excludes disability and physical impairment from successful aging (Cosco et al., 2014; Depp & Jeste, 2006). The critique of eliminating disability from successful aging is discussed extensively by Martinson and Berridge (2015). First, they maintain that Rowe and Kahn’s model contains too few dimensions to characterize the aging processes sufficiently, in particular those related to psychological wellbeing. Second, the model lacks the person’s spiritual qualities of meaning and identity. Third, the model can create stigma and discrimination as it excludes older adults with disabilities and functional impairment (Von Faber et al., 2001). Martinson and Berridge argue that the concept of successful aging should be expanded to include various living situations for those who grow old in good health and for those who unfortunately age with visible care needs. Therefore, the focus has to be expanded beyond the individual and should also include environment and care-related strategies. Tesch-Römer and Wahl (2017) summarized the reflection of successful aging in seven propositions: Proposition 1: Stable and Substantial Prevalence of Disability and Care Needs They believe that Rowe and Kahn’s model of successful aging strongly hinges on the idea of compression of morbidity. They propose that “individual and

Aging with disability 37 societal strategies toward healthy aging will probably not eliminate disability and care needs at the end of life, but will entail both extended years in good health and extended years with care needs. Hence, the prevalence of older people with care needs will remain stable and substantial in modern societies” (Tesch-Römer and Wahl, 2017, p. 312). Proposition 2: Aging in Good Health and Aging with Care Needs as Consecutive Phases in the Life Course Rowe and Kahn’s approach underlines two distinct classes of aging trajectories: “healthy aging trajectories” and “aging with multimorbidity, frailty and care needs” that run in different directions. One is considered successful aging and the other unsuccessful aging. They think that individuals accumulating advantages over the life span tend to also be healthier in later life, whereas individuals accumulating disadvantages over the life span are more likely to experience disabilities and care needs in old age. Hence, social inequality seems to regulate access to the world of healthy aging to a significant extent. Therefore, the second proposition states that “healthy aging and aging with disability and care needs cannot be treated as separate categories (‘Two-World’ argument of aging), but should be considered as consecutive phases within the life course” (Tesch-Römer and Wahl, 2017, p. 312). Proposition 3: Expanding the Concept of Successful Aging toward Aging with Disability and Care Needs Rowe and Kahn’s definition of successful aging primarily focuses on individual resources and capacities (low probability of disease and illness, high cognitive and functional functioning). They believe that aging with disability and care needs have to involve the individual, the environment, and the social context. They state the following: “the traditional concept of successful aging should be expanded to capture desirable living situations (autonomy, well-being) and to consider effective strategies and resources for aging in good health and aging with disability and care needs (individual, environmental, and care related strategies and resources)” (Tesch-Römer and Wahl, 2017, p. 312). Proposition 4: Individual Strategies and Resources for Successful Aging When Facing Disability and Care Needs Martinson and Berridge (2015) argue that aging persons can regulate their development over their life, even in very old age. They based their belief on Baltes and Baltes’s model of selective optimization with compensation (1990), Brandstädter’s dual process model of developmental regulation (2009), and Heckhausen and Schulz’s model of primary and secondary control (Heckhausen, Wrosch, & Schulz, 2013). This applies also to those who can cope efficiently and in different ways with disability and care needs (Gignac, Cott, & Badley, 2000). Therefore, they state that “individual strategies

38 Aging with disability and resources for coping with care needs involve the ability to maintain autonomy and wellbeing (e.g., through secondary control, goal selection) in a situation of disability and care needs” (Tesch-Römer and Wahl, 2017, p. 312). Proposition 5: Environmental Strategies and Resources for Successful Aging When Facing Disability and Care Needs The current conceptualization of disability is based on the International Classification of Functioning, Disability and Health (ICF; WHO, 2001). The classification defines disability with respect to individual and environmental factors which enable an individual to take part in activities and society. It implies that successful aging with disability and care needs depends, to a large extent, on environmental factors, particularly housing and accessibility, but also on any environmental conditions. The latter influence quality of life and may increase their resilience and capacity for successful aging (Golant, 2015), who states that “environmental strategies and resources for coping with care needs consist of the use of compensatory and optimizing devices to maintain autonomy and wellbeing (e.g., adequate housing, mobility and other technology)” (Tesch-Römer and Wahl, 2017, p. 312). Proposition 6: Care-Related Strategies and Resources for Successful Aging When Facing Disability and Care Needs Long-term care tends to minimize the caregiver’s role, which would seem to be a precondition for successful aging (Baltes, Wahl, & Reichert, 1991). Care takes place in different settings (e.g., community-based and institutional), can have diverse forms of funding, and can be provided by both formal and informal caregivers (Leichsenring, Billings, & Nies, 2013). Another important issue is the quality of care which is associated with social economic status and ethnicity (Fennell et al., 2010). Therefore “successful aging” has to incorporate quality of care and also address changes in organization and culture of care. The sixth proposition states that “care related strategies and resources consist of interaction and negotiation between caregiver and care receiver in order to maintain the care receiver’s autonomy and wellbeing. Both care receiver and caregiver provide in many instances the context for successful aging with care needs” (Tesch-Römer and Wahl, 2017, p. 312). Proposition 7: Visionary Component for Successful Aging Including Individuals with Disability and Care Needs Rowe and Kahn (1998) believe that “successful” aging reflects forms of aging that are not yet normative and hence have innovative potential. Their concept recognizes that aging involves a dynamic process and change, including focusing on retaining functional abilities instead of maintenance. Therefore,

Aging with disability 39 in their final proposition Martinson and Berridge call for more traditional concepts of successful aging as well as definitions broadened to include aging with care needs should operate with a strong visionary view of aging. In their systematic review of “successful aging,” Martinson and Berridge argued that the missing voice was the subjective definition of the persons themselves. Birren and Cunningham (1985) distinguished between biological, social, and psychological age. In their opinion, biological age represents the organic system, the second represents the social role, and the third represents the psychological and subjective perception of the person’s aging. The latter is a complex term affecting different facets of the person. It is often defined as “subjective age” (Keith, 1997) or “personal age” (Kastenbaum et al., 1972). In terms of subjective perception of aging, research suggests that people suffering from poor health are more likely to describe themselves as older than their chronological age (Keller, Leventhal, & Larson, 1989; Markides & Boldt, 1983). A recent Israeli study that examined the subjective age of veterans with PTSD compared to veterans without PTSD found that those with PTSD perceived themselves as older. They believed that their physical health problems contributed to their older age identity. Molton and Yorkston (2017) used nine focus groups to study how 49 middleaged and older Americans with disabilities viewed their own “successful aging.” In a thematic analysis, they found that the most important factors were (a) resilience and adaptation – perceived by participants as improving over time, but as an ongoing struggle, particularly with their future uncertain; (b) autonomy – seen by participants as “independence” and the ability to make choices, which was a relevant issue that emerged early in coping with disability and as such might overlap with resilience and adaptation; (c) social connectedness – participants viewed interaction with friends and family and social life, including social support, as the core component of “successful aging.” However, they showed concern that they would not be able to take a proactive role in their social life, as well as fear of being lonely or stigmatized by others; (d) physical health – they valued management of secondary conditions as essential for “successful aging.” For middle-aged participants there was concern that the secondary conditions would force them to retire early. Most of them thought that in order to cope with their secondary health conditions they needed access to health care resources and appropriate services and equipment. They were concerned about their provider’s lack of updated knowledge about their disability and their attitudes. Finally, Trieschmann (1987) views successful aging from the perspective of persons with disabilities themselves. The most important mechanism is calculating when a person with disability’s age, biological, psychological, and social variables may affect the balance. Therefore, Trieschmann’s model is an adaptive model in which persons with disabilities learn health and functional survival skills and how to engage supportive environments and resources. A key emphasis in the

40 Aging with disability model is maintaining productivity and meaningful social participation in order to age successfully.

Disability, secondary conditions, and ‘premature aging’ Individuals with long-standing physical disabilities are vulnerable to acute or chronic health conditions that may be influenced by the presence of impairment prior to and during the process of aging. The first to study these health conditions was Michael Marge (1988), who used the term “secondary conditions” to describe health conditions that develop after the onset of a primary disability. However, it has been defined quite broadly to include all health conditions, whether or not they are related to the primary disability during mid-life or aging. Houk and Thacker (1989) from the Centers for Disease Control and Prevention in the United States call them “secondary complications” and suggest the construction of prevention programs. There are additional labels for secondary conditions, the most known of which are “comorbid conditions” or “comorbidities” (Public Health Foundation (1988). Other terms are “medical complications” (Cosar et al., 2010) or “associated conditions” (Agency for Toxic Substances and Disease Registry, 1988), while the Institute of Medicine (IOM) still defined the term broadly as any additional physical or mental health condition associated with a primary disability or the result of long-term effects of aging with disability (Pope & Tarlov, 1991). The most frequent secondary conditions in acquired disability include arthritis, pain, pressure ulcers, fatigue, depression, contractures, and urinary tract infections. However, the risk of developing a particular secondary condition depends on a person’s primary condition. The term “secondary conditions” was expanded after the adoption of the International Code of Functioning of Disability and Health (ICF) to include limitation of social participation and quality of life. Marge (2008) clarified the terminology and suggested using “secondary conditions” to describe any adverse medical problem (physical or mental) resulting from disease or injury. As such, secondary conditions have the following features: 1 2 3 4 5 6

It is the result of increased risk or susceptibility to such health conditions caused by the primary disability. The primary disability could be adventitious or congenital. It is distinguished from other health conditions by the lapse in time from the acquisition of the primary disability to the occurrence of the condition. It may exacerbate the primary disability, increasing the level of dysfunction. Many of the identified secondary conditions are considered preventable. Knowledge about the specific additional health complications related to the primary disability has major implications for developing a program of disease prevention and health promotion for the individual in a program of habilitation or rehabilitation.

Regarding aging with disability, Campbell and Putnam (2017) identify three types of associations between aging and disability. The first is known as disability-related

Aging with disability 41 secondary conditions (physical and/or mental health conditions) that are common among the aging population with disability but that can occur earlier in younger age groups. It is phrased as “premature aging” or as “accelerated aging.” A second type is considered to be “age-related conditions” experienced by aging persons but also those aging with disability. These conditions or health complications are associated with aging and with the long-term exposure to environmental risks and/or the effects of poor health behaviors. The most common are hypertension, high cholesterol, diabetes, heart disease, gait and mobility problems, urinary incontinence, osteoporosis, hearing and vision loss, and dementia. The third type of consequences is having multiple chronic conditions of at least two different kinds. The most common are hypertension and diabetes or hypertension and cholesterol. According to Campbell and Putnam, these three types of relationships between aging and disability are very closely related to one another and may impact general health, daily functioning, and social participation. There are two recent publications that shared their thoughts on “accelerated aging.” Ohry et al. (2015) published a commentary on “premature aging” in people with disability which they describe as “wear and tear resulting in decline of physical functions or psychosocial pathways influenced by the homeostasis of the internal and external environment of people with disabilities.” They speculate that due to reduced activities, the person with disability lacks opportunities to exercise and therefore there is a faster degeneration of cells and tissues and hence reduction of functional ability. Similarly, Lafortune et al. (2016) believe that the core risk factor for “premature aging” is lack of physical activity which has been associated with increased risk of cardiovascular disease, diabetes, dementia, and cognitive function. Physical activities are demonstrated to be associated with social contacts and coping resources. It appears that “accelerated aging” among persons with disabilities is based on clinical impressions and descriptive data. There is a lack of empirical evidence whether it exists or not. It is therefore important to provide evidence-based data that support the existence of “accelerated aging” with respect to disabilities that are quite common among veterans with disabilities. The most recognized acquired disabilities are SCI and PTSD.

Persons with spinal cord injury (SCI): aging and secondary conditions Spinal cord injury is a disabling disorder with significant consequences for functioning and health conditions and impacts on physical, psychological, and social life (Vasiliadis, 2012). It is caused by trauma to the vertebral column, thereby affecting the spinal cord’s ability to send and receive messages from the brain to the body’s systems that control sensory, motor, and autonomic function below the level of injury. The severity of an injury depends on the part of the spinal cord that is affected. The higher the SCI on the vertebral column, or the closer it is to the brain, the more effect it has on how the body moves and what one can feel. More movement, feeling, and voluntary control are generally present with injuries at lower

42 Aging with disability levels (Kirshblum et al., 2014). The sudden onset of SCI is tragic and has a critical impact on the person’s life as well as his or her immediate family. According to the National Spinal Cord Injury Association, as many as 450,000 people in the United States are living with an SCI. According to the association’s site, males represent 81.2% of the cases, and more than half of the injuries in the United States (53.1%) occur in the 16–30 year old age group. In a comprehensive review chapter, Hallam et al. (2018) explore the impact of aging in SCI. Although there is scarce longitudinal research regarding changes over time, most of the studies indicate there is accelerated aging in some areas. A systematic review carried out by Jensen et al. (2013) focused on secondary health conditions associated with age on body and mental health, including changes in cardiovascular, endocrine, neurology, respiratory, musculoskeletal, skin, genitourinary, and gastrointestinal systems, as well as psychological conditions (Hitzig et al., 2011). Cardiovascular (CVD): The prevalence of cardiovascular diseases is much higher in persons with SCI than in the general population, and it is considered as a core cause of morbidity and mortality in people with long-term SCI (Charlifue, Jha, & Lammertse, 2010). The most known risk factors of CVD are obesity, lipid disorders, metabolic syndromes with insulin resistance, and diabetes. In a recent retrospective survey, close to two-thirds of the sample were overweight, and about 30% were obese (Gupta, White, & Sandford, 2006). LaVela et al. (2012), who studied aging veterans with SCI that were injured at least 20 years earlier, veterans, and the general population, found that the veterans with SCI injured at least 20 years earlier than 65 years of age had 1.4 times more strokes than veterans and the general public had. Both veterans’ samples also had a higher prevalence of diabetes, myocardial infarction (MI), and coronary heart disease as compared to men in the general public. Endocrine: People with SCI typically have elevated levels of glucose and insulin, suggesting that there is a greater risk for glucose intolerance and diabetes mellitus in the cohort of people aging with SCI compared to an age-matched nondisabled group (Bauman & Spungen, 1994). Additional research demonstrates that fat mass declines with age, and there are alterations of serum insulin-like growth factors and testosterone (Nuhlicek et al., 1988; Tsitouras et al., 1995). Musculoskeletal: The effects of physical aging are evident in the musculoskeletal system in particular, reduction in muscle mass and loss of strength, endurance and flexibility, and osteoporotic weakening of bones. SCI is not directly related to chronological age but to number of years since injury. This distinction was made by Krause, Kemp, and Coker (2000) in their exploration of the impact of aging on secondary complications by defining the age of onset of injury. Several researchers have found bone density decline already in young adults with SCI (Dauty et al., 2000; Garland et al., 2001). Osteoporosis may not only increase fractures, but the risk for non-union is also higher in the aging SCI population when compared to able-bodied controls. Respiratory: Disorders of the respiratory system are among the most common causes of mortality and morbidity in people with SCI, with age being a contributory

Aging with disability 43 factor (Stolzmann et al., 2008). Persons with SCI have sleep-disordered breathing issues such as sleep apnea and oxygen desaturation, which worsen with age. Some persons experience low lung volume and a weak cough if respiratory muscles are paralyzed and/or spastic. The risk of lung collapse and pneumonia increases with age (Van Silfhout et al., 2016). Genitourinary and Gastrointestinal System: A decline in genitourinary function can occur at any time (Elmelund et al., 2016). Many persons with SCI complain that they suffer from constipation and that it worsens with age (Faaborg et al., 2008). Bowel dysfunction can have a negative effect on quality of life over time (Inskip et al., 2018). Neurology: A post-traumatic syringomyelia (“syrinx”) may occur over time due to cyst formation obstructing cerebrospinal fluid and causing pressure on the spinal cord (Biyani & Masry,1994). Persons with SCI are highly exposed to postures and positions that increase their risk for peripheral compression neuropathies, such as carpal tunnel syndrome from long-term wheelchair use and ulnar nerve compression from long-term gait aid use (Asheghan et al., 2016). Skin: There are changes in skin elasticity and breakdown with age. The pressure on tissues overlying bony prominences leads to ischemia, cell death, and tissue necrosis. This pressure is related to friction, shear forces, immobility, and moisture imbalance (Kruger et al., 2013). Pain: Approximately 65% of persons with SCI experience chronic pain (Perry, Nicholas, & Middleton, 2009). Neuropathic pain occurs within the first year of injury, whereas musculoskeletal pain is experienced later in life (Finnerup et al., 2016). Aging Persons with SCI often report pain in the upper limbs due to overuse and, in particular, transfer situations. The incidence of shoulder pain increases over time in people with SCI (Jensen, Hoffman, & Cardenas, 2005). Rates of distress about chronic pain are comparable in both younger and older SCI cohorts. Therefore, chronic pain management becomes a very important issue with age (Molton et al., 2014). Psychology and Family Issues: Older persons with SCI cope better mentally with their disability than younger adults do (Jörgensen et al., 2017). Depression often appears following SCI and in later life when there are significant declines in physical health (Krause, Kemp, & Coker, 2000). According to Middleton and Craig (2008), suicide rates for persons with SCI are five times higher than for the general population. Rates of depression are higher in individuals with SCI suffering from chronic pain, most likely owing to pain interfering with participation in valued activities. Psychological distress is more common in persons who experience chronic pain related to their disability (Turner et al., 2002). A large portion of SCI pain is not helped with medications or surgical intervention, therefore a multidisciplinary approach to pain is often most effective, including evidence-based psychotherapy (Hadjipavlou, Cortese, & Ramaswamy, 2016). Stress is more common for persons who report constipation, sleep-disordered breathing, fractures, and hypothalamic-pituitary-adrenal dysregulation (Baldini, Von Korff, & Lin, 2012).

44 Aging with disability SCI can affect the whole family, both physically and emotionally. Persons with SCI are likely dependent on their spouses or children for assistance, in particular as they age. Therefore, any intervention has to take into consideration family members who are also aging and may develop health issues of their own.

Evidence of “accelerated aging” Campbell and Barras (1999) were among the first researchers who believed that the occurrence of aging conditions in mid-life among people with physical disability was “accelerated aging.” Some researchers characterize the relationship between aging and SCI as “accelerated aging” of organ systems, although the relationship between the two is complex and inconclusive (DeVivo et al., 1992; Frontera & Mollett, 2017; Jörgensen et al., 2016). Most of the evidence of “accelerated aging” is based on clinical observations of secondary complications or functional decline. Rodakowski et al. (2014) base their thesis of “accelerated aging” or “premature aging” on the evidence of increased frequency of secondary health complications and the risk of re-hospitalization. DeVivo and colleagues (1992) also comment on the role of age of onset, claiming that persons older than 61 years are likely to develop some kind of serious secondary condition immediately after the lesion and that the age of onset could have an effect on re-hospitalization and on other long-term consequences. However, Chen and colleagues (2016) claim that these increased complications are related to external and behavioral reasons such as slipping, tripping, and falls that account for about 60% of secondary conditions.

Persons with post-traumatic stress disorder (PTSD): comorbidity and aging Posttraumatic stress disorder is a serious mental illness characterized by symptoms of avoidance and nervous system arousal after experiencing or witnessing a traumatic event. Although PTSD was once considered a type of anxiety disorder, it is categorized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a trauma and stress-related disorder. The criteria for PTSD involve exposure to one or more traumatic events that may include direct exposure, witnessing in person, indirect exposure, or repeated extreme indirect exposure to death, actual or threatened serious injury, or actual or threatened sexual violence. The symptoms of PTSD are clustered into four categories: (a) intrusion symptoms; (b) avoidance symptoms; (c) negative alterations in cognition and mood; and (d) alterations in arousal and reactivity. Persons who are diagnosed with PTSD have significant comorbidity conditions. According to Kessler et al. (1995), about 80–90% of individuals with PTSD have one or more comorbid conditions, and two-thirds have two or more additional diagnoses. The most frequent comorbid diagnosis is major depression, followed by anxiety disorders, substance use disorders, borderline personality disorder, and psychotic disorders. This population tends to be diagnosed as

Aging with disability 45 suicidal, dissociative, or possessing distorted and negative trauma-related cognitions, persistent negative trauma-related emotions, and poor social functioning (van Minnen et al., 2015). Researchers offer possible explanations for the complex relationship between PTSD and mental disorders. Mueser et al. (2002) hypothesize that PTSD mediates the effects between traumatization and the course of severe mental illness both directly (through specific PTSD) or indirectly. Lockwood and Forbes (2014) review the association between the two and believe that PTSD and comorbid conditions share similar etiologies or vulnerabilities. The relationship can be reciprocal, suggesting that PTSD may influence comorbid conditions and vice versa, as in the case of the relationship between PTSD and either substance abuse or major depression. There is a need for additional research to unravel the mechanisms that predict comorbidity or severity. The core comorbidities of PTSD and mental disorders are listed here: PTSD and major depression is the most known comorbidity and is interrogated in a large meta-analysis study showing that 52% of individuals with PTSD have suffered major depression (Rytwinski et al., 2013). Personality disorders – comorbidity with trauma cases is common and reported in clinical studies (Dunn et al., 2004). However, the range is very wide, ranging between 39% and 79%. However, a meta-analysis of 125 clinical and non-clinical studies (Friborg et al., 2013) demonstrates that the prevalence is lower (35%) for those who have at least one personality disorder. The most common type was paranoid (26%) followed by avoidant (23%) and borderline (22%). Psychosis is a less common morbidity with PTSD and was estimated to be 12.4% in the meta-analysis study (Achim et al., 2009). Suicidality is more common among PTSD patients than in the general public. Panagioti, Gooding, and Tarrier (2012), who studied a sample of 91 persons who have had either PTSD or experienced a serious traumatic event in the past, found that about one-third had suicidal thoughts in the previous year. Those with PTSD were significantly more likely to report lifetime suicidal behavior and suicidal behavior in the previous year compared to the trauma comparable group. Dissociation is quite common among PTSD patients. Some dissociative symptoms, such as flashbacks, numbing, and psychogenic amnesia, are included in the PTSD DSM diagnostic criteria and are, as such, considered part of the diagnosis of PTSD. On the other hand, derealization, depersonalization, and current reduction in awareness are diagnosed separately from the PTSD diagnosis. Wolf, Lunney et al. (2012) found that 12% of the veteran sample reported elevated symptoms of derealization and depersonalization. However, there are studies that found a wider range of 15% to 30% (Wolf, Miller et al., 2012). Negative cognitions and emotions are prevalent among PTSD patients. Miller et al. (2013) found that 35% reported negative beliefs, 34% reported

46 Aging with disability guilt or shame, and 30% reported anger or aggression symptoms in the previous month in their national sample. They claimed that these numbers are lower than those known before.

PTSD and secondary physical health conditions There is recent evidence that PTSD has been associated with physical disease (Wolf & Schnurr, 2016), in particular cardiovascular secondary conditions. Gradus et al. (2015) found increased incidence of MI, stroke, ischemic stroke, and venous thromboembolism in Danish medical records of PTSD patients. In fact, the standardized incidence ratios were 1:4 to 2:1 as compared to the general population. In a large study of US veterans receiving outpatient VA care, Roy, Foraker, and Girton (2015) found that PTSD was associated with an approximately 50% increased risk (hazard ratio) of new-onset heart failure over the course of eight years. Similarly, in a large population study of 138,000 VA users aged 55 and older, PTSD was associated with a 25% to 50% incidence of cardiovascular disease and congestive heart failure, MI, and peripheral vascular disease (Beristianos et al., 2016). Ahmadi, Hajsadeghi, et al. (2011) examined whether PTSD-related cardiac conditions might lead to premature mortality. They found that PTSD among veterans was associated with a 59% increased chance of having a biologic marker of atherosclerotic coronary artery disease, and with a greater than 200% increased risk on average for mortality over the course of 3.5 years. Mortality risk increased as a function of greater coronary artery pathology, and this pattern was accentuated for people with PTSD; among those with the highest levels of coronary artery-related morality risk, comorbid PTSD increased risk by 81%. Aging adults with PTSD demonstrate more risk than a comparable general aging group for a broad range of medical morbidities, ranging from heart disease to arthritis. The PTSD symptoms may precipitate or exacerbate symptoms of these conditions, such as shown in the study of 605 male World War 2 and Korean War combat veterans who had PTSD symptoms associated with increased onset of physician-diagnosed arterial, lower gastrointestinal, dermatologic, and musculoskeletal conditions (Schnurr, Spiro, & Paris, 2000).

“Accelerated aging” and PTSD In recent years, there have been serious efforts to study the relationship between PTSD and premature physical health problems, ranging from metabolic and cardiovascular diseases to dementia (e.g., Ahmadi, Hajsadeghi, et al., 2011; Wolf et al., 2016). Wolf, who has summarized the research on PTSD and accelerated aging, believes that the stress of PTSD symptoms leads to an accelerated pace of cellular aging relative to chronological age. She cited an earlier work of Miller and Sadeh (2014) that suggested that PTSD symptoms such as sleep disturbance and emotional arousal might contribute to cellular aging. Most of the early research on accelerated aging in PTSD used telomeres (stretches of DNA at the ends of chromosomes) as the marker of cellular age, the idea being that these telomeres may

Aging with disability 47 index accelerated aging when they are shorter than would be expected based on chronological age. However, in their review Müezzinler, Zaineddin, and Brenner (2013) raised doubts about the strength of association between telomere length and chronological age. A twin-study design hinted that PTSD was associated with premature development of age-related health conditions. Vaccarino et al. (2013) used the twin design to demonstrate that among Vietnam-era twin pairs who were discordant for PTSD, the incidence of cardiovascular disease was about double in the PTSD+ twin, strongly suggesting that PTSD may play a causal role in the development of cardiovascular disease. Additional research found that PTSD was prospectively associated with new incidences of heart disease among a large veteran epidemiological sample (Roy et al., 2015). A much smaller body of research examines the association between PTSD and dementing disorders. A US Department of Veterans Affairs-led study on health care users found that veterans with PTSD had more than twice the risk of developing dementia than those without the disorder (Yaffe et al., 2010). Related work suggests that PTSD chronicity is associated with reduced cortical thickness in prefrontal and temporal brain regions, even after controlling for age-related effects (Lindemer et al., 2013). Wolf, Sadeh et al. (2016) suggested that at least some of this effect might be related to metabolic syndrome as a potential mechanism, linking PTSD to age-independent reductions in cortical thickness. In conclusion, there are efforts to provide evidence that PTSD is associated with accelerated aging and that this is reflected in an array of metrics ranging from genetics to physical health diagnoses. The impression is that the literature concerning PTSD and the aging process is inconclusive; nevertheless, there is evidence that PTSD is a significant issue for older adults. Persons with recognized PTSD suffer significant impairment in daily life, are less satisfied, and feel that their subjective aging is related to greater health problems (Solomon et al., 2009). The less explored areas are impairments related to attention, memory, and other executive functions of the brain (Moore, 2009). A recent article retrospectively reviewed the association between PTSD and dementia in veterans (Rafferty et al., 2018). Searches were performed for articles published between 1990 and July 2016 (using the MEDLINE, EMBASE, EBSCO, and Web of Science electronic databases), and six articles relating to the issue were found. Five of the studies asserted that veterans with a diagnosis of either PTSD or major depressive disorder (MDD) are at a significantly greater risk of developing dementia than “healthy” controls were. The final study, conducted in Australia, found only a small, but non-significant, correlation between earlier MDD and future dementia. No concurrent correlation was found. Although it is impossible to determine causality, the review indicates that it is likely that PTSD and depressive disorders are related to an increased risk of dementia in military veterans.

Conclusion This chapter highlights aging with disability by discussing “successful aging” and “accelerated aging,” two popular terms often used by clinicians. “Successful

48 Aging with disability aging” emphasizes the importance of reducing the secondary conditions associated with the core disability through health behavior practices while also preserving active social life. “Accelerated aging” is a much more challenging concept; it is a subjective term described in clinical reports that refers to a person with disability who presents signs of aging at pre-retirement age. The phenomenon has not been studied in large samples with rigorous age-matched controls. This chapter demonstrates the complexity of “accelerated aging” by discussing two common disabilities that exist among veterans with disabilities, SCI, and PTSD. In SCI, there are inconclusive findings regarding the early onset of cardiac disease as well as other secondary conditions. The same applies to PTSD, in particular regarding premature aging related to cardiac and dementia symptoms. Although the nexus between disability and aging provides insightful knowledge about the issue, it is important to understand the relevance to unmet needs of veterans with disabilities in the United States, the United Kingdom, and Israel.

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54 Aging with disability Vaccarino, V., Goldberg, J., Rooks, C., Shah, A. J., Veledar, E., Faber, T. L., . . . Bremner, J. D. (2013). Post-traumatic stress disorder and incidence of coronary heart disease: A twin study. Journal of the American College of Cardiology, 62(11), 970–78. Vander Zyl, S. (1979). Psychosocial theories of aging: Activity, disengagement, and continuity. Journal of Gerontological Nursing, 5(3), 45–8. van Minnen, A., Zoellner, L. A., Harned, M. S., & Mills, K. (2015). Changes in comorbid conditions after prolonged exposure for PTSD: A literature review. Current Psychiatry Reports, 17(3), 17. Van Silfhout, L., Peters, A. E. J., Berlowitz, D. J., Schembri, R., Thijssen, D., & Graco, M. (2016). Long-term change in respiratory function following spinal cord injury. Spinal Cord, 54(9), 714. Vasiliadis, A. V. (2012). Epidemiology map of traumatic spinal cord injuries: A global overview. International Journal of Caring Sciences, 5(3) 335–47. Von Faber, M., Bootsma-van der Wiel, A., van Exel, E., Gussekloo, J., Lagaay, A. M., van Dongen, E., . . . Westendorp, R. G. (2001). Successful aging in the oldest old: Who can be characterized as successfully aged? Archives of Internal Medicine, 161(22), 2694–700. Wilmoth, J. M., Landes, S. D., & London, A. S. (2018). The health of male veterans in later life. Annual Review of Gerontology and Geriatrics, 39(1), 23–38. WHO. (2001). International classification of functioning, disability and health (ICF). Geneva. Wolf, E. J., Bovin, M. J., Green, J. D., Mitchell, K. S., Stoop, T. B., Barretto, K. M., . . . Rosen, R. C. (2016). Longitudinal associations between post-traumatic stress disorder and metabolic syndrome severity. Psychological Medicine, 46(10), 2215–26. Wolf, E. J., Lunney, C. A., Miller, M. W., Resick, P. A., Friedman, M. J., & Schnurr, P. P. (2012). The dissociative subtype of PTSD: A replication and extension. Depression and Anxiety, 29(8), 679–88. Wolf, E. J., Miller, M. W., Reardon, A. F., Ryabchenko, K. A., Castillo, D., & Freund, R. (2012). A latent class analysis of dissociation and posttraumatic stress disorder: Evidence for a dissociative subtype. Archives of General Psychiatry, 69(7), 698–705. Wolf, E. J., Sadeh, N., Leritz, E. C., Logue, M. W., Stoop, T. B., McGlinchey, R., . . . Miller, M. W. (2016). Posttraumatic stress disorder as a catalyst for the association between metabolic syndrome and reduced cortical thickness. Biological Psychiatry, 80(5), 363–71. Wolf, E. J., & Schnurr, P. P. (2016). Posttraumatic stress disorder-related cardiovascular disease and accelerated cellular aging. Psychiatric Annals, 46(9), 527–32. Wykle, M., Whitehouse, P., & Morris, D. (Eds.). (2005). Successful aging through the life span: Intergenerational issues in health. Springer. Yaffe, K., Vittinghoff, E., Lindquist, K., Barnes, D., Covinsky, K. E., Neylan, T., . . . Marmar, C. (2010). Posttraumatic stress disorder and risk of dementia among US veterans. Archives of General Psychiatry, 67(6), 608–13.

3

Health and psychosocial concerns of aging veterans with disabilities

The term “veteran” is phrased and defined differently in the United Kingdom, the United States, and Israel. In the United Kingdom, the term used is “ex-service” to describe a man or woman who was employed in the armed forces (Dandeker et al. 2006). However, it seems that the term “veteran” is reserved for those who have served in military operations and for those who have been called upon to perform the unique obligations implied by the military contract. In the United States, the term is defined in Title 38 of the Code of Federal Regulations as “a person who served in an active military, naval, or air service and who was discharged or released under conditions other than dishonorable” (38 U.S.C. §101(2); 38 C.F.R. §3.1 (d)). However, the definition of veteran for the purpose of obtaining VA benefits has to rely upon military service records (38 C.F.R. §3.203). Therefore, similar to the distinction in the United Kingdom, there is a distinction between combat veterans serving during a period of war or other conflict and those who have not been deployed to combat zones. In Israel, national military service is mandatory with a few exceptions (ultra-Orthodox, Arabs, religious women). Therefore, all soldiers who have been discharged after their compulsory service in the Israeli Defense Forces (IDF) are considered veterans. In the United Kingdom, the United States, and Israel, there are different criteria for being recognized as a veteran or ex-serviceman with disability. However, the process of being recognized is quite similar and based on a two-stage decision, i.e., that the disability is related to army service (e.g., occurred during or as a consequence of service or on the way to and from the service) and assessment of severity and level of compensation. The three countries vary in their demographics and in the characteristics of veterans or ex-servicemen and women with disabilities because of their different engagement in warfare locations and time of service. However, they share two common characteristics: an increased aging population and a significant number of persons with PTSD. The chapter introduces the current demographics and profiles of midlife and aging veterans or ex-servicemen and women with disabilities in the United Kingdom, the United States, and Israel. It introduces common physical and mental disabilities including secondary conditions and frequent psychosocial problems. Furthermore, it discusses recent studies, particularly longitudinal ones, focusing on current concerns of veterans with disabilities in these countries. The chapter concludes with the unmet health and psychosocial concerns of aging veterans with disabilities.

56 Concerns of aging veterans with disabilities

The unique needs of veterans aging with disabilities Veterans are influenced a great deal by their military service, especially by being exposed to different historical events, types of warfare, and other circumstances (Fletcher et al., 2016). The effects of military service for older veterans are both positive and negative. It has an impact on one or more domains of aging such as physical and mental health, cognitive functioning, social and economic wellbeing, and social contacts (Spiro & Settersten, 2012). Spiro, Schnurr, and Aldwin (1997) called the effect of military service the “hidden variable,” reflecting mental health problems, such as PTSD and depression, that arose during aging. Veterans face increased risks of developing chronic illnesses and disabilities as they age. The most serious exposure during military service is in times of war or military operation and may have physical and mental health consequences (Schnurr et al., 1998), as well as the deterioration of social life and the ability to maintain quality of life (MacLean & Elder, 2007). Most of the early evidence of the impact of army service, particularly combat exposure, is based on studies of World War 2 veterans. According to Segal and Segal (2004), about one quarter of World War 2 veterans who participated in combat experienced mental health problems later in life. In comparison to nonveterans, veterans reported an increased risk of developing comorbid conditions and disabilities (Kazis et al., 1998). Aging can also complicate preexisting disabilities and induce secondary conditions at higher rates than in the general population (Clarke, Gregory, & Salomon, 2015). For instance, veterans with SCI may suffer strokes, and those with amputations or limb loss have higher rates of cardiovascular disease (Rose et al., 1987) and of obesity, back pain, and mental health problems (Foote et al., 2015). Most of the veterans with severe disabilities will need health services and psychosocial support all their lives; in many cases efforts are aimed to prevent medical complications and the development of secondary conditions.

Ex-servicemen and women and veterans with disabilities in the United Kingdom: an overview The most recent overview of the UK ex-service community was published by Ashworth, Hudson, and Malam (2014). Although their survey refers to all veterans’ households, including those with disabilities, it provides comprehensive data about the aging population. The UK’s ex-service community is aging, with an average age of 67 years, compared with 47 years for the general adult population. Almost half are over 75, and 64% are over the age of 65. This reflects the large numbers of those who served during World War 2, or who undertook post-war national service. Older veterans experience problems with self-care, exhaustion and pain, bladder control, and difficulty in managing their households. These problems peak for those aged 75 and are also associated with depression and loneliness, in particular among those recently bereaved. Among the most commonly reported physical problems are musculoskeletal, cardiovascular, respiratory and sensory impairments. Aside from their reported health problems, they have income and financial

Concerns of aging veterans with disabilities 57 concerns. While the ex-service community as a whole reports a household income of £21,000 after tax, those aged 65 or over report an average post-tax income of £15,900. This represents an above inflation increase from 2005 but is below the national average for this age group. Ex-servicemen and women and veterans with disabilities in the United Kingdom receive compensation from the War Pensions Scheme (WPS). The WPS provides no-fault compensation for all ex-service personnel or their families where illness, injury, or death is caused by service from the start of World War 1 in 1914 up until April 5, 2005. Recipients of WPS are older, and more than half are at retirement age. Those who were ill or injured as a result of service after April 6, 2005 are entitled to pensions from the Armed Forces Compensation Scheme (AFCS). They do not need to have left the armed forces before claiming. However, those receiving AFCS compensation are younger (86% are between the ages of 20 and 39). As of March 31, 2019, there were 97,556 persons receiving WPS compensation, and more than half (52.36) were at retirement age (65 plus). More than one-third (36%) received additional allowances. Regarding percentage of disablement, almost four-fifths (79.28%) are classified in the range of 20% to 40%, and slightly more than one-fifth have more than 40% disablement. A closer look at the age bar and disablement percentage table (Table 3.1) reveals that recipients from the retirement group (65+) had a higher disablement percentage (54.89%) than the younger group (45.11%). The mid-life age group of 55 to 65 consisted of 21.44% of the recipients. They are similar in age distribution to pensioners in the 65–74-year age group. As of March 31, 2019, 15,556 pensioners (15%) received benefits because they had mental disorders, and 8,063 were specifically categorized as suffering from PTSD. A closer look at the changes in the number of pensioners with mental health conditions and PTSD diagnoses reveals that from 2015 to 2019, the nominal number of pensioners increased from 13,757 to 14,556. However, those with PTSD increased at a greater pace, from 6,663 in 2015 to 8,063 in 2019. Since 2009–10, there has been a reduction by over one-third in disablement claims. This is primarily the result of the takeover by the AFCS of the administration of compensation arrangements for service-attributable injury/illness and deaths from April 6, 2005. In the last decade, there has been a steady growth of recipients of old age pensions and a slight decline in the number of pensioners due to an increased death rate (see Figure 3.1).

Aging veterans with disabilities in the United States: an overview US veterans with disabilities receive monthly tax-free benefits from the VA in recognition of the effects of disabilities caused by diseases, events, or injuries incurred or aggravated during active military service. To be eligible for disability compensation, the veteran must have served under conditions other than dishonorable, and the disability must not be the result of the veteran’s own misconduct. The amount of disability compensation varies according to the degree of disability and the

3,664

8,857

10,294

11,321

9,595

8,285

9,552

8,452

10,689

7,100

7,001

40 to 44

45 to 49

50 to 54

55 to 59

60 to 64

65 to 69

70 to 74

75 to 79

80 to 84

85 to 89

90 and over

Source: The Ministry of Defense UK, 2019

2,238

35 to 39

Total

508

% of DP

Under 35

Age Group

2,562

3,006

4,741

3,490

3,768

3,080

3,524

4,446

4,272

3,815

1,670

1,073

  280

20%

1,725

1,836

2,642

1,902

2,271

1,907

2,346

2,738

2,611

2,149

  907

  543

  117

30%

1,013

  982

1,352

1,170

1,328

1,310

1,497

1,669

1,481

1,281

  496

  291

  55

40%

596

480

681

661

738

690

776

912

695

646

221

124

16

50%

359

246

415

403

511

460

548

560

512

397

156

76

14

60%

236

171

275

239

324

266

290

322

229

182

59

33

3

70%

175

127

213

209

227

219

221

243

173

131

55

31

3

80%

52

57

60

68

73

62

52

72

47

31

3

4

3

90%

Table 3.1 Recipients of War Pensions Scheme (WPS) by Age Band and Percentage of Disablement, March 31, 2019

232

160

254

272

276

253

291

287

206

133

40

27

4

100%

51

35

56

38

36

38

50

72

68

92

57

36

13

Unknown

58 Concerns of aging veterans with disabilities

Concerns of aging veterans with disabilities 59 180,000

Numbers in Receipt

160,000 140,000 Disablement Pensioners

120,000 100,000 80,000 60,000 40,000

War Widow(er)s

20,000 0 2008/09

Financial Year End

2018/19

Figure 3.1 Number of Recipients of Disablement Pensioners and War Widow(er)s from 2008–9 to 2018–9

number of dependents. The degree of disability varies from 0% to 100% in increments of 10%. The VA calculates the total service-connected disability by combining evaluations for individual disabilities rather than adding them (Wilmot, 2016). In September 2018, the total number of veterans with disabilities receiving compensation was 4,743,108. The Gulf War recipients (1990–present) comprise 50.3% of all recipients, followed by the Vietnam era (29.8%), while far behind are the Korean War (2.3%) and World War 2 (1.2%). Recipients in peacetime and other military activities make up 16.5% of the total. In terms of age group, the oldest veterans with disabilities are from World War 2 (1941–6), the Korean War (1950–5), and the Vietnam War (1961–75). The youngest group of veterans with disabilities is from the Gulf War era and other military activities, or those injured in peacetime. Table 3.2 presents the distribution of all recipients by disablement percentage. The number of veterans with disabilities receiving compensation increased by 20.1% from 3,949,066 in 2014 to 4,743,108 in 2018. The most remarkable increase was in the most severe disablement bars 70% (6% increase), 80% (8% increase), 90% (12% increase), and 100% (12% increase).1 It should be noted that the data regarding disabilities are different from counting the number of veterans with disabilities – a veteran may be receiving benefits based on one or more disabilities, which is why the number of disabilities is much higher than the number of veterans. In fact, the average number of disabilities per compensation recipient was 5.30 (25,127,129 divided by the total number of recipients = 4,743,108). However, what contributes to the considerably higher average of disabilities per veteran is the Gulf War era, with an average of 6.96 spinal cord (SC) disabilities per recipient. This is compared to an average of 3.88 disabilities per veteran in the Vietnam era and even less in the Korean War (2.46) or World War 2 (2.42).

60 Concerns of aging veterans with disabilities Table 3.2 All Recipients of Disability Benefits by Disablement Percentage Disablement Percentage

Number of Recipients

Percentage

0–20

1,334,104

28.1

30–40

783,099

16.5

50–60

1,166,864

24.6

80–100

1,459,659

30.8

Total

4,743,108

100.0

The five most prevalent SC disabilities of all compensation recipients in the last four years are presented in Table 3.3. The most prevalent SC disabilities are musculoskeletal-like limitation of the flexion, lumbosacral of cervical strain, and limitation of motion of the ankle. The second most prevalent SC disabilities are hearing loss (primarily tinnitus), followed by neurological disabilities (particularly paralysis of the sciatic nerve and migraine). The fourth most prevalent disability is related to the skin, such as scars and eczema. The fifth most prevalent SC disability is mental, particularly PTSD and MDD. The most prevalent disabilities of World War 2 and the Korean War are hearing loss and tinnitus, and residuals of cold injury. The most prevalent Vietnam War disabilities are tinnitus, hearing loss, PTSD, and diabetes mellitus. The Gulf War era is slightly different from the previous wars. Tinnitus is still leading, followed by limitation of flexion, knee, lumbosacral or cervical strain, scars, and PTSD.

Mid-life and aging IDF veterans with disabilities in Israel: an overview IDF veterans are considered disabled if they have been recognized for their militaryrelated service and have a disablement percentage of 20% or more (excluded from this rule are those who have been recognized with 10% before 1996). The distribution of IDF veterans with disabilities by age is presented in Table 3.4. Distribution of aging veterans with disabilities by disablement percentage is presented in Table 3.5. The largest age group is 60–69, which consists of almost 60% of all veterans with disabilities from the age of 60 and above. The 70–69 age group is about 30% of all aging veterans with disabilities from the age of 60 and above. The smallest age group is 80 years and above and consists of 10% of veterans with disabilities. The largest disablement percentage category in all age groups is under 50%. In the introduction of their study, Shnoor et al. (2017), who studied IDF veterans with disabilities in 2011, mention the changes in mental disability rates in mid-life veterans versus aging age groups. The rate of mental disorders in the 45–54 age group was 22.64%, reduced to 20.78% in the 55–64 age group, then to 15.76%

2014

6,397,255

2,352,609

1,788,151

1,910,027

1,230,063

Body System

Musculoskeletal

Auditory

Neurological

Skin

Mental

1,368,427

2,111,444

2,058,164

2,613,285

7,117,586

2015

1,492,483

2,292,040

2,299,581

2,846,483

7,779,603

2016

1,622,814

2,503,676

2,561,741

3,101,223

8,481,844

2017

Table 3.3 The Five Most Prevalent SC Disabilities of All Compensation Recipients (2014 to 2018)

1,754,644

2,719,071

2,842,749

3,363,237

9,232,650

2018

8%

9%

11%

8%

9%

Percentage of Change between 2014 and 2018

Concerns of aging veterans with disabilities 61

62 Concerns of aging veterans with disabilities Table 3.4 Distribution of IDF Veterans with Disabilities by Age (N = 51,454) Age Group

Number of IDF Veterans with Disabilities

Percentage of Total IDF Veterans with Disabilities

Under 40

5,953

11.57

40–49

8,354

16.24

50–59

9,884

19.21

60–69

16,130

31.35

70–79

8,016

15.58

80 plus

3,117

6.05

Source: Ministry of Defense, Division of Rehabilitation, January 30, 2018 Note: IDF veterans with disabilities receiving benefits are considerably older: 52.98 of them are above the age of 60, and 21.63% are above the age of 70. Most of the oldest group were injured in the 1967 and 1973 wars.

Table 3.5 Distribution of Aging Veterans with Disabilities by Medical Disablement Percentages Disablement Percentages Age Group

Under 50%

50% to 74%

75% to 100%

Special 100% Plus

Total

60–69

13,320

2,098

506

175

16,099

70–79

6,954

941

235

73

8,203

80 and above

2,672

36

90

24

2,822

22,956

3,404

831

272

27,124

Total

in the 65–74 age group and 9.05% in the 75-plus age group. There is no doubt that the low rate of mental disorders is related to lack of recognition of PTSD and major depression in the 1960s and 1970s.

Research on health and psychosocial concerns of aging veterans with disabilities: core findings from the United Kingdom, the United States, and Israel There have been efforts to study the health and psychosocial concerns of aging veterans with disabilities. The United Kingdom, the United States, and Israel recently published surveys about the needs and challenges of older veterans. There are also updated longitudinal studies that can shed light on the specific problems of older veterans with limb loss (the United Kingdom) and mental health problems and PTSD (the United States and Israel).

Concerns of aging veterans with disabilities 63

Core findings and lessons from the United Kingdom An annual population survey of veterans residing in Great Britain in 2015 reveals that there was a difference in the health conditions of those below the age of 65 and above (The Ministry of Defense UK, 2015). Those of working age (under 65) did not view their general health differently from the non-veteran population. In fact, they viewed their general health as good and very good more or less similarly (74.3% versus 77.7% respectively). The top three reported conditions across working age veterans and non-veterans were heart-, blood pressure-, or circulatory-related conditions (34.4% and 33.9% respectively), leg- or feet-related conditions (33.1% and 26.7% respectively), and back- or neck-related conditions (32.0% and 24.6% respectively). Perceptions of general good and very good health dropped for veterans and non-veterans at retirement age (65+) to 53.9% for veterans and 59% for non-veterans, without a statistical significance between the two. There was no statistical difference between the retirement age veterans and non-veterans in relation to the percentage who reported a long-term health condition (50.5% and 47.9% respectively), nor was there any difference for each long-term health condition. The top three reported conditions across retirement age veterans and nonveterans were heart-, blood pressure-, or circulatory-related conditions (53.9% and 54.5% respectively), leg- or foot-related conditions (40% and 34.2% respectively), and arm- or hand-related conditions (25.1% and 22.5% respectively). A recent study by Fear, Wood, and Wessely (2009) reveals that UK ex-servicemen and women have higher rates of alcohol use compared to the mid-life general population. Alcohol problems, depression, and anxiety disorders are the most frequent mental health issues for ex-service personnel. Military personnel with mental health problems are more likely to leave their service over a given period compared to those without these problems and are at a higher risk of poorer outcomes post-service. Studies on delayed-onset PTSD are based on small samples and are mostly retrospective and should be treated with caution. Poor mental health outcomes are associated with deployment to Iraq or Afghanistan for personnel with pre-service vulnerabilities, those exposed to high levels of combat, and reservists compared with regulars. Similarly, Murphy et al. (2017) reported that these mid-life veterans expressed symptoms of PTSD followed by problems with anger (74%), common mental health difficulties (72%), and alcohol misuse (43%). Comorbidity was frequent, with 32% of those with PTSD meeting criteria for three other health outcomes versus only 5% with PTSD alone. Aside from the complexity of presentations, these veterans postpone treatment outcomes that may result in them having serious difficulties in handling family and social problems in their transition to aging. The most covered area of aging military veterans with disabilities in the United Kingdom is research on limb loss (Caddick et al., 2019). UK veterans with physical disabilities are often cited as struggling against decline or living as normal people in expressing their efforts to overcome the impact of severe life-course impairments (Cooper et al., 2018).

64 Concerns of aging veterans with disabilities Two studies (Desmond, 2007; Desmond & MacLachlan, 2006) provide insights regarding psychosocial adaptation among older limbless veterans. Desmond and MacLachlan (2006) surveyed coping strategies and psychosocial adaptation with a sample of elderly lower-limb amputees (mean age = 74 years) who were members of the British Limbless Ex-Servicemen’s Association. Psychosocial adaptation was described in relation to an individual’s ability to adapt to a range of challenges including impairments in physical functioning, prosthesis use, pain, changes in occupation, and alterations in body image and self-concept. The authors reported that a lack of solving problems and of seeking social support were associated with more depressive symptoms and low psychosocial adaptation among older veteran amputees. Most of the avoidant veterans who used denial showed poor psychosocial adjustment, including excessive alcohol use. In a separate study, Desmond (2007) explored coping and adjustment with upper limb amputees using a sample obtained from the British Limbless Ex-Servicemen’s Association. The prevalence of depression (28.3%) and anxiety symptoms (35.5%) was higher than rates reported in a non-clinical sample broadly representative of UK adults (Crawford et al., 2001). The findings indicate the importance of coping styles as predictors of psychosocial adaptation. In particular, avoidance was strongly associated with psychological distress and poor adjustment. The research suggests reducing reliance on avoidant coping and enhancing problem-focused approaches to coping with difficulties and challenges in order to facilitate adaptation and prevent problems in psychosocial functioning. A recent study (Edwards et al., 2015) discusses the long-term economic cost of British amputees from the Afghanistan conflict, particularly those with complex wounds such as multiple amputations, including the impact of aging. Unlike the United States, which has a separate funding source for veterans through the VA, the service delivery in the United Kingdom is predominantly delivered by the NHS, supplemented or supported by third-sector organizations such as Blesma, The Limbless Veterans. Therefore, life-long planning has to be taken into consideration to avoid underfunding and a lack of rehabilitation and provision for midlife and aging veterans with multiple amputations.

Core findings from the United States Holder (2016), who provided the most detailed analysis of service-connected disabilities among veterans in the United States, demonstrated that veterans of the Vietnam and Gulf War eras were more likely to report higher service-connected disability ratings. About 47% of Gulf War 2 and 45.6% of Vietnam-era veterans with a service-connected disability reported a rating of 50% or higher. These percentages are far beyond those of the Korean War and World War 2 or service in peacetime. It is no wonder, then, that most of the research on health and psychosocial issues of aging veterans with disabilities is generated from Vietnam and Gulf War data. In a meta-analytic article that consisted of 11 studies of older veterans (aged 65 and above), Williamson et al. (2018) focused on mental health problems in elderly veterans. The meta-analyses found high prevalence rates of substance (5.7%) and

Concerns of aging veterans with disabilities 65 alcohol (5.4%) use disorders in older veterans. In a recent review, Cook and Simiola (2018) presented a succinct review of the major studies on PTSD and aging. They covered several longitudinal investigations on the relationship between traumatic exposure and subsequent effects on health and functioning. They found signs that older adults with PTSD were at risk of not receiving timely and appropriate mental health treatment, indicating that targeted outreach could be helpful in increasing service use and improving care. They recommended that additional analysis was needed to explore the differences in functioning of young-old (65–74 years), middle-old (75–84 years), and old-old (85 years and older) subjects. One of the recent cross-sectional studies, conducted by Goldberg et al. (2014), assessed functioning and PTSD in male Vietnam-era veteran twins. The study used the Vietnam Era Twin (VET) registry which consists of a national sample of twin pairs identified from military discharge records of males who served during the Vietnam era (1964–75). Findings indicated that PTSD was associated with diminished health functioning and increased disability in aging Vietnam-era veterans. The reductions in function were seen across a broad set of functional domains that included aspects of physical and mental health. Those who had both PTSD and full combat exposure showed diminished mental health functioning in their aging as compared to those with low or non-exposure to combat. The research is consistent with earlier studies (Kazis et al., 1999; Kessler et al., 1995; Magruder et al., 2004). There is a debate among researchers whether PTSD is related to physical health. Boscarino (2004) and Schnurr, Spiro III, and Paris (2000) believe that PTSD has an impact on physical health, while others have emphasized behavioral factors as mediating the relationship between PTSD and physical health (Beckham et al., 1998; Schnurr & Spiro, 1999). A recent study explored the association between PTSD and the prevalence of dementia in older veterans in an administrative database study of individuals seen within one regional division of the VA’s health care network (Qureshi et al., 2010). The study controlled for confounding factors in multivariate logistic regression. The group that had a significantly higher incidence and prevalence of dementia was veterans with PTSD who were decorated with the Purple Heart for being injured in military activity. However, it is unclear whether this is due to a common risk factor underlying PTSD and dementia or to PTSD being a risk factor for dementia. The researchers suggest that veterans with PTSD should be screened more closely for dementia. Some evidence about the association between PTSD and dementia was published by Spielberg et al. (2015), who studied functional magnetic resonance imaging (MRI) data from 208 veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. Findings of this study demonstrated that PTSD re-experiencing symptoms were linked to weakened connectivity in a neural network involved in providing contextual information. A similar relationship was found in a separate network typically engaged in the gating of working memory, but only in veterans with mild traumatic brain injury (mTBI). As in the earlier study, it is unclear whether dementia is presented before the trauma or is the consequence of trauma exposure itself.

66 Concerns of aging veterans with disabilities An interesting recent review of the literature from 2010–16 (Wolf & Schnurr, 2016) searched for the link between PTSD, cardiovascular health conditions (e.g., metabolic syndrome, coronary artery disease, stroke, and myocardial infarction), and accelerated cellular aging. PTSD was associated clinically with increased risk of cardio-metabolic health problems, offering evidence that behavioral (e.g., poor sleep, cigarette use, poor diet, insufficient exercise) and biological (e.g., autonomic reactivity, inflammation) factors served as mediators of these associations. It is possible that these behavioral and biological mechanisms lead to accelerated cellular aging, as regulated in the epigenome, which contributes to premature cardiometabolic health decline. In terms of practice, the review recommends monitoring the changes of cardio-metabolic conditions among mid-life PTSD veterans. Another concern with aging veterans with disabilities in the United States is their expressed social and economic problems. Wilmoth, London, and Heflin (2015) used data from the Survey of Income and Program Participation (SIPP) to examine whether veteran and disability statuses were jointly associated with poverty and material hardship among households that include an older adult. They found that disabled veteran households were not significantly different in terms of poverty, but exhibited the highest odds of home hardship, medical hardship, billpaying hardship, and food insufficiency. The findings suggest that current public income support programs for older veterans with disabilities, including those provided by the VA to disabled veterans, are not sufficient and need to be adjusted (Fulton et al., 2009). Another concern is the utilization of health care services by mid-life and aging veterans with disabilities. Wu and Lewis (2015) studied utilization of health care services by 2,890 veterans with disabilities. Their primary core health problems were related to back and neck, arthritis, and cardiac secondary conditions. Additional common medical problems were bone fractures, joint injury, hypertension, and diabetes. Nearly 60% of the sample served in wartimes prior to 1975; 31.51% served in the Vietnam War (1964–75); 14.36% served in the period of 1955–64; 9.40% served in the Korean War; and 5% served in earlier wars (World War 2), implying that veterans in this sample were older on average. In terms of health care utilization, veterans aged 65 years and older were less likely to visit hospital emergency departments, and less likely to stay overnight at the hospital. The younger group may be more at risk for accidental injuries than middle-aged or older veterans are, while the oldest group may be more at risk for illnesses and therefore should stay overnight at the hospital. Garcia et al. (2014) studied the attitudes of older and younger veterans toward mental health treatment and found that Vietnam War veterans (average age 62 ± 4.2 years) and veterans of the Gulf War (43 ± 6.8 years) were less likely to report negative treatment, while the younger veterans from Operation Enduring Freedom and Operation Iraqi Freedom (32 ± 8.2 years) were more likely to report negative treatment. However, older veterans’ utilization rates were higher compared to younger veterans (Lee et al., 2015). There is no doubt that marital status played an important role in health utilization; being married predicted a lower likelihood of staying overnight at the

Concerns of aging veterans with disabilities 67 hospital compared to veterans who were unmarried. The spouse and family members provided social support and tangible resources. Persons who were single – by virtue of divorce, widowhood, or never having been married – were without in-home care for recuperation after an outpatient procedure or a condition that required oversight. Therefore, they were more likely to remain overnight in the hospital to recover. These data are supported by Mistry et al.’s earlier study (2001) demonstrating that veterans who were socially isolated were more likely to be rehospitalized compared to veterans who had a social support network.

The Israeli study on aging veterans with disabilities and PTSD longitudinal studies The first survey of mid-life and aging veterans with disabilities carried out by Shnoor et al. in 2011 and published in 2017 introduced self-reporting health and psychosocial concerns of this subpopulation. The sample consisted of 2,392 veterans with all types of disabilities (at least 20% medical disability) and was compared to health and social statistics of the general population of parallel years by the Israeli Central Bureau of Statistics. In terms of health statistics, veterans with disabilities in the mid-life and aging groups had considerably high secondary health conditions that increased with age. Table 3.6 presents the percentages of secondary conditions that increased with age, e.g., CVA, heart attack, or heart failure. Veterans with disabilities in mid-life and older ages reported twice the rates of cardiovascular illness and hypertension, cancer, CVA, heart attack, or heart failure than the parallel ages of the general population, and three times as much of diabetes mellitus. In terms of hospitalization, about 19% of mid-life and aging veterans with disabilities were hospitalized in the past year. The average hospitalization rate was four times greater than in parallel age groups of the general population. The hospitalization rate in veterans aged 75 and above was twice as much as veterans in the 55–64 age group. Regarding health behavior, veterans with disabilities smoked less than the general population at the same ages (24% versus 35% respectively) and kept similar healthy physical activities and periodic medical examinations as the general public. The less encouraging finding is related to psychosocial aspects. Older veterans with disabilities had fewer family contacts compared to the general public; this was particularly Table 3.6 Veterans Reported Secondary Conditions by Age Group (in %) (2011) Secondary Conditions Age Group

Cardiovascular and Hypertension

Cancer

55–64

51.5

10.2

65–74

69.5

75+

74.1

Cerebro Vascular Accident (CVA)

Heart Attack or Heart Failure

Diabetes mellitus

5.5

14.0

33.6

15.9

7.5

20.5

38.9

16.9

18.6

34.6

34.8

68 Concerns of aging veterans with disabilities evident for veterans living on their own and above the age of 75. Twenty percent reported loneliness, twice as much as older people in the general population (9%). Close to one third (31%) of veterans aged 75 and older experienced loneliness compared to 22% in a parallel age group of the general population. Their poor social participation was seen also in leisure activities: 24% reported lack of any activities in open spaces in the community (e.g., parks, beaches); 37% did not participate in social events; about 61% did not participate in cultural activities or events; and 82% did not attend community centers, including those aimed at veterans. Finally, veterans with disabilities reported on personal assistance and support that they had received. More than one fifth of the older veterans (21%) aged 75 and above received a paid personal caregiver. However, another 26% reported that they needed paid personal assistance but had not received it. An additional 16% received support from members of their family. Regarding household management, 34% received paid home-making services, which increased to 54% in veterans aged 75 and above. There were an additional 34% who needed additional home-making services. In terms of responding to their health and psychosocial needs related to their disability, 63% reported that the MoD responded to their requests. However, the response rate was reduced to 58% in the 65–74 age group and to 53% among veterans aged 75 and above. It is important to note that in terms of their health needs, veterans with disabilities have to navigate between the MoD for services related to their military disability and national health services for other medical needs. Finally, the survey reported the concerns of veterans with primary mental disabilities. They had higher diabetes rate (30%) compared to those with physical disabilities. In terms of health behavior, 40% of veterans with mental disabilities smoked compared to 20% among those with physical disabilities. In respect to social life, about 14% reported that they did not leave their house during the week compared to 4% in veterans with physical disabilities. In terms of feelings of loneliness, 43% reported that they did not have friends compared to 14% among veterans with physical disabilities. Most of the Israeli studies tracked mid-life and aging veterans with PTSD. Ginzburg, Ein-Dor, and Solomon (2010) published a follow-up on the prevalence of comorbidity of PTSD, anxiety, and depression in an effort to examine whether PTSD comorbid with anxiety and depression is implicated in more impaired functioning compared to PTSD by itself. The sample consisted of 664 war veterans who were followed up one, two, and 20 years after their participation in the 1982 Lebanon War. Findings indicated that at each point of assessment, rates of triple comorbidity (PTSD, anxiety, depression) were higher than rates of PTSD, either by itself or comorbid with depression or anxiety. Interestingly, PTSD predicted depression, anxiety, and comorbid disorders, but not vice versa. At Time 1 and Time 2 assessments, triple comorbidity was associated with more impaired functioning than PTSD alone. In addition, triple comorbidity at Time 2 was associated with more impaired functioning than double comorbidity. The researchers concluded that almost one half of war veterans would endorse a lifetime triple

Concerns of aging veterans with disabilities 69 comorbidity, and that those who do are likely to have more impaired functioning. The findings pointed out that PTSD seemed to be a dominant disorder associated with comorbid anxiety and depression in the life course of Israeli veterans. In a recent study, Stein et al. (2019) examined the impact of negative life events and social factors, including impostorism and loneliness, of aging decorated and non-decorated veterans on a sample of Israeli veterans of the 1973 Yom Kippur War. The veterans were assessed in middle adulthood (1991) and recently (2018). Impostorism, loneliness, and psychiatric distress were inter-correlated. However, non-decorated veterans demonstrated more impostorism, loneliness, and negative life events in aging than decorated ones did. The conclusion was that decorated aging veterans seemed less vulnerable in aging as compared to the non-decorated ones. The authors found indications that expressions of loneliness changed in aging, from earlier feelings after the war that they could not share their post-war experiences, to losses of an intimate partner or friends and heath impediments in aging. Tsur et al. (2019) studied the reciprocal effects of subjective physical health and loneliness among a group of war veterans of the Yom Kippur War over four decades. Findings showed that loneliness was an early predictor of subjective physical health. However, assessment of veterans over four decades also demonstrated that subjective physical health predicted loneliness. Additional findings confirmed that PTSD moderated the association between loneliness and subjective physical health. The study strengthens the importance of monitoring the reciprocal effects of subjective physical health and loneliness during the lifecourse of war veterans. An interesting study by Solomon, Helvitz, and Zerach (2009) studied midlife veterans of the Lebanon War of 1982 and particularly the contribution of PTSD and physical health to “subjective old age.” This term is quite innovative as older subjective age can be different from chronological age. Persons feel that in terms of image and functioning they seem older than their chronological age. Findings revealed that veterans with PTSD reported older subjective age than veterans without PTSD did. Both PTSD and general physical health contributed to subjective age above and beyond chronological age and negative life events. Along with physical health problems, memory problems and weight gain were found to contribute to older age identity. Surprisingly, the association between general physical health and subjective age was stronger among veterans without PTSD than among veterans with PTSD. This unexpected finding demonstrates the complexity of PTSD and the term of subjective aging of mid-life veterans.

Conclusion: unmet needs of older veterans with disabilities Older veterans with disabilities have significantly more mental health psychopathology than non-veterans do, particularly PTSD and depression (Williamson et al., 2018). In addition, they report problems of isolation and loneliness (Findlay, 2003; Royal British Legion, 2014). This applied to older and frail veterans living on their own without a spouse or companion. There is a concern that they are faced

70 Concerns of aging veterans with disabilities with substantial financial difficulties and an inability to manage their daily living. In this context, Wilmoth, London, and Heflin (2015) examined households of older veterans with disabilities in the United States as compared to non-disabled veteran and aging non-veteran groups. They found that – although older disabled veteran households were not significantly different from non-disabled, non-veteran households in terms of the odds of poverty – they exhibited difficulties in managing their homes, in particular with taking care of their medical needs, paying bills, and obtaining sufficient food (DeNavas-Walt, Proctor, & Smith, 2012). One of the most serious problems raised was that the current public income support programs provided by the VA to older disabled veterans was insufficient. Similar concern was raised by Fulton et al. (2009), who called for revision of the status of income compensation, as in many cases they were inferior to comparable non-veteran groups because the veteran benefits were not updated to match the current standard of living. In terms of mental health problems, the most vulnerable veterans are those suffering from PTSD symptoms and depression, which have been linked to physical health problems, disabilities, and poorer cognitive functioning. This may be related to poor health management or indirectly to lack of social support and receptiveness from health services. There is growing longitudinal research that demonstrates perceived poor health among aging veterans and physiciandiagnosed medical conditions, including arterial, gastrointestinal, and musculoskeletal disorders (Schnurr, Spiro, & Paris, 2000). Data from three aggregated nationally representative samples show that older adults with chronic PTSD were three times more likely to have secondary medical conditions than those without PTSD (Byers et al., 2014). Another study that included a sample of more than 10,000 veterans aged 65 and older demonstrated that mid-life and elderly veterans with PTSD had almost twice the chance of having dementia (Qureshi et al., 2010). Depression in older veterans worsened the outcome of medical conditions, including neurocognitive illnesses, uncontrolled pain, vascular risk factors, substance abuse, and insomnia (Chang & Chueh, 2011). Reported psychosocial problems are associated with depression. In a recent study, 44% of veterans aged 60+ reported feeling lonely at least “some of the time,” and 10.4% reported “often” feeling lonely (Kuwert, Knaevelsrud, and Pietrzak, 2014). Other known psychosocial risk factors for the elderly veteran included the death of a spouse, adverse life events, low socioeconomic status, functional impairment from illness, and nursing home residence (Bruce, 2001). Depression is often underdiagnosed and undertreated, particularly in primary care settings (Allan et al., 2017). Policies and social work programs have to be receptive to the loneliness and lack of social support for older veterans with disabilities primarily because these factors are linked to depression. Kuwert, Knaevelsrud, and Pietrzak (2014) reported that 44% of veterans experienced feeling lonely at least some of the time (10.4% reported often feeling lonely). Greater age, disability in activities of daily living, lifetime traumas, perceived stress, and current depressive and PTSD symptoms

Concerns of aging veterans with disabilities 71 were positively associated with loneliness, while being married/cohabitating, higher income, greater subjective cognitive functioning, social support, secure attachment, dispositional gratitude, and frequency of attending religious services were negatively associated with loneliness. The largest magnitude of associations was observed for perceived social supports, secure attachment style, and depressive symptoms. An additional concern is navigating and coordinating the medical needs of older veterans with disabilities through various health providers. In the US, the greatest numbers are enrolled in Medicare, employer-sponsored insurance, VA health care, TRICARE, and Medicaid. In the United States, among Vietnam-era veterans surveyed during the 2010 National Survey of Veterans, the majority neither used nor considered using VA health care: 18.8% used it for some services, 11.8% for prescriptions, 2.7% for specialized care, and 1.4% in some other way, while 27.9% of respondents said they did not plan to use the VA at all. The fact that most of the older veterans have not used VA health care is puzzling and raises questions about its availability and accessibility, as well as whether other health providers can supplement their special needs. UK and Israeli health care provisions are different because both countries have national health insurance. UK veterans receive their health care through the NHS, and the concern is whether the NHS responds to the special needs of old veterans with disabilities. Although all veterans are supposed to get priority in the NHS, the situation is far from being satisfactory. For example, a new report published by the House of Commons Defense Committee on the provision of mental health services to veterans showed serious concerns regardless of efforts to introduce veteran-specific specialists across NHS services. Access to and quality of mental health services are unacceptable. Veterans reported waiting up to a year for treatment. Many of these veterans saw their conditions deteriorate further while waiting for access to treatment and, in the most extreme cases, they took their own lives while awaiting help. Unfortunately, veterans with long-term mental health needs, among them aging veterans, have relied on armed forces charities. However, they lack sufficient resources to offer all of the services and care that are needed. Israel is different from the United Kingdom and the United States; veterans with disabilities receive their health services from the MoD, but only for their recognized medical disability. They receive their other health needs from selected providers of national health insurance. The only subgroup that is exempted from this division is veterans with severe disabilities who are recognized for 100%-plus medical disability, who receive all their health needs from the MoD. It is interesting that, although the health services are provided according to the veteran’s recognized impairment, psychosocial provisions are fully provided. It is evident that most of the veterans with disabilities are aged 60 and above and have secondary conditions on top of their recognized disability. Veterans are caught between the MoD and receiving services from providers of national health insurance. This situation is unfortunate and causes confusion and underservice, in particular for older veterans with depression or PTSD who lack social support.

72 Concerns of aging veterans with disabilities

Note 1 Retrieved from U.S Veterans Benefits Administration.

References Allan, N. P., Gros, D. F., Myers, U. S., Korte, K. J., & Acierno, R. (2017). Predictors and outcomes of growth mixture modeled trajectories across an exposure-based PTSD intervention with veterans. Journal of Clinical Psychology, 73(9), 1048–63. Ashworth, J., Hudson, M., & Malam, S. (2014). A UK household survey of the ex-service community, 2014. Royal British Legion. Beckham, J. C., Moore, S. D., Feldman, M. E., Hertzberg, M. A., Kirby, A. C., & Fairbank, J. A. (1998). Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder. American Journal of Psychiatry, 155(11), 1565–69. Boscarino, J. A. (2004). Posttraumatic stress disorder and physical illness: Results from clinical and epidemiologic studies. Annals of the New York Academy of Sciences, 1032(1), 141–53. Bruce, M. L. (2001). Depression and disability in late life: Directions for future research. The American Journal of Geriatric Psychiatry, 9(2), 102–12. Byers, A. L., Covinsky, K. E., Neylan, T. C., & Yaffe, K. (2014). Chronicity of posttraumatic stress disorder and risk of disability in older persons. JAMA Psychiatry, 71(5), 540–46. Caddick, N., Cullen, H., Clarke, A., Fossey, M., Hill, M., McGill, G., . . . Kiernan, M. D. (2019). Ageing, limb-loss and military veterans: A systematic review of the literature. Ageing & Society, 39(8), 1582–610. Chang, T. Y., & Chueh, K. H. (2011). Relationship between elderly depression and health status in male veterans. Journal of Nursing Research, 19(4), 298–304. Clarke, P. M., Gregory, R., & Salomon, J. A. (2015). Long-term disability associated with war-related experience among Vietnam veterans: Retrospective cohort study. Medical Care, 53(5), 401–8. Cook, J. M., & Simiola, V. (2018). Trauma and aging. Current Psychiatry Reports, 20(10), 93. https://doi.org/10.1007/s11920-018-0943-6 Cooper, L., Caddick, N., Godier, L., Cooper, A., & Fossey, M. (2018). Transition from the military into civilian life: An exploration of cultural competence. Armed Forces & Society, 44(1), 156–77. Crawford, J. R., Henry, J. D., Crombie, C., & Taylor, E. P. (2001). Normative data for the HADS from a large non-clinical sample. British Journal of Clinical Psychology, 40(4), 429–34. Dandeker, C., Wessely, S., Iversen, A., & Ross, J. (2006). What’s in a name? Defining and caring for ‘veterans’: The United Kingdom in international perspective. Armed Forces & Society, 32(2), 161–77. DeNavas-Walt, C., Proctor, B. D., & Smith, J. C. (2012). US Census Bureau, current population reports, P60–43, income, poverty, and health insurance coverage in the United States: 2011. U.S. Government Printing Office, Washington, DC. Desmond, D. M. (2007). Coping, affective distress, and psychosocial adjustment among people with traumatic upper limb amputations. Journal of Psychosomatic Research, 62(1), 15–21. Desmond, D. M., & MacLachlan, M. (2006). Coping strategies as predictors of psychosocial adaptation in a sample of elderly veterans with acquired lower limb amputations. Social Science & Medicine, 62(1), 208–16.

Concerns of aging veterans with disabilities 73 Edwards, D. S., Phillip, R. D., Bosanquet, N., Bull, A. M., & Clasper, J. C. (2015). What is the magnitude and long-term economic cost of care of the British military Afghanistan amputee cohort? Clinical Orthopaedics and Related Research, 473(9), 2848–55. Fear, N., Wood, D., & Wessely, S. (2009). Health and social outcomes and health service experiences of UK military veterans. ACDMH/KCMHR, 1–2. Findlay, R. A. (2003). Interventions to reduce social isolation amongst older people: Where is the evidence? Ageing & Society, 23(5), 647–58. Fletcher, K. L., Albright, D. L., Rorie, K. A., & Lewis, A. M. (2016). Older veterans. In J. Beder (Ed.), Caring for the military: A guide for helping professionals (pp. 54–71). Routledge. Foote, C. E., Mac Kinnon, J., Robbins, C., Pessagno, R., & Portner, M. D. (2015). Longterm health and quality of life experiences of Vietnam veterans with combat-related limb loss. Quality of Life Research, 24(12), 2853–61. Fulton, L. V., Belote, J. M., Brooks, M. S., & Coppola, M. N. (2009). A comparison of disabled veteran and nonveteran income: Time to revise the law? Journal of Disability Policy Studies, 20(3), 184–91. Garcia, H. A., Finley, E. P., Ketchum, N., Jakupcak, M., Dassori, A., & Reyes, S. C. (2014). A survey of perceived barriers and attitudes toward mental health care among OEF/OIF veterans at VA outpatient mental health clinics. Military Medicine, 179(3), 273–78. Ginzburg, K., Ein-Dor, T., & Solomon, Z. (2010). Comorbidity of posttraumatic stress disorder, anxiety and depression: A 20-year longitudinal study of war veterans. Journal of Affective Disorders, 123, 249–57. Goldberg, J., Magruder, K. M., Forsberg, C. W., Kazis, L. E., Üstün, T. B., Friedman, M. J., . . . Huang, G. D. (2014). The association of PTSD with physical and mental health functioning and disability (VA Cooperative Study# 569: The course and consequences of posttraumatic stress disorder in Vietnam-era veteran twins). Quality of Life Research, 23(5), 1579–91. Holder, K. A. (2016). The disability of veterans. Paper released by the U.S Census Bureau, Washington, DC. https://www.census.gov/content/dam/Census/library/workingpapers/2016/demo/Holder-2016-01.pdf House of Commons Defense Committee. (2019). Mental health and the armed forces: Part 2: The provision of care. 14th Report of Care Session 2017–2019. https://publications. parliament.uk/pa/cm201719/cmselect/cmdfence/1481/1481.pdf Kazis, L. E., Miller, D. R., Clark, J., Skinner, K., Lee, A., Rogers, W., . . . Linzer, M. (1998). Health-related quality of life in patients served by the Department of Veterans Affairs: Results from the veterans health study. Archives of Internal Medicine, 158(6), 626–32. Kazis, L. E., Ren, X. S., Lee, A., Skinner, K., Rogers, W., Clark, J., & Miller, D. R. (1999). Health status in VA patients: Results from the veterans health study. American Journal of Medical Quality, 14(1), 28–38. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52(12), 1048–60. Kuwert, P., Knaevelsrud, C., & Pietrzak, R. H. (2014). Loneliness among older veterans in the United States: Results from the national health and resilience in veterans study. The American Journal of Geriatric Psychiatry, 22(6), 564–69. Lee, S. E., Fonseca, V. P., Wolters, C. L., Dougherty, D. D., Peterson, M. R., Schneiderman, A. I., & Ishii, E. K. (2015). Health care utilization behavior of veterans who deployed to Afghanistan and Iraq. Military Medicine, 180, 374–79. MacLean, A., & Elder Jr, G. H. (2007). Military service in the life course. Annual Review of Sociology, 33, 175–96.

74 Concerns of aging veterans with disabilities Magruder, K. M., Frueh, B. C., Knapp, R. G., Johnson, M. R., Vaughan Iii, J. A., Carson, T. C., . . . Hebert, R. (2004). PTSD symptoms, demographic characteristics, and functional status among veterans treated in VA primary care clinics. Journal of Traumatic Stress, 17(4), 293–301. The Ministry of Defense UK. (2015). Annual population survey. UK armed forces veterans residing in Great Britain. Ministry of Defense, London, UK. The Ministry of Defense UK. (2019, June). War pension scheme annual statistics 1 April 2009 to 31 March 2019. Ministry of Defense, London, UK. Mistry, R., Rosansky, J., McGuire, J., McDermott, C., & Jarvik, L. (2001). Social isolation predicts re-hospitalization in a group of older American veterans enrolled in the UPBEAT program. International Journal of Geriatric Psychiatry, 16(10), 950–59. Murphy, D., Ashwick, R., Palmer, E., & Busuttil, W. (2017). Describing the profile of a population of UK veterans seeking support for mental health difficulties. Journal of Mental Health, 28(6), 654–61. Qureshi, S. U., Kimbrell, T., Pyne, J. M., Magruder, K. M., Hudson, T. J., Petersen, N. J., . . . Kunik, M. E. (2010). Greater prevalence and incidence of dementia in older veterans with posttraumatic stress disorder. Journal of the American Geriatrics Society, 58(9), 1627–33, esp. 1797–98. Rose, H. G., Schweitzer, P., Charoenkul, V., & Schwartz, E. (1987). Cardiovascular disease risk factors in combat veterans after traumatic leg amputations. Archives of Physical Medicine and Rehabilitation, 68(1), 20–23. Royal British Legion. (2014). A UK household survey of the ex-service community. http:// media.britishlegion.org.uk/Media/2273/2014householdsurvey_execsummary.pdf Schnurr, P. P., & Spiro III, A. (1999). Combat exposure, posttraumatic stress disorder symptoms, and health behaviors as predictors of self-reported physical health in older veterans. The Journal of Nervous and Mental Disease, 187(6), 353–59. Schnurr, P. P., Spiro III, A., Aldwin, C. M., & Stukel, T. A. (1998). Physical symptom trajectories following trauma exposure: Longitudinal findings from the normative aging study. The Journal of Nervous and Mental Disease, 186(9), 522–28. Schnurr, P. P., Spiro III, A., & Paris, A. H. (2000). Physician-diagnosed medical disorders in relation to PTSD symptoms in older male military veterans. Health Psychology, 19(1), 91–7. Segal, D. R., & Segal, M. W. (2004). America’s military population (Vol. 59, No. 4). Population Reference Bureau, Washington, DC. Shnoor, Y., Ziv, A., Brodsky, J., & Naon, D. (2017). Aging among IDF veterans with disabilities: Implications on need for services. Myers-JDC Brookdale, Jerusalem. Solomon, Z., Helvitz, H., & Zerach, G. (2009). Subjective age, PTSD and physical health among war veterans. Aging and Mental Health, 13(3), 405–13. Spielberg, J. M., McGlinchey, R. E., Milberg, W. P., & Salat, D. H. (2015). Brain network disturbance related to posttraumatic stress and traumatic brain injury in veterans. Biological Psychiatry, 78(3), 210–16. Spiro III, A., Schnurr, P. P., & Aldwin, C. M. (1997). A life-span perspective on the effects of military service. Journal of Geriatric Psychiatry, 30, 91–128. Spiro III, A., & Settersten Jr, R. A. (2012). Long-term implications of military service for later-life health and well-being. Research in Human Development, 9(3), 183–90. Stein, J. Y., Levin, Y., Aloni, R., & Solomon, Z. (2019). Psychiatric distress among aging decorated and non-decorated veterans: The role of impostorism and loneliness. Aging & Mental Health, 2, 1–9.

Concerns of aging veterans with disabilities 75 Tsur, N., Stein, J. Y., Levin, Y., Siegel, A., & Solomon, Z. (2019). Loneliness and subjective physical health among war veterans: Long term reciprocal effects. Social Science & Medicine, 234, 112373. Williamson, V., Stevelink, S. A., Greenberg, K., & Greenberg, N. (2018). Prevalence of mental health disorders in elderly US military veterans: A meta-analysis and systematic review. The American Journal of Geriatric Psychiatry, 26(5), 534–45. Wilmot, K. A. (2016). The disability of veterans. Social, Economic, and Housing Statistics Division, U.S. Census Bureau, Washington, DC. Wilmoth, J. M., London, A. S., & Heflin, C. M. (2015). Economic well-being among olderadult households: Variation by veteran and disability status. Journal of Gerontological Social Work, 58(4), 399–419. Wolf, E. J., & Schnurr, P. P. (2016). Posttraumatic stress disorder-related cardiovascular disease and accelerated cellular aging. Psychiatric Annals, 46(9), 527–32. Wu, L., & Lewis, M. W. (2015). Disabilities among veterans and their utilization of health care. Health Psychology and Behavioral Medicine, 3(1), 296–314.

4

Government policies towards aging veterans with disabilities

Most veterans with disabilities in Western countries, including the United Kingdom, the United States, and Israel, were injured in the massive wars of the 20th century. Their number is growing rapidly, and in some countries they are actually the majority of veterans who served (Fletcher et al., 2016). However, most of the services are provided to young veterans who have been recently injured and are aimed at improving their health and social functioning, but primarily their integration into the labor market. The core programs are career development programs, including vocational rehabilitation and higher education (Ben-Shalom, Tennant, & Stapleton, 2016). The first effort to provide specialized services to World War 2 veterans aging with disabilities was made in the early 1970s in the United States and marked a change in policy toward prevention of secondary health complications and promotion of healthy aging (Wilmoth, London, & Heflin, 2015). However, the overwhelming funding is still being spent on employment, job placement, and higher education, while only a portion is devoted to supporting older veterans (Fletcher et al., 2016). This chapter reviews policies toward aging veterans with disabilities in the United Kingdom, the United States, and Israel. In the final section, it discusses similarities and differences in their policies.

United Kingdom The United Kingdom’s policy regarding veterans reflects close collaboration between the state and charities. It is based on the Armed Forces Covenant of 2011 (Taylor, 2011), which, although not legally creating enforceable rights for veterans, portrays the nature of commitment of the nation (Ministry of Defense, November 21, 2018). “The New Strategy,” published by the MoD in 2018, set the goals to be achieved by 2028 in terms of ex-servicemen and women and veterans in civic society (Ministry of Defense, November 14, 2018). Three principles demonstrate the essence of UK policy: (a) veterans are viewed as civilians who need to contribute to wider society; (b) they are expected to maximize their potential as civilians; and (c) they are not viewed as special recipients, but when necessary use supplemental services from public and voluntary sectors. These rules are also applied in addressing the needs of aging veterans with disabilities.

Government policies towards aging veterans 77

Health and social care Veterans, including those who are aging with disabilities, receive health services from the NHS. The dilemma for the UK government is how to address the unique needs of veterans. Its solution was twofold: to provide priority and personalize services for veterans and to supplement health care by allocating, in 2015, additional funds to the NHS and charities to provide special mental health services as well as serious physical health concerns.

Priority services in the NHS All veterans are entitled to priority access to NHS care, including hospital and primary or community care for conditions that are service-related. The commitment to obtain a priority treatment for conditions relating to their service was set in 1953, when the Ministry of Pensions hospitals were transferred to the NHS. Under this arrangement, veterans claiming a war pension were entitled to priority treatment and free prescriptions from the NHS and could also be entitled to a number of allowances, equipment, or long-term nursing care. On November 23, 2007, the MoD announced that priority access would be extended from January 1, 2008 to include all veterans whose medical conditions or injuries are suspected of being due to military service, irrespective of whether they are claiming a war pension. The priority path is based on the guidance of the veteran’s GP at referral. However, an annual report by the Royal British Legion raised doubts about the implementation of this policy. It revealed that there was a lack of awareness and understanding in the NHS system, including inconsistencies and an inability to prioritize health services. It seems that the confusion was related to the difference between the NHS and the covenant’s interpretation. It is therefore important to clearly articulate how priority treatment should be implemented across the United Kingdom.

Personalized care In March 2019, the NHS in England, Scotland, and Wales jointly established with the MoD a framework for personalized care to support veterans who have complex and enduring physical, neurological, and mental health issues resulting from injury or disability that are related to military service. It is not clear how many aging veterans can benefit from the personalized care as it is aimed primarily at armed forces personnel in transition to civic life. The personalized care is part of the NHS Long-Term Plan and is designed to promote shared decision making, enabling choice and supported self-management including a personal health budget.

Dedicated health care services Most of the dedicated health programs for aging veterans with disabilities are provided through charities. One of the exceptions of the NHS’s special services to veterans is the NHS service for amputee veterans and substantially older veterans,

78 Government policies towards aging veterans which was recently renewed after a report from Dr. Andrew Murrison, MP. The report, “A better deal for military amputees,” published in 2011, recommended that a small number of NHS disablement centers would provide specialist prosthetic and rehabilitation support to veterans to ensure that they continue to have access to high quality care. Nine Disablement Service Centers (DSCs) were established. Most of the mental health services provided to ex-servicemen and women are aimed at a younger population of those who face difficulties after being discharged from army service. The dedicated Transition, Intervention and Liaison Service (TILS) and Complex Treatment Service (CTS) provide out-patient care for fairly young ex-servicemen and women, while the aging veterans benefit from NHS care, like the rest of the population does. Therefore, most of the mental health services for aging veterans are provided by charities as supplemental services. The Veterans and Reserves Mental Health Program (VRMHP) is a good example of the need for mental health assessments for veterans with operational service since 1982. All veterans referred to the VRMHP receive a full psychiatric assessment completed by a consultant psychiatrist; this assessment report is then sent to the veteran’s GP and, if needed, to the local mental health service with advice on further treatment and care. Another charity that provides additional mental health services is Combat Stress, established in 1919, which provides veterans with treatment services in specialist centers, on the phone, and online. Another example of this policy approach is the provision of medical supplemental resources for a short period through the Veterans Medical Fund. In 2015, the MoD contracted the Royal British Legion to manage £13m received from HM Treasury using income generated from the London Interbank Offered Rate (LIBOR) rate-fixing fines. The Veterans Mobility Fund (VMF), which handles £10m of the funds, supports veterans with service-related serious physical injuries that fall outside the provisions or whose warranty has expired. The Hearing Veterans Fund (HVF), with £3m of the funds, provides support to veterans who suffered hearing loss during service, but whose needs cannot be met through statutory services such as the NHS. It is intended to cover the cost of hearing aids, peripherals, or therapies such as lip reading and tinnitus management. Additional funding from LIBOR fines has been used to cover sporadic projects such as Project ADVANCE Plus, which was allocated £5m over the next five years for research into the psychological impact of battlefield injuries and severe battlefield trauma; Guide Dogs for Military Veterans which received £4.7m to provide a guide dog and support for life for each of the 90 blind veterans registered with the charity; and £1.05m to Supporting Wounded Veterans Ltd. to expand and develop a proven pain management program for wounded veterans across the United Kingdom.

The Aged Veterans Fund However, the most well-known of LIBOR’s funding schemes is the Aged Veterans Fund, a five-year, £30m grant to support non-core health, wellbeing,

Government policies towards aging veterans 79 and social care needs for older veterans born before 1950. It funds four areas: (a) practical support and companionship to improve older veterans’ wellbeing; (b) the provision of services to assist individuals in the completion of personal paperwork; (c) projects to build or enhance access to centers where aging veterans can meet and avoid isolation; and (d) the promotion of education of aged veterans’ needs. An examination of the grants awarded in 2015–16 and 2016–17 reveals that most of the funds were allocated to areas less well-funded by charities. For example, the 2015–16 budget was allocated to the Royal British Legion to establish the Aged Veterans Healthy Living Program; to the British Nuclear Test Veterans Association to support their program “Making the Difference”; to the St. John and Red Cross Defense to establish services for families of older veterans in Greater Manchester; and to the Royal Air Force Benevolent Fund to build a program of outreach services to combat loneliness and social isolation. The 2016–17 budget was similar, with the addition of funds to assist Rural Action Yorkshire to expand its services to older veterans. One of the Legion’s most recent grants was to the Soldiers, Sailors, Airmen and Families Association (SSAFA) to support the quality of life and wellbeing of veterans born before 1950 and their family members. The project includes advice, improving access to health care, social interaction, and respite care, along with creative activities and events for those in care settings across Scotland, Greater Manchester, and Bristol.

The role of armed forces charities Military charities in the United Kingdom provide support for ex-service personnel, veterans, and their families. Most of the core charities can be traced to World War 1 and World War 2 and reflect a public desire to care for those wounded in war. These charities continue their mission despite the establishment of national health policy (NHP) and national insurance (Cowen, 2008). Furthermore, the formation of new charities continues; these charities have even witnessed a 14% increase in their income between 2008 and 2012 (Pozo & Walker, 2014). There are welfare charities, service funds, armed forces associations, and mixed-type charities. Paradoxically, despite the criticism of the UK’s recent involvement in wars, there is growing sympathy for these charities, reflecting societal responsibility for veterans. The clearest appreciation of the veteran’s role is evident in the introduction of the Armed Force Covenant in 2010. Most charities are geared to supporting ex-servicemen and women and veterans by providing advice about pensions and compensation, and some have a 24-hour helpline and referral service. Although veterans are offered priority in the NHS, accessing health services is problematic for them, and they may need to receive assistance from charities. Many armed forces charities seek to strengthen their bond with veterans by serving their beneficiaries. This is not an easy task because tight resources and competition to stay relevant have forced charities to establish groups such as the Confederation of Service Charities (COBSEO) in a bid to

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improve information sharing and partnerships, while risking loss of identity in an effort to survive financially and continue their mission (Smith, 2010).

Charities serving aging veterans The establishment of the LIBOR Aged Fund reflects the lack of charities primarily serving aging veterans with disabilities. A good example is the SSAFA charity which has teamed up with Age UK, a civilian charity, to offer older veterans the “Call in Time” project. It is funded by the LIBOR Aged Fund to counteract loneliness by offering a free telephone befriending service. SSAFA matches people over the age of 60 with a volunteer to enjoy a telephone call once a week and have a friendly chat based on common interests and the chance to share stories. The Call in Time project is also developing specific services tailored to veterans’ individual needs and invites anyone with military experience to sign up for a oneon-one or group phone call. Most of the armed forces charities lack specialized support aimed at aging veterans with disabilities. Among the charities most used by aging veterans are those offering physical health services. According to Doherty, Robson, and Cole (2018), these charities provide physical rehabilitation and prosthetics, nursing homes, adapted housing, medical equipment, and helplines. Prosthetics services are the most common grants awarded to organizations and individuals, while only 14% of the charities provide actual prosthetics themselves. In contrast, physical rehabilitation is the most common service delivered by charities themselves (62%). Most of the charities making provision for nursing home or home care deliver the service themselves (61%). Another common service is adapted housing delivered by 41% of charities, while 59% deliver mobility aids and hearing aids via grants to individuals. About 77% of charities in this area offer helplines. Another need demonstrated by aging veterans is for mental health provisions. According to Cole, Robson, and Doherty (2017), 57 out of 76 armed forces charities offer services for PTSD services; 43 charities provide support for those suffering from depression and anxiety; and 33 provide support for those seeking help for substance abuse.

United States Aging veterans are eligible for a wide variety of benefits available to all veterans, including those with disabilities (Scott & Davis, 2009). The benefits include disability compensation, education and training, health care, home loans, insurance, vocational rehabilitation, and employment. There are two VA programs that provide certain elderly veterans with an additional monetary amount if they are eligible for or are receiving a VA pension benefit. Aid and Attendance (A&A) is an increased monthly pension amount paid if the veteran meets the following conditions: (a) requires help in performing daily functions, including bathing, eating, or dressing; (b) is bedridden; (c) is a patient in a nursing home; or (d) has limited eyesight. In addition, Housebound is an

Government policies towards aging veterans 81 increased monthly pension amount paid to veterans substantially confined to an immediate premise because of a permanent disability. Elderly veterans are eligible for geriatric health care for those with complex needs. Extended care – also known as long-term care – is a program for veterans of all ages who need the daily support and assistance of another individual. Elderly veterans can receive geriatric and long-term care programs at home, at VA medical centers, or in the community.

Benefits and pension provided to veterans with disability, particularly aging disability benefits for ex-servicemen and women or veterans with disabilities Financial benefits are essential for providing economic stability and survival for ex-servicemen and women and veterans with disabilities. They are entitled to three major military benefit programs that provide financial support to ex-servicemen and women and veterans with disabilities: the DoD Disability Retirement program, the VA Disability Compensation, and veterans pension programs. In addition, they may be entitled, like any civilian, to the Social Security Disability Insurance (SSDI) and the Supplemental Security Income (SSI) programs. These programs vary in terms of purpose, eligibility criteria, beneficiary characteristics, amount of benefits, interactions with other programs, as well as the effect of employment on continued eligibility and cash benefit amount (Kregel & Miller, 2016). Table 4.1 presents the purposes of various benefit programs for ex-servicemen and women and veterans with disabilities. The DoD Disability Retirement benefits is a wage replacement program that compensates veterans whose disability prevents them from returning to their pre-disability position in the armed forces. Table 4.1 Benefit Programs Available to Ex-servicemen and Women and Veterans with Disabilities Department of Defense (DoD)

Department of Veterans Affairs (VA)

Social Security

Disability Retirement Provide financial support to service members whose disabling conditions render them unable to perform their military duties

Disability Compensation Compensate veterans for average reduction in earnings capacity due to their serviceconnected disabilities

SSDI Replace lost wages for workers under the age of 66 who have paid into Social Security, but can no longer work because of a disability

Veterans Pension Provide a needs-based benefit to a veteran because of permanent and total nonservice-connected (NSC) disability

SSI Provide cash payments ensuring a minimum income for aged, blind, or disabled beneficiaries who have very limited income and assets

Source: U.S Government Accounting Office (U.S GAO)-09–62 (2009), p. 54

82 Government policies towards aging veterans The amount of compensation is based on their income in the military. The VA Disability Compensation program compensates for the shortfall relative to their non-disabled peers’ future earnings. Both the SSI and the SSDI offer cash benefits to individuals with disabilities, but the financial eligibility requirements are different. The main difference between the SSDI and the SSI is the fact that the SSDI is available to workers who have accumulated a sufficient number of work credits, while SSI disability benefits are available to low-income individuals who have either never worked or who haven’t earned enough work credits to qualify for SSDI.

The Department of Defense (DoD) disability retirement policy The DoD military retirement policy is non-contributory and is considered a significant incentive in retaining a career military force. The monthly retirement compensation is provided after an active or reserve military career, disability retirement for those physically unfit to continue to serve, and survivor benefits for the eligible survivors of deceased retirees. It is adjusted annually by a Costof-Living Allowance (COLA) to ensure that the annuity is protected from the adverse consequences of inflation. Disability retirement is provided to service members who have been determined to be unfit for continued service and who have a permanent and stable disqualifying physical condition (Henning, 2010). According to disability retirement, commonly referred to as 10 USC Chapter 61 (Retirement, or Separation for Physical Disability), eligibility is based on having a 30% disability rating or greater and at least six months or more of active duty service where the disability was not noted at the time of entrance to active duty. However, according to 10 U.S.C. 1201 (b)(3)(B) prior to 2008 (Section 1641), disability retirement requires at least eight years of service or a disability that resulted from active duty or was incurred in the line of duty during war or national emergency. According to 10 U.S.C. 1401, disability retirees may select one of two available options for calculating their monthly retired pay: (a) the longevity formula, which is computed by multiplying the years of service times by 2.5% and then by the pay base (either final pay or “high three,” as appropriate); or (b) the disability formula, which is computed by multiplying the DoD disability percentage by the pay base. The maximum retired pay calculation under either formula cannot exceed 75% of basic pay. Retired pay computed under the disability formula is fully taxed unless the disability is the result of a combat-related injury. Retired pay under the longevity formula is taxable only to the extent that it exceeds what the individual would receive for a combat-related injury under the disability formula.

Service-connected disability compensation VA service-connected disability compensation benefits are monthly payments made to veterans, and, in some cases, their families. Monthly disability compensation varies with the degree of disability and the number of eligible dependents.

Government policies towards aging veterans 83 Disability compensation benefits are not subject to federal or state income tax. Veterans with certain severe disabilities may be eligible for additional Special Monthly Compensation (SMC). The latter may be paid to a veteran who, as a result of military service, incurred the loss or loss of use of specific organs or extremities. Loss, or loss of use, is described as either an amputation or having no effective remaining function of an extremity or organ. Higher rates are paid for combinations of these identified disabilities (such as loss or loss of use of the feet, legs, hands, and arms) in specific monetary increments based on the particular combination of the disabilities. There are also higher payments for various combinations of severe deafness with bilateral blindness. Additional SMC is available if a veteran becomes paraplegic due to service, with complete loss of bowel and bladder control. In addition, for veterans who have other service-connected disabilities that, in combination with the above special monthly compensation, meet certain criteria, a higher amount of SMC can also be considered. A veteran who has a service-connected disability at the 100% rate and is “housebound, bedridden, or is so helpless to need the aid and attendance of another person,” may be considered for payment of additional SMC. This additional monthly payment is referred to as “Aid and Attendance and Housebound Allowance.” They are discussed separately with respect to special benefits aimed primarily at aging veterans.

VA disability pension Veterans with permanent and total non-service-connected (NSC) disability are entitled to a pension, which is provided also to a surviving spouse or child because of a wartime veteran’s nonservice-connected death. There are three types of VA pensions: (a) Improved Pension, per Public Law (P.L.) 95–88; (b) Section 306 Pension, per P.L. 86–11; and (c) Old Law Pension. The Old Law and Section 306 Pension programs have been terminated, and new applicants are required to qualify under the Improved Pension program. Those beneficiaries who qualified prior to December 31, 1978 can choose whether they wish to continue receiving the pension rate they were receiving on that date or to comply with the Improved Pension program. This rate generally continues as long as the beneficiary’s income remains within established limits, his or her net worth does not bar payment, and the beneficiary does not lose anything. Disability Pension payments are aimed to bring the veteran’s total income, including other retirement or Social Security income, up to a level set by Congress. Unlike service-connected disability compensation, the pension program is means-tested. In addition, Disability Pension payments are reduced by the amount of countable income of the veteran, spouse, or dependent children.

Aging veterans special provisions Aside from the DoD disability pension, the VA disability compensation, and the other previously mentioned pensions, veterans (particularly aging ones) can use two additional provisions: A&A and Housebound allowances. According to

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journalist Susan Seliger (2012), they are less recognized benefits for aging veterans that can cover the costs of caregivers in the home or can be used for assisted living or nursing home facilities. A&A is a benefit paid in addition to the monthly veteran pension and disability compensation. It covers the cost of in-home care, assisted living, or a nursing home. The eligible veteran needs to demonstrate the aid of another person in order to perform personal functions required in everyday living, such as bathing, feeding, dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting themselves from the hazards of their daily environment. Additionally, veterans are eligible if they are bedridden, are patients in a nursing home due to mental or physical incapacity, or are blind or have corrected vision of 5/200 or less (in both eyes) or concentric contraction of the visual field to 5° or less. Not all of the factors listed previously have to be present for the beneficiary to receive a higher maximum pension benefit due to the need for aid and attendance. The totality of the circumstances guides the determination of need, and the pension claimants do not need to demonstrate the need for round-the-clock care, but only a regular and ongoing need for the aid and attendance of another person. Housebound allowance is provided to veterans eligible for the pension when they are unable to leave their homes. Eligible recipients have a single permanent disability evaluated as 100% disabling and are permanently and substantially confined to his or her immediate premises due to such disability, Additionally, they may have a single permanent disability evaluated as 100% disabling and along with an additional disability or combination of disabilities evaluated as 60% or more disabling. A person is considered “housebound” when he or she is substantially confined to a dwelling and the immediate premises due to a disability, and it is reasonably certain that this confinement will continue throughout that person’s lifetime. A “dwelling” can be any care facility aside from the person’s home.

The interaction of Department of Defense (DoD) pension, VA benefits and pension, and Social Security provisions Veterans with disabilities may receive financial benefits from more than one source. The impact of benefit receipt across multiple programs varies widely (Kregel & Miller, 2016). Often, veterans cannot receive duplicate benefits for the same disability, or obtaining a benefit in one program may have an effect on the benefit amounts from another program. The following three examples may demonstrate the interaction between social security and DoD and VA programs: a

b

DoD Disability Retirement is not affected in any way by eligibility for Social Security benefits of any type. However, SSDI and SSI payments may be reduced or eliminated due to receipt of military disability and retirement benefits. DoD retirement benefits are subject to state and federal income tax. VA Disability Compensation is not affected by receipt of Social Security benefits or military retirement. It is also specifically exempt from state and federal income tax. In addition, while SSDI benefits are typically reduced or

Government policies towards aging veterans 85

c

“offset” by federal public disability benefits (PDB) – such as military retirement based on disability. This does not include benefits paid by the VA under Title 38 U.S.C. Eligibility for the Veterans Pension program may be affected by receipt of all Social Security disability, retirement, and survivor benefits. Every dollar of Social Security allowance received is subtracted from the Veterans Pension payment. However, the VA Pension program does not count SSI payments as income. Therefore, the SSI is counted as a noncontributory program and therefore is considered by recipients of Veterans Pension as unearned income.

The health and long-term care policy toward aging veterans In the early 1960s, the VA lacked an explicit long-term care policy for aging veterans and therefore provided a limited form of institutional care in its hospitalization system. Toward the end of 1964, the VA began making plans to implement a nursing home care program with 2,000 beds in VA hospitals “for those veterans who have obtained maximum hospital benefits, [but] are too physically disabled for domiciliary care, and still have a need for nursing care which for various reasons cannot be provided in the community” (US Congress, House Annual Report of Administrator of Veterans Affairs, 1964). The first long-term care legislation for eligible veterans was P.L. 88–50, approved on August 19, 1964 (38 U.S.C. 620, 5001, and 5033). The legislation authorized, among other things, 4,000 beds for nursing home care. In addition, it authorized care in private or public nursing homes for no more than six months at VA expense for VA patients who had received maximum hospital benefits but who still needed long-term nursing home care. The legislation allowed using state veterans’ nursing homes for the care of eligible veterans. In enacting P.L. 88–50, Congress recognized the growing need for nursing home care for World War 2 veterans in future years. An additional reason was economic, i.e., moving veterans from hospitals to less expensive nursing homes. Two pieces of legislation lifted restrictions on veterans with service-connected disabilities. P.L. 91–01 OF October 29, 1969 eliminated the six-month limitation of nursing home care for veterans with service-connected disabilities. P.L 93–2 marked the provision of health care services to dependents and survivors of certain veterans (Colello & Panangala, 2017). In the early 1970s, the VA Department of Medicine and Surgery began to plan for the challenges of veterans of World War 2 who demonstrated signs of aging, in particular those with severe disabilities and secondary health complications. At that time, geriatric medicine was a recognized area of specialty in the United Kingdom but had little presence in the United States. In 1998, a Federal Advisory Committee on the Future of VA Long-Term Care found that the long-term care programs offered institutional care and incremental home and community-based care programs. In addition, the committee found that the VA long-term care of the 1970s and 1980s lacked systematic planning and coordination, or integration into the general health care system. Based on the

86 Government policies towards aging veterans recommendations of the Federal Advisory Committee on the Future of VA LongTerm Care, Congress began to examine the VA’s long-term care programs, which led to the enactment of the Veterans Millennium Health Care and Benefits Act (P.L. 106–17) in November 1999 (Public Law 106–117 1999). This act also mandated nursing home care for veterans with a service-connected condition in need of such care and for veterans with nonservice-connected conditions who are 70% or more service-connected disabled. Among other things, it also required the VA to provide non-institutional care, such as home-based care and adult day health care, to all enrolled veterans (Gardner & Hendricks, 2004). In parallel, the VA developed the Geriatric Research, Education and Clinical Centers (GRECCs) (Supiano et al., 2012). The expansion of these centers to 25 was supported by two Congressional acts (P.L. 96–30 OF 1980 and P.L. 99–66 OF 1985). The impact of these centers was monitored by the Geriatrics and Gerontology Advisory Committee (CGAC). The GRECC program accelerated not only the advancement of aging research and training but also research and clinical care beyond the VA (Solomon, 1994). Since 1994, there were four significant changes in the VA administration that influenced the GRECC program. The first change was the joining of new waves of aging veterans from the Korean and Vietnam wars. Most of them were part of the post-World War 2 generation followed by younger veterans of Operation Iraqi Freedom who demonstrated different disabilities and psychosocial concerns. The second change was the adoption of the GRECC program’s conceptual model by other specialty areas within the Veterans Health Administration (VHA), resulting in the establishment of ten Mental Illness Research, Education and Clinical centers in 1989 and six centers designated for Parkinson’s disease. The third change was the decentralization of resource allocation into 21 regional Veterans Integrated Service Networks (VISNs). The funding for GRECC became the responsibility of each GRECC’s host VISN and medical center. The fourth change was initiated in 1996, creating evidence-based research to demonstrate improvement of outcome. One of the most interesting surveys developed by GRECC researchers was the Vulnerable Elders Survey, a tool that allowed clinicians to identify older veterans at risk of functional decline and death (Saliba et al., 2001). An additional achievement was the adaptation of interRAI Home Care for those who participated in home-based primary care (HBPC) program, with the intention of identifying health and functional deterioration and reducing hospital admissions and emergency department visits (Saliba et al., 2001). Among common practical clinical contributions were the prevention of falls among geriatric patients (Perell et al., 2006), constructing screening tests for depression (Wilkins et al., 2011), and treatment protocols for stroke survivors (Hula, Doyle, & Rossi, 2009). The GRECC staff developed hospice and palliative models of care which demonstrated that a multicomponent palliative care program improves end-of-life care. (Bailey et al., 2005). Finally, there were a few administrative improvements, such as use of a regional health information organization that allowed VA and non-VA facilities to share electronic medical records (Hung et al., 2011) and the provision of in-home interdisciplinary geriatric evaluation

Government policies towards aging veterans 87 and short-term management to prevent inappropriate use of services and to reduce unnecessary hospital readmissions (Kind et al., 2010).

The current VHA Geriatric and Extended Care (GEC) programs The VA offers long-term institutional and non-institutional care. Institutional provision includes both inpatient acute care and nursing home care, although the majority occurs in a nursing home setting, which is the primary focus of this report. Non-institutional care includes outpatient or ambulatory care settings, as well as home or community-based care. These services cover a full spectrum of care needs, spanning veterans who are largely independent, to those who require significant assistance with basic daily activities and those who are near the end of life. The current VHA Geriatric and Extended Care (GEC) programs were reviewed by Colello and Panangala (2017) and also included a graphical presentation of the core continuum of programs. Figure 4.1 was shown at the VHA’s Ambulatory Care

Impatient Acute

Home and Community Long Term Services and Supports (LTSS)

Facility Based Care

Hospice Care

Geriatric Evaluation and Management.

Geriatric Evaluation and Palliative Care Unit.

Adult Day Health Care.

VA Community Living Centers.

Community Home Hospice.

Home Based Primary Care.

Community Nursing Homes.

Inpatient Hospice.

Geriatric and Palliative Care Consultation.

Homemaker and Home Health Aide.

State Veterans Home.

Geriatric Primary Care (Geri-Pact). Outpatient Palliative Care.

Community Residential and Medical Foster Care. Respite. Skilled Home and Palliative Care. Veteran Directed Care.

Independence End of Life

Figure 4.1 VHA Geriatrics and Extended Care Programs

Dependence

88 Government policies towards aging veterans presentation at “Geriatrics and Extended Care: Next Steps Summit” on August 4, 2016. The programs varied according to level of dependency and restriction, from ambulatory through home and community care to hospice care. The VHA also provides additional components of care including specialized dementia care, transitional care, health care workforce development, GRECCs, and Geriatrics and GEC field programs and resource centers.

Non-institutional care The VA provides home and community-based care to eligible veterans. The primary goal of these is to support veterans in their home settings with optimum health and wellness as they age. There are two non-institutional long-term care services: adult health care and respite care (38 U.S.C. §1710B(a)(4) and §1710B(a) (6)). The VA’s other non-institutional long-term care services are considered part of the health-care benefits package (38 C.F.R. §17.38). The VA provides many of these services directly, but needs to purchase certain services from community providers, similar to Medicare. Among the VA’s services are the following: 1 2

3

4 5

6

7

Home-Based Primary Care (HBPC) which provides long-term comprehensive primary care services to eligible veterans. Such services are coordinated by an interdisciplinary team that makes home visits. Community Residential Care (CRC), a supported housing program where veterans reside in a VA-approved group home. VA staff provide case management services to the veteran and monitor the care provided by the group home staff. Medical Foster Home (MFH), a subset of the CRC program providing a higher level of care to eligible veterans. The veteran resides in a VA-approved adult foster care setting, with caregivers providing 24 hour-a-day supervision. The program is designed for veterans who would need nursing home level of care if not for significant in-home supports. Outpatient clinic-based services including geriatric evaluation in outpatient, inpatient, and long-term care settings, among others. Palliative Care Clinics aimed at increasing the veteran’s quality of life. The palliative care team includes a medical provider, social worker, nurse, chaplain, and may include a psychologist and dietitian. Hospice, a specific form of palliative care for veterans with six months or less to live, is provided in home or inpatient settings. A limited number of facilities offer onsite Adult Day Health Care (ADHC), an outpatient day program that provides activities, socialization, supervision, and meals in a congregant setting. This program is targeted toward veterans who would need nursing home care by offering personal care and daily living skills. The VA purchases additional services in the community such as adult home care, homemaker or home health aide, and respite services. The VA also purchases skilled home care or home hospice.

Government policies towards aging veterans 89 8

A limited number of VA facilities offer Veteran-Directed Home and CommunityBased Services (VD-HCBS), which provide veterans with a budget for services, and the veteran determines how to use that budget to hire home health aides or arrange other supportive services to help the veteran live independently. The goals of the program are to provide the veteran with more control and choices related to his or her care and to keep the veteran safely in his or her home. The veteran may use the funds to pay a family member or private citizen to provide aide services.

Institutional care The VA is mandated by the Veterans Millennium Health Care and Benefits Act (P.L. 106–17) to provide nursing home care to certain eligible service-connected veterans. Depending on available resources, the VA may also provide nursing home care to nonservice-connected veterans who are clinically in need of institutional care. This care may be provided in a VA Community Living Center (CLC), a Community Nursing Home (CNH), or a State Veteran’s Home. The VA has CLCs associated with Veterans Administration Medical Centers (VAMCs) which provide nursing home level of care. CLCs are staffed by VA employees and may provide rehabilitation, custodial, and hospice care to veterans. Some CLCs may offer specialty services such as a specialized dementia unit. In the mid-2000s, this program underwent a change in the model of care, renaming the facilities from Nursing Home Care Units to Community Living Centers offering more personalized services and a homelike atmosphere. While not all VAMCs have CLCs, they are required to operate a CNH program. An additional option is the State Veterans Home (SVH). SVHs are owned and operated by the state in which they reside, and eligibility requirements are determined by the state of jurisdiction. In addition to providing long-term care, VA facilities may choose to provide respite, hospice, and palliative care, as well as geriatric evaluation programs, to eligible veterans in an institutional setting.

Concerns in provision of long-term care VA long-term care provisions offer personalized and patient-centered services for aging veterans. The intention is to respond to ongoing geriatric needs such as handling dementia, complicated pharmacy, or complex medical conditions (Shay & Schectman, 2010). Unfortunately, these services are not available everywhere because of a shortage in geriatric staff, particularly doctors. According to Colello and Panangala (2017), the number of aging veterans who have disabilities that are rated as 70% or are more service-connected, and therefore eligible for VA-paid nursing home care, has increased. This growth in demand may lead to addressing the right balance between home/community and institutional care and coverage of these services and accessibility issues. Over the past two decades, federal financing and delivery of long-term care – particularly for Medicaid, the largest federal payer of long-term services

90

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and supports (LTSS) – has shifted toward the provision of care in home and community-based settings rather than institutional care. There is evidence that the current proportion of Medicaid LTSS spending on institutional care has decreased significantly. The transition to community-based services (HCBS) was boosted by the Supreme Court decision in Olmstead v. L.C., stating that the institutionalization of people who can be cared for in community settings is a violation of Title II of the Americans with Disabilities Act (ADA). Following these changes, in 2016 the Subcommittee on Military Construction, Veterans Affairs and Related Agencies made a decision to provide a “more balanced offering of home and community-based services.” However, an examination of the 2015 VA budget of reveals that 71% is still spent on institutional care. There is no doubt that one of the reasons for this high institutional care rate is the requirement to provide nursing home care to veterans with 70% or more service-connected disability. An additional obstacle is related to the current design of the SVH program which generally favors the construction of institutional care over HCBS. Another barrier is related to the fixed per diem that the VA provides to states for each veteran who receives care in a state veterans’ home. However, changing budgeting priorities are quite difficult to handle because they may limit the VA to purchasing institutional care and may hurt veterans’ personal choices. Another concern has to do with coverage and federal government coordination. It is evident that not all veterans rely primarily on VA health care and particularly long-term care. About 78% of veterans enrolled in the VHA have additional private or public health care coverage such as Medicare and private insurance (Gasper et al., 2015). Veterans who have Medicare or private health insurance may seek services from the VA not covered by those plans, such as adult day health care or respite care. For example, veterans prefer the VA over Medicaid for longterm care services because it does not require them to spend assets or to meet strict income guidelines to receive long-term care. There are some exceptions, as eligible veterans may choose to receive their health care in the community. According to Miller and Intrator (2012), the VHA called on the federal government to give special consideration for cross-system use. They thought that failure to account for non-VHA care could bias conclusions about prevalence and incidence in utilization, diagnoses, and other characteristics. Furthermore, they argued that it was difficult for the VHA to ensure continuity of care. To better coordinate services, the VHA would need to construct the necessary health information bridges while widening the purview of case management programs. The final issue has to do with accessibility to health care, and particularly to long-term care. Studies have demonstrated that VA veterans have more physical comorbidities and worse health-related quality of life than persons living in urban and suburban locations. Unfortunately, they have reduced access to VA care or alternatives to other health services (Weeks et al., 2004; West & Weeks, 2009). Rural veterans with disabilities often report limited supply and availability of VA services, particularly in transitioning to aging. Aside from the limited specialized options for assessment and treatment referrals, they complain that their providers

Government policies towards aging veterans 91 are not aware of their health needs. An additional problem is proximity, as they need to travel long distances to receive VA health services (Buzza et al., 2011). A real concern is the lack of mental health specialists in rural versus urban localities. In this regard, Teich et al. (2017) reported that veterans living in rural areas had 70% lower chances than urban veterans did of receiving mental health services. Furthermore, veterans with mental health conditions in rural areas have approximately 52% and 64% lower odds of receiving outpatient treatment and prescription medications, respectively, compared to those living in urban areas. Among veterans seeking treatment for serious mental illness, travel distance was found to be the strongest predictor of lack of service and of poor service (McCarthy et al., 2007). Additional barriers to health services among older veterans with disabilities are related to their impairment. For example, regardless of the efforts of the VA to improve PTSD care, veterans complain that the system is far from being receptive and aware of the stigma associated with PTSD (Ouimette et al., 2011). Older veterans tend to be underserved because they express PTSD and a complexity of depressive symptoms and cognitive disabilities. They are consistently overlooked by health providers, particularly when they demonstrate comorbidity and lack social support (Clark et al., 2017).

Israel Chapter 1 introduced the evolution of policy and legislation toward IDF veterans with disabilities. The early legislation of the Invalids Law (1949) demonstrated government commitment to veterans with disabilities by offering compensation allowances to recognize their role in the ethos of building the nation (Tal-Katz, Araten-Bergman, & Rimmerman, 2011). As introduced earlier, the law also provided medical services related to the recognized disability and the development of vocational rehabilitation services to facilitate their integration into the labor market. The early legislation not only strengthened the compensation but also the importance of work and career development. The 1959 revision of the legislation marked the construction of the rehabilitation approach, particularly in light of the organization of the MoD. The core professional approach was influenced by the medical rehabilitation model; thus, the veteran’s severity of impairment had an impact on the percentage of their compensation. Since the core path for rehabilitation is the vocational rehabilitation and career development approach, most of the amendments attached to the 1959 legislation are linked to employment and integration into the labor market. This approach was quite common in the development of the rehabilitation policies and programs of the United States and the United Kingdom after World War 2 (MacLean, Murray, & Lazier, 2019). The impression is that most of the 1959 amendments are aimed at young veterans with disabilities and focus on integrating them into the labor market. Over the 70 years since the Invalids Law was first enacted, there have been 30 revisions of the law, and just recently the Welfare and Health Committee of the Knesset intended to approve a version that

92 Government policies towards aging veterans accommodated all the internal changes agreed by the MoD and the ZDVO in 2016. The intended changes are supposed to integrate the “piecemeal approach” of responding to gradual needs expressed by war veterans with disabilities. The first structured criticism about the need to modify the rehabilitation approach was recommended by the Vardi Report (2002). The committee, headed by a retired general, called for two core changes: updating the vocational rehabilitation model and decentralizing committee’s report operation. However, the report did not touch upon the growing aging population of veterans with disabilities. Additional efforts to revise the policy were made internally by the MoD from 2006 to 2009. The efforts were aimed at better and faster responses to the rehabilitation needs of new veterans with disabilities by establishing accountability and evidence-based measures. The internal discussions also addressed the MoD’s medical services provided to veterans, in particular to those with severe disabilities. In terms of mid-life and aging veterans with disabilities, the most serious problems reported by them were the lack of integration of MoD-provided medical services related to the recognized military disabilities and the medical needs served mainly by providers of national health insurance. In particular, a frequent complaint made by mid-life veterans with severe disabilities was the lack of standardization for the replacement of prosthetic legs and other devices. However, the most serious challenges were reported by mid-life veterans with PTSD, prisoners of war (POW) with PTSD, and veterans who served as naval commandos and had operated in the highly polluted Kishon River. In terms of PTSD, the MoD invested substantial efforts in improving treatment and services for recognized veterans. However, many veterans experienced delayed PTSD symptoms later in life but failed to apply for recognition and treatment (Horesh et al., 2011). Very similar problems were experienced by IDF veterans who were prisoners of war, as they reported suffering from delayed PTSD and secondary medical conditions (Mikulincer et al., 2011). It was only in 2005 that they were recognized by the MoD as entitled to 20% medical disability compensation, and even given compensation retroactively in 2010 (Compensation to POW veterans, 2005). The Kishon veterans complained that as a result of their diving in the polluted river in the 1960s, 1970s, and 1980s, many developed cancer and other serious illnesses in their mid-life and aging years. The veterans demanded that the MoD take responsibility for their illnesses, finance their medical treatment, and support their families if they died. The causal association between the polluted river and the veterans’ cancers was denied, and their demands were rejected. The dispute quickly escalated into a bitter public controversy, and a high-ranking commission composed of one of Israel’s top jurists (Judge Meir Shamgar) and two prominent scientists was called upon to study the disputed causal relation (The Shamgar Commission, 2002). However, after nearly three years of intense inquiry, the jurist and the scientists reached opposing conclusions: Judge Shamgar found a causal connection, while the scientists rejected it. The scientific view of the commission was perceived by many as a dehumanizing decision toward those who suffered.

Government policies towards aging veterans 93 The public and the press praised Shamgar’s courageous stance which preferred the moral obligation over the scientific evidence (Golan, 2010). The minister of defense at the time, Shaul Mofaz, declared that the government reviewed the commission’s report and decided to embrace Shamgar’s minority opinion: all veteran divers would receive medical treatment from the MoD. However, in terms of compensation, the Kishon affair continued to attract public and media attention. The debate was whether to compensate them for their illnesses as the number of claims continued to grow, in particular from mid-life and aging veterans. The MoD tried to scale down the claims by announcing that it would not recognize those who trained in the Kishon River prior to 1975. Only divers who belonged to special units were recognized for immediate compensation, while others had to submit their claims individually. It is still seen by the public and media as a crack in the MoD’s commitment to veterans who were exposed to polluted water during their military service and who developed latent cancer. It is similar to the experience of older war veterans of the 1967 Six Day War and the War of Attrition who expressed delayed PTSD symptoms. The Division of Rehabilitation of the MoD has responded, primarily in the 21st century, to the growing needs of mid-life and aging veterans with disabilities. The internal instructions and one amendment related to the benefits for mid-life IDF veterans are summarized in Table 4.2. The only amendment that is related to an aging veteran’s compensation is 7(a), which was enacted early in 1968, and recognizes that senior veterans of the War of Independence may need additional pension funds. It was adjusted to the current retirement age in 2004. All of the internal instructions are related to medical services and were provided later in response to demonstrated needs. Instruction 50.04, initiated in 2010 and revised in 2012, provides veterans aged 40 and above with 50% medical disability related to certain disabilities and medical treatment (ambulatory, prescriptions, medical and rehabilitation devices, nursing, and reimbursement for transportation for treatment) for cardiovascular and neurological secondary conditions that veterans with specific disabilities may be vulnerable to earlier than others. Instructions 50.13, 50.23 and 51.04 are examples of scattered needs expressed by mid-life and aging veterans. Instruction I 50.13, revised in 2014, provides additional spa services to veterans with 50% medical disabilities, while older veterans aged 65 and above obtained longer spa services than those aged 55. Instruction 50.23 provides veterans with 50% mobility disability at the age of 55 and above to purchase a scooter that improves their access to community services. Instruction 51.04, from 2005, entitles veterans living alone, aged 65 and above, with 30% medical disability, to a distress button to obtain services in case of emergency. Instructions 80.18 and 85.04 are aimed at the medical needs of senior veterans with disabilities. Instruction 80.18 finances senior veterans with 50% to 100% medical disabilities and is increased by age whether the veteran lives alone or has to support a dependent spouse. Instruction 85.04, also initiated recently, provides pre-retired veterans with disabilities of two age groups (aged 55 to 59, and above 59) with additional compensation and accompaniment fee as related

Retirement age of 62 for women and 67 for men

A veteran aged 40 and above with at least 50% medical disability for specific disabilities treatment for services related to cardiovascular or neurological conditions

A veteran aged 50 and above with at least 50% medical disability is entitled to seven additional days per year. A veteran who reaches 65 is entitled to coverage of a companion A veteran aged 55 and above with mobility disability of at least 50%

A veteran aged 65 and above with 30% medical disability living alone

Veterans who reach retirement age receive a supplement of 10% to their basic allowance

Medical treatment for mid-life veterans beyond the letter of law

Spa services

The provision of cost of a light electric mobility scooter

A distress button

Age supplement

Medical treatment (ambulatory, prescriptions, medical and rehabilitation devices, nursing, and reimbursement for transportation for treatment)

Spa

Electric scooter

Devices for veterans with severe disabilities

Monthly rent

Additional supplement to finance “special needs”

Additional benefits to midlife and aging veterans with disability

A 7(a)

I 50.04

I 50.13

I 50.23

I 51.04

I 60.06

I 80.18

I 85.04

Accompaniment fee

Additional compensation to mid-life and aging veterans with disability

To veterans aged 65 and above based on dependency measures of Instrumental Activities Daily Living (IADL)

A veteran aged 55–57 with more than 50% medical disability is entitled to 7% additional compensation, 14% at the age of 55–59, and 21% after the age of 59

A veteran aged 57–59 with 40%–50% of medical disability is entitled to additional compensation of 7%, and 14% after reaching age 59

Financing “special needs” Aging veterans with “special needs” with medical disability of 50%–100% are entitled to an additional fee calculated by age (women from the age of that have increased with aging 60 and men from 65). The award is increased by age and living conditions (whether the veteran lives alone or has to support a dependent spouse)

Financing of monthly rent A veteran above the age of 65 who does not currently own any housing

Eligibility

Brief Explanation

Number of MoD Title Amendment (A) or Instruction (I)

Table 4.2 Benefits Provided to Israeli Mid-life and Aging Veterans with Disabilities

94 Government policies towards aging veterans

Government policies towards aging veterans 95 to their medical disability and age group. This means that those above the age of 59 are compensated at a higher rate than the younger group. The instruction is an indication that the MoD recognizes accelerated aging in those in their late fifties. Instruction 60.06 is a fairly recent benefit (2014) which covers monthly rent for veterans with disabilities aged 65 and above who do not have housing. Most of the benefits above are related to veterans’ health, except for Amendment 7a (a), which provides a 10% increase to retired veterans with disabilities, and Instruction 60.06 which covers monthly rent for retired veterans who lack housing. Aside from these benefits, all veterans with disabilities are entitled to health and social insurance benefits like any other citizen. Four pieces of legislation are the core entitlements: the National Health Insurance Act (Chok Briut Mamlachti) of 1994 provides health services through health providers ensuring appropriate services for all ages. In addition, all insured retired residents are entitled to old age monthly pension, provided by the NII. Although these pensions are considerably lower in comparison to OECD countries, they offer a minimum base for retired people. A unique progressive legislation is the Long-term Care Insurance Law (Chok Seud) of 1988, designed to provide home-care assistance to elderly persons who have reached retirement age and need help in daily activities (washing, mobility, control over bodily functions, etc.), or whose condition necessitates constant personal care and supervision (such as individuals with Alzheimer’s disease). In most cases, the long-term care benefit is given as home-care hours of a caregiver employed through a nursing care company (Morginstin, Baich-Moray, & Zipkin, 1993). Finally, the Senior Citizen’s Law of 1989 (Chok Ha’ezrachim Havatikim) introduces discounts and special benefits for senior citizens on public transportation, municipal taxes, national parks, nature reserves, and cultural institutions supported by the government. The benefits are provided upon presentation of an official senior citizen’s card, issued to every resident of Israel at the designated age. Although the legislation provides senior citizens with discounts and benefits, according to Doron (2008) its impact on the political power of senior citizens has been minimal.

Conclusion: differences in policies toward aging veterans with disabilities This chapter provides insights about differences in policies toward aging veterans with disabilities in the United Kingdom, the United States, and Israel. The United Kingdom’s approach reflects the spirit expressed in “The New Strategy,” published by the MoD in 2018, on integration in civic society. Therefore, there is a reliance on the regular services provided to the general population. Veterans with disabilities, including the aged, are supposed to receive priority in the NHS, in cases where the preference is justified. There are necessary dedicated health care services for amputees, or the PTSD special subpopulation, as well as the provision of specific supplements, but these are considered the exception. However, a recent study demonstrated that the NHS was inconsistent in serving veterans with disabilities, in particular those with mental health needs. In addition, the

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Government policies towards aging veterans

Armed Forces Covenant, which called for providing priority treatment to veterans with service-related disability, fails to be practiced by health care professionals (McGill et al., 2019). Throughout the years, the UK government has expanded its support for military charities. There are hundreds of charities providing unique services to veterans with disabilities. Recently, the government established “The Aged Fund” which generated money from LIBOR fines. The fund provided about £30m to support non-care health wellbeing and social care needs for old veterans born before 1950. It demonstrates the role of charity money to improve social care services and address veterans’ loneliness at old age. The United States developed a “target compensation” policy as a response to the Civil War and World War 2. The VA was established in 1930 and became a cabinet-level department in 1989. It provides comprehensive health-care services to eligible military veterans at VA medical centers and outpatient clinics located throughout the country. VA benefits include disability compensation, vocational rehabilitation, education assistance, home loans, and life insurance. Aging veterans with disabilities are entitled not only to veteran’s benefits and services but also to social security and medical services. Veterans with severe disabilities, among them a growing number of aging recipients, are entitled to A&A and Housebound allowances primarily, reflecting preference for community care over nursing homes. The United States became a frontrunner in the development of innovative geriatric programs for aging veterans with disabilities. The development of GRECCs, supported by two Congressional acts (P.L. 96–30 of 1980 and P.L. 99–66 OF 1985), furthered the advancement of aging research and training, particularly research and clinical care beyond the VA (Solomon, 1994). Many of the protocols for promotion of “successful aging” have been initiated in these centers. The problems found in veteran care are usually in its implementation, particularly among rural aging veterans with disabilities who lack availability and accessibility to long-term care and specialized services (Gale, John, & Heady, 2013). Additional vulnerable veterans are those with delayed PTSD and depression who lack proactive mental health services in the community (Smith et al., 2016). Israel’s policy is the most recent among the three countries but is considered to be the most generous to veterans with disabilities. However, with the exception of veterans with 100% plus medical disability, the medical services are provided only for recognized medical disabilities. In recent years, the MoD has responded to the aging needs of those veterans with disabilities based on severity of disability. Veterans receive additional compensation at retirement age. The MoD recognized, in practice, accelerated aging for veterans aged 40 and above with 50% medical disability related to medical treatment (ambulatory, prescriptions, medical and rehabilitation devices, nursing, and reimbursement for transportation for treatment) for cardiovascular and neurological secondary conditions. Another indication of flexibility is Instruction 60.06 which covers monthly rent for veterans with disabilities aged 65 and above who do not have housing.

Government policies towards aging veterans 97 One of the problems expressed by veterans with disability, and in particular older ones, is that MoD medical services are provided only for the recognized disability. Veterans have to manage the MoD and their national health insurance in handling their health problems. In many cases, they cannot cope with the divided health systems and may be underserved. This can be evident in cases of delayed depression and PTSD or when the older veteran lives by him or herself with a lack of social support.

References Bailey, F. A., Burgio, K. L., Woodby, L. L., Williams, B. R., Redden, D. T., Kovac, S. H., . . . Goode, P. S. (2005). Improving processes of hospital care during the last hours of life. Archives of Internal Medicine, 165(15), 1722–27. Ben-Shalom, Y., Tennant, J. R., & Stapleton, D. C. (2016). Trends in disability and program participation among US veterans. Disability and Health Journal, 9(3), 449–56. Buzza, C., Ono, S. S., Turvey, C., Wittrock, S., Noble, M., Reddy, G., . . . Reisinger, H. S. (2011). Distance is relative: Unpacking a principal barrier in rural healthcare. Journal of General Internal Medicine, 26(2), 648–54. Clark, G., Rouse, S., Spangler, H., & Moye, J. (2017). Providing mental health care for the complex older veteran: Implications for social work practice. Health & Social Work, 43(1), 7–14. Cole, S., Robson, A., & Doherty, R. (2017). Focus on: Armed forces charities’ mental health provision 2017. Directory of Social Change, London. Colello, K. J., & Panangala, S. V. (2017). Long-term care services for veterans (pp. 24–28, No. CRS-R44697). Congressional Research Service, Washington, US. Compensation to POW veterans. (2005). (In Hebrew) www.nevo.co.il/law_html/Law01/ 999_473.htm Cowen, D. (2008). The soldier-citizen. In E. Isin (Ed.), Recasting the social in citizenship (pp. 189–209). University of Toronto Press. Doherty, R., Robson, A., & Cole, S. (2018). Armed forces charities’ physical health provision. Directory of Social Change, London. Doron, I. (2008). Law and older people: The rise and fall of Israel’s senior citizen’s act. Journal of Aging & Social Policy, 20(3), 353–75. Federal Advisory Committee on the Future of VA Long-Term Care. (1998, June). VA longterm care at the crossroads (Vol. 2). Washington, DC. Fletcher, K. L., Albright, D. L., Rorie, K. A., & Lewis, A. M. (2016). Older veterans. In J. Beder (Ed.), Caring for the military: A guide for helping professionals (pp. 54–71). Routledge. Gale, M. S., John, A., & Heady, H. R. (2013). Rural vets: Their barriers, problems, needs. Health Progress, 94(3), 48–51. Gardner, J., & Hendricks, A. (2004). VA long-term care patients’ medicare and medicaid expenditures. Washington, DC: Department of Veterans Affairs, 20(4), 2004–5. Gasper, J., et al. (2015, December 11). 2015 Survey of Veteran enrollee’s health and use of health care: Main results report. Golan, T. (2010). The Kishon affair: Science, law, and the politics of causation. Science in Context, 23(4), 535–69. Government Accounting Office. (September 2009). Social security: Additional outreach and collaboration on sharing medical records would improve wounded warrior’s access to benefits. GAO-09-62, Washington, DC.

98 Government policies towards aging veterans Henning, C. A. (2010, July). Military retirement: Background and recent developments. Library of Congress, Congressional Research Service, Washington, DC. Horesh, D., Solomon, Z., Zerach, G., & Ein-Dor, T. (2011). Delayed-onset PTSD among war veterans: The role of life events throughout the life cycle. Social Psychiatry and Psychiatric Epidemiology, 46(9), 863–70. Hula, W. D., Doyle, P. J., & Rossi, M. I. (2009). New approaches to understanding and treating aphasia. Federal Practitioner, 26, 35–38, 40. Hung, W., Moodhe, N., Dunn, C., & Boockvar, K. (2011). Improving veteran health care with regional health information organizations. Federal Practitioner, 28(3), 33. Kind, A. J., Bartels, C., Mell, M. W., Mullahy, J., & Smith, M. (2010). For-profit hospital status and rehospitalizations to different hospitals: An analysis of medicare data. Annals of Internal Medicine, 153(11), 718–27. Kregel, J., & Miller, L. (2016). Disability benefits for veterans: Interactions among Department of Defense, Department of Veterans Affairs, and Social Security Administration programs (No. 1dcd842da92e40578ff982843a65788c). Mathematica Policy Research Center, Virginia Commonwealth University, Richmond, VA. MacLean, M. B., Murray, R., & Lazier, R. (2019). Disability and compensation principles in military-to-civilian transition support. In C. A. Castro & S. Dursun (Eds.), Military veteran reintegration (pp. 157–83). Academic Press. McCarthy, J. F., Blow, F. C., Valenstein, M., Fischer, E. P., Owen, R. R., Barry, K. L., . . . Ignacio, R. V. (2007). Veterans Affairs health system and mental health treatment retention among patients with serious mental illness: Evaluating accessibility and availability barriers. Health Services Research, 42, 1042–60. McGill, G., Wilson, G., Hill, M., & Kiernan, M. D. (2019). Utilisation of the principles of the armed forces covenant in NHS trusts and clinical commissioning groups across England: A freedom of information investigation. BMJ Open, 9(1), bmjopen-018. Mikulincer, M., Ein-Dor, T., Solomon, Z., & Shaver, P. R. (2011). Trajectories of attachment insecurities over a 17-year period: A latent growth curve analysis of the impact of war captivity and posttraumatic stress disorder. Journal of Social and Clinical Psychology, 30(9), 960–84. Miller, E. A., & Intrator, O. (2012). Veterans use of non-VHA services: Implications for policy and planning. Social Work in Public Health, 27(4), 379–91. Ministry of Defense. (2018, November 14). The strategy for our veterans. CM 9726. Ministry of Defense. (2018, November 21). Armed forces covenant report 2018 (p. 23). Morginstin, B., Baich-Moray, S., & Zipkin, A. (1993). Long-term care insurance in Israel: Three years later. Ageing International, 20 (2), 27–31. The National Health Insurance Law 5754–1994. Olmstead v. L.C. ex rel. Zimring, 527 U.S. 581, 597 (1999). Ouimette, P., Vogt, D., Wade, M., Tirone, V., Greenbaum, M. A., Kimerling, R., . . . Rosen, C. S. (2011). Perceived barriers to care among veterans’ health administration patients with posttraumatic stress disorder. Psychological Services, 8(3), 212–23. Perell, K. L., Manzano, M. L. P., Weaver, R., Fiuzat, M., Voss-McCarthy, M., OpavaRutter, D., & Castle, S. C. (2006). Outcomes of a consult fall prevention screening clinic. American Journal of Physical Medicine & Rehabilitation, 85(11), 882–8. Pozo, A., & Walker, C. (2014). Sector insight: UK armed forces charities: An overview and analysis. Directory of Social Change, London. Public Law 106-117 Veterans Millennium Health Care and Benefits Act of 1999. Saliba, D., Elliott, M., Rubenstein, L. Z., Solomon, D. H., Young, R. T., Kamberg, C. J., . . . Wenger, N. S. (2001). The vulnerable elders survey: A tool for identifying vulnerable

Government policies towards aging veterans 99 older people in the community. Journal of the American Geriatrics Society, 49(12), 1691–9. Scott, C., & Davis, C. D. (2009). Veteran’s benefits: Pension benefit programs. Library of Congress. Congressional Research Service, Washington, DC. Seliger, S. (2012, September 19). A little-known benefit for aging veterans. The New York Times. https://newoldage.blogs.nytimes.com/2012/09/19/few-know-of-benefit-tohelp-aging-veterans/ The Shamgar Commission (2002, February 24). www.sviva.gov.il/InfoServices/Reservoir Info/DecisionStockpileGovernment/Pages/2002/Decision-509.aspx (in Hebrew) Shay, K., & Schectman, G. (2010). Primary care for older veterans. Generations, 34(2), 35–42. Smith, N. B., Cook, J. M., Pietrzak, R., Hoff, R., & Harpaz-Rotem, I. (2016). Mental health treatment for older veterans newly diagnosed with PTSD: A national investigation. The American Journal of Geriatric Psychiatry, 24(3), 201–12. Smith, S. R. (2010). Hybridization and nonprofit organizations: The governance challenge. Policy & Society, 29, 219–29. Solomon, D. H. (1994). The role of GRECCs in the US geriatrics revolution. Journal of the American Geriatrics Society, 42(9), 1020–1. Supiano, M. A., Alessi, C., Chernoff, R., Goldberg, A., Morley, J. E., Schmader, K. E., . . . Writing on behalf of the GRECC Directors Association. (2012). Department of Veterans Affairs Geriatric Research, Education and Clinical Centers: Translating aging research into clinical geriatrics. Journal of the American Geriatrics Society, 60(7), 1347–56. Tal-Katz, P., Araten-Bergman, T., & Rimmerman, A. (2011). Israeli policy toward veterans with disabilities: A snapshot and insights of the proposed reform. Journal of Social Work in Disability & Rehabilitation, 10(4), 232–46. Taylor, C. (2011). Armed forces covenant. Standard note SN/IA/5979. Government Publication, London. Teich, J., Ali, M. M., Lynch, S., & Mutter, R. (2017). Utilization of Mental Health Services by veterans living in rural areas. Journal of Rural Health, 33(3), 297–304. U.S. Congress, House. (1964). Annual report of the administrator of veterans affairs, FY1964, 89th Congress., 1st session., H.Doc.89, 28. Washington, DC. Vardi, R., Greenberg, Z., & Erlich, H. (2002, February). Division of rehabilitationexamination report. Ministry of Defense, Tel Aviv. Weeks, W. B., Kazis, L. E., Shen, Y., Cong, Z., Ren, X. S., Miller, D., . . . Perlin, J. B. (2004). Differences in health-related quality of life in rural and urban veterans. American Journal of Public Health, 94(10), 1762–67. West, A. N., & Weeks, W. B. (2009). Health care expenditures for urban and rural veterans in veterans health administration care. Health Services Research, 44, 1718–34. Wilkins, S. S., Guzman-Clark, J., Osato, S., et al. (2011). Comparing depression screening tests in older veterans. Federal Practitioner, 28, 11–6. Wilmoth, J. M., London, A. S., & Heflin, C. M. (2015). Economic well-being among olderadult households: Variation by veteran and disability status. Journal of Gerontological Social Work, 58(4), 399–419.

5

Proposed policy to address unmet needs of older veterans with disabilities in Israel

Introduction Most of the early policies toward veterans with disabilities in the United States and the United Kingdom were aimed at younger veterans who were wounded in World War 2 and in warfare operations during the second half of the 20th century. Based on the GI Bill of 1944, the federal government offered veterans free tuition for higher education and training, stipends, and other services (Bennett, 2017; Mettler, 2002). The bill provided weekly unemployment benefits for up to one year for veterans looking for work, job counseling, loans to purchase a home, business, or farm, and health care. Compared to the civic population, veterans with disabilities were prioritized in hiring, primarily by offering them employment quotas in government and public jobs (Angrist & Krueger, 1994; Malisoff, 1952). The initial need to examine the geriatric needs of war veterans with disabilities in the United States was expressed already in the early 1970s by Stanford and Dolson (1972). Both had seen the growing numbers of World War 2 veterans with disabilities struggling to cope with their secondary health conditions as they aged. The same impression is shared by Fletcher et al. (2016) in an effort to understand physical and mental health concerns and cognitive and psychosocial functioning in providing care for older veterans over time. One of the core questions is whether aging veterans with war-related disabilities require special and separate health care and psychosocial services or whether they can be integrated, wholly or partially, within the general health and social welfare services. The research evidence is far from being explored or justified. Spiro and Settersten (2012) argue that older veterans may demonstrate special needs because their physical and mental disabilities are quite different from the civic population. Settersten (2006) suggests that there are many unseen health conditions that arise during their lifetime that are often overlooked by health providers. The fact that there are separate health systems for veterans in the United States and Israel is historical. In the United States, medical care for injured soldiers was established after the Civil War to respond to their immediate needs which was not available to the civic population. The separate health system was expanded during World Wars 1 and 2 and thereafter. The separate Israeli system was established after the War of Independence (1948) to respond to the increasing

Proposed policy to address unmet needs 101 number of veterans with disabilities. However, there are differences between the two systems. The US VA health system is optional, and eligible veterans can choose whether to receive medical care through the VA or elsewhere. In Israel, veterans are split in receiving their health care needs between MoD medical care and the provider of their national health insurance. The MoD is responsible only for responding to their medical care needs in their recognized disability. There have been initiatives in Israel to transfer the MoD medical care services to one of the providers of national health insurance. However, veterans resist any change in their health benefits (Gal & Bar, 2000). Similar efforts have been made in preventing the duplication among VA health services and Medicare, Medicaid, and other health providers, but veterans blocked these initiatives (Stevens, 1991). The United Kingdom is a good illustration of a country that provides medical care to veterans within its NHS. Veterans are supposed to receive priority in the NHS for their military-related medical problems, and additional support from numerous military charities. But it is not clear whether that priority in the NHS exists in practice, and the rest is supplemented by charities. The United States has a separate VA system that is responsible for older veterans with rehabilitation and geriatric needs. However, many older veterans report difficulties with respect to eligibility and accessing these services, or they use Medicare, a federal health insurance program for people who are 65 and older, or other health insurance, alternatively. It appears that the veterans living in rural and remote areas from VA health centers experience the most difficulty. Israel’s policy toward veterans with disabilities is different from the United Kingdom and the United States. Veterans with disabilities are entitled to MoD health services only in their recognized disability (the exceptions are veterans with 100% plus medical disability who receive comprehensive services). Veterans with disabilities need to navigate their health needs between the MoD and their national insurance health provider. This situation is particularly difficult for aging veterans with secondary conditions that are not considered associated with their recognized disability or those requiring geriatric services. The chapter examines the current problems reported by aging IDF veterans with disabilities and introduces the current benefits and services. In the second part, it reviews and discusses the recent efforts of the MoD to address their unmet needs by establishing a Committee of Experts headed by the author of the book that has submitted its recommendations (Committee of Expert’s Recommendations to MoD, 2019).

Problems reported by aging veterans with disabilities The Division of Rehabilitation in the MoD is mandated to provide health services to veterans with disabilities in their recognized disability (the only exception is those with 100% plus disablement who can receive all their health needs from the MoD). Veterans are entitled to receive non-medical rehabilitation services that include vocational rehabilitation, higher education, and career development programs as well as psychosocial services. More than half of recognized veterans with disabilities are aged 60 and above, and the projection is that their number is

102 Proposed policy to address unmet needs going to be significantly higher. About 52.5% of veterans with disabilities who applied for a change in their disablement rate were veterans above the age of 60. In 2018, the director of Rehabilitation Division of the MoD called on a Committee of Experts headed by Prof. Arie Rimmerman (the author) to examine the current unmet needs of older veterans with disabilities, with the expectation that the committee would recommend future policy direction. One of the starting points was to define the target population in terms of age and severity of disability. One of the core questions was whether to focus on pre-aging veterans or whether to concentrate only on those who reached retirement age. The committee reached a compromise to target veterans from the age of 60 and above who have at least 50% disablement, about 4,597 veterans in all. The reason for restricting the target population was probably budgetary, as the number of all veterans with recognized disabilities was 27,127, and those with less disablement (less than 50%) was 22,956 (see Table 3.4 in Chapter 3). The majority of the target population was in the 60–69 age bracket (2,779), followed by 1,249 in the 70–79 age bracket. The number of veterans aged 80 years and above was 150. Similarly, most of the target population (3,404) fall into the 50–74% medical disablement range, followed by 831 in the 75–100% bracket, while only 272 are considered 100% plus. The reported health and psychosocial problems were based on Shnoor et al.’s survey (2017), which demonstrated increased secondary conditions (such as cardiovascular, diabetes, and cancer) as compared to a parallel age group in the general population. In the sample reported, 26% suffered from six or more secondary conditions compared to 4% in a comparable age group in the general public. The most vulnerable aging veterans with disabilities were those with PTSD and psychiatric disabilities, primarily depression. They were reported in the study as having a higher rate of diabetes than those with physical disabilities, a higher rate of smoking, and limited social networks. Last but not least are veterans with severe physical disabilities who reported higher rates of cardiovascular disease, heart disease, cancer, and lack of opportunities for social participation. Finally, although veterans with disabilities experienced more loneliness than the general public, those aged 75 and above experienced the highest rate. In terms of unmet needs, a substantial number reported that they lived alone, without a spouse or contacts with friends and required homemaking services. Furthermore, about a quarter of veterans aged 75 and above complained that they did not have anybody who would help them in case of a health crisis or emergency.

Mapping regulatory infrastructure for aging veterans with disabilities MoD infrastructure and services Invalids (Pensions and Rehabilitation) Law, consolidated version 1959, provides rights and benefits to IDF veterans with disabilities. It grants medical treatment

Proposed policy to address unmet needs 103 and rehabilitation for the recognized disability as well as non-medical benefits such as vocational rehabilitation and career development services, housing, and other benefits to enhance their integration into the workforce and civic society (Araten-Bergman, Tal-Katz, & Stein, 2015). Since this legislation, the MoD has granted, by “Internal Instructions,” additional benefits and has updated those that already existed. Most of those additions were granted after negotiations between the Rehabilitation Division of the MoD and the representative IDF disability association. The exception are veterans with 100% plus disablement who are entitled to receive all their medical needs from the MoD. They have additional benefits with respect to their housing, mobility, and personal economic welfare. The MoD provides ongoing solutions for problems expressed by veterans who are beyond the “letter of the law.” It should be noted that the State Comptroller criticized the MoD for the need to update the 1959 legislation and turned the aforementioned internal instructions into amendments. In February 2017, the Knesset began discussing the updated legislation, and the process was supposed to be finalized in 2019. The proposed updated legislation is not the only change in the status of veterans with disabilities. In January 8, 2012, the government decided to adopt the Goren Committee’s recommendations with some modifications (Decision number 4088) and implemented it on April 27, 2017. It changed eligibility benefits to those injured in non-military-related activities, and they were supposed to be served by the NII like those injured in a work-related situation. There is no doubt that the government’s adoption of Goren’s recommendations will reduce the number of aging veterans with disabilities in the future. Ex-servicemen and women who used to apply for disability benefits toward the end of their service will be no longer be counted as veterans with disabilities. The Committee of Experts has decided not to be refer to issues related to the updated legislation or to the implementation of Goren’s recommendations. Therefore, it has focused on interfaces between the MoD’s provisions and those entitled by the NII, health providers, and other governmental services for aging veterans with disabilities. The committee also reviews internal MoD expenditure on younger versus older veterans with disabilities by examining the 2016 budget. Although veterans aged 60 and above comprise 53% of the population in terms of expenditure, their share is only 48% of the total budget; younger veterans aged 20–29 cost twice as much as older veterans aged 80 and above. The cost is quite high in the younger age groups (20–29 and 30–39) and drops dramatically at the ages of 40–49 and further with older age groups. Regarding medical expenditures, the cost is almost three times more in the younger age groups, and about two-thirds more with respect to benefits and other services. These figures reflect the mission and commitment of the Division of Rehabilitation in the MoD to provide health, vocational rehabilitation, and career development services to those young veterans with disabilities who have been released from service, in order to integrate them into the workplace and society. It seems that older veterans with disabilities, except those with 100% plus disablement, receive only part of their health and geriatric services from the MoD.

104 Proposed policy to address unmet needs Analysis of the MoD’s benefits to mid-life and aging veterans, introduced in Chapter 4, reveals that they reflect generous additions to this target population. The fact that there is a fairly old amendment (7(a)) from 1968 which provides senior veterans with disabilities with a 10% addition to their pension reflects the favorable approach. There are actually two internal instructions that are extremely progressive. Instruction 50.04 from 2010 and revised in 2012 recognized beyond the letter of the law that veterans with certain moderate to severe (from 50% disablement) physical disabilities may develop secondary health conditions at the age of 40. They are entitled to medical treatment (ambulatory, prescriptions, medical and rehabilitation devices, nursing, and reimbursement for transportation for treatment), although the MoD’s health services are limited to the recognized disability. This benefit reflects the MoD’s sensitivity and responsiveness toward the accelerated aging of veterans with certain physical disabilities. Most Western countries, including the United Kingdom and the United States, have been hesitant in approving it. In fact, there is a debate whether accelerated aging is related to health behavior or certain types of disabilities (Lafortune et al., 2016; Ohry et al., 2015). Another recognition of veteran’s pre-term aging is seen in Instruction 85.04, which provides pre-retired veterans with disabilities (aged 55–59 and above 59) with additional compensation and accompaniment grant related to their medical disability (aged 40–50 and above 50). Other age-related benefits that are provided to veterans with disabilities prior to and at retirement age include: distress button, scooter for mobility, additional spa services, and reimbursement for housing rental in the case where the veteran does not own a home. Most of these were approved in the 21st century and reflect flexible eligibility with regard to age, added value benefits, or compensation for older age.

Core health services and benefits for senior citizens The Committee of Experts also reviews core rights and benefits to which veterans with disabilities are entitled as senior citizens. In general, there has been a substantial improvement in the 21st century in health care and social services for the aging population. The emphasis has been placed on strengthening community services, making modern medical technology and interventions increasingly available to older people, and developing multidisciplinary community-based geriatric units (Dwalatzky et al., 2017). A pivotal legislation is the NII’s Old Age Pension, which is meant to ensure a regular monthly income for residents of Israel in their old age, thus providing them with a minimal quality of life during this period (Doron, 2016). Israel was one of the first countries to increase the age of eligibility for retirement benefits from 65 to 67 years for men and 62 for women (Israeli Retirement Age Law 5764–004 number 1919). The applicant may receive the pension depending on his or her age and provided he or she was insured by the NII for the length of time required by law. When a person continues to work after retirement age, or

Proposed policy to address unmet needs 105 when his or her income without the pension is higher than a specified amount, the pension is postponed until the person reaches the age which entitles him or her to pension regardless of income. Those who receive only an old-age pension or have a low income will, in certain circumstances, be eligible for an additional “income supplement.” The basic old-age pension rate is NIS 1,554 (as of January 1, 2019) for an individual and NIS 2,335 (as of January 1, 2019) for a couple (the pension rate for a couple is composed of a pension for an individual plus an increment for the spouse). The basic old-age pension rate for those aged 80 or older is NIS 1,641 (as of January 1, 2019) for an individual and NIS 2,422 (as of January 1, 2019) for a couple. If each spouse separately meets the conditions of entitlement to an old-age pension, each of them will receive an individual pension. In terms of health, all citizens and legal residents are insured under the National Health Insurance Act of 1994. This legislation regulates the health services provided to residents of the State of Israel through the health providers, so as to ensure appropriate services for insured persons of all ages (Clarfield et al., 2017). Every citizen of Israel is insured in the health fund of his or her choice, and is therefore entitled to the medical services offered by this health provider. Senior citizens who suffer from health problems may benefit from a range of health services and other community services, which will enable them, in most cases, to continue to remain in their homes in the community. Among the services covered by national health insurance for the aging population are the following: medical services at home including physician visits, nurse visit, physiotherapy, etc., consultation with a geriatrician, medical functional rehabilitation, consultation, diagnosis, and treatment of cognitive decline. In addition, for persons over 75 years of age who are at high risk for medical and functional deterioration there is a comprehensive geriatric evaluation to prevent recurrent falls, recent functional decline of no clear reason, treatment with eight or more medications, recurrent hospitalizations, morbidity that requires many referrals to specialists, and the like. Senior patients are entitled to discounts and exemptions with respect to copayment at their health provider and the purchase of medicines. There are additional services provided directly by the Ministry of Health. It participates in the funding of rehabilitation and mobility devices under the provision of the Third Addendum to the National Health Insurance Law and in accordance with the ministry’s procedures, in the framework of a defined budget. This service is not specifically for the elderly but is provided for all ages. The Ministry of Housing, in cooperation with the Ministry of Health, assists in the adaptation of the interior of the home and of access to the home for persons who are permanently mobility disabled and utilize assistive devices. The assistance is provided in accordance with criteria stated in Procedures of the Ministries. A unique and progressive legislation is the Long-term Care Insurance Law of 1988 (Schmid, 2005). The law is designed to provide home-care assistance to elderly persons who have reached retirement age and need help in daily activities (washing, mobility, control over bodily functions, etc.), or whose condition necessitates constant personal care and supervision (such as individuals

106 Proposed policy to address unmet needs with Alzheimer’s disease). In most cases, the long-term care benefit is given as home-care hours of a caregiver employed through a nursing care provider (private or not-for-profit). A current trial program conducted by the NII in several locations in Israel offers the benefit in the form of direct payment to the insured person as the Monetary Long-Term Care Benefit. The number of home-care hours a person may receive depends on an income test. Eligibility for home-care hours above a certain level may be converted, when needed, into financial participation toward the employment of a permanent caregiver (usually a foreign worker) in the home of the elderly person. There are also 175 day-care centers around the country licensed by the Ministry of Labor and Social Affairs that offer social and recreational activities, personal care, hot meals and transportation up to six days a week. These benefits have been expanded under the Longterm Care Insurance Law of 1988 which offers an entitlement to these day-care centers. Community-based and hospital-based medical care for the aging population is an important part of Israel’s universal comprehensive health care. Most of the funding is public and is based primarily upon per capita government reimbursement, which accounts for 72% of the public health budget. An additional 28% of funding is provided directly by the Ministry of Health for services, which include long-term nursing care (Dwolatzky et al., 2017). Long-term institutional care is a relatively small system in comparison to other developed countries. Only 3.5% of the elderly population resides in any type of long-term care facility compared with the OECD average of 4.1%. There are about five categories of long-term beds on the basis of the physical and cognitive function of the residents: semiindependent, frail, cognitively frail, nursing care, and skilled nursing care. Inpatient geriatric care is provided in specialized geriatric departments, located in either general or large public geriatric hospitals. There is a shortage of geriatric rehabilitation services and subacute geriatric care, and the system is quite fragmented with structural disparities in service provision between the central region and the periphery (Zucker et al., 2013). Finally, the Senior Citizen’s Law provides senior citizens with special benefits such as discounts on public transportation, municipal taxes, national parks, nature reserves, and cultural institutions supported by the government. The benefits are provided upon presentation of an official senior citizen card, issued to every resident of Israel at the designated age. Although expectations of the legislation have been high, it is symbolic in promoting older people’s rights and, particularly, in changing society’s personal and social status (Doron, 2008). The Committee of Experts assumes that the MoD’s benefits and services to veterans with disabilities are considered to be generous. Provisions to aging veterans reflect growth in response to the sporadic needs of aging veterans similar to Western countries such as Australia, the United Kingdom, and the United States. The committee has undertaken a brief benchmarking review of recent provisions allocated to veterans with disabilities in selected countries. In Australia and the United Kingdom, aging veterans with disabilities receive priority in national health services. In the United States, veterans can choose whether to use Medicare

Proposed policy to address unmet needs 107 or VA health services. Israel has a unique system as veterans with disabilities can get MoD medical services only for their recognized disability. In terms of geriatric services, each country is at a different stage. However, it seems that most of these services are community-based services, such as for those who are housebound. In any case, it seems that age-related benefits and community services are broader in Israel than in other countries. Members of the Committee of Experts were impressed by the unique provision that exists in the United States and is missing in Israel, that of legal assistance in supported decisions and wills. The key to enhanced services for aging veterans with disabilities is in optimal utilization of the MoD and civic services and, in particular, in assuring optimal coordination between the two systems. The committee recognizes the lack of integration between health and welfare services, in particular to aging veterans who need to navigate between their MoD health and psychosocial rights related to their recognized disabilities and others provided to senior citizens. The impression of the committee’s members is that in many cases veterans with disabilities get lost between the two systems and fail to identify health or psychosocial problems in time and, unfortunately, deteriorate to a serious condition.

Committee of Experts’ approach toward aging veterans’ assumptions Prior to discussion of possible policy directions, the Committee of Experts determined the following assumptions: 1

2

3

4 5

The Division of Rehabilitation in the MoD is responsible for providing veterans’ rehabilitation needs (health and psychosocial) as related to the recognized and approved military disability (which has to be at least 20% disablement). It is mandated to offer age-related services and benefits, including provisions to aging veterans. Veterans with certain disabilities may express “accelerated aging” that needs to be responded to. In many veterans with disabilities, there is a “gray area” between their recognized and approved military medical disability and health problems related to their aging process. This may cause a synergy that hampers their activities of daily living and their quality of life. This gap requires special consideration beyond the traditional approach of responding to the recognized and approved disability. The core caregiver, primarily the family, has an important role in providing support to aging veterans with disability. The impression is that the Division of Rehabilitation in the MoD views family caregivers as a crucial support for aging veterans and therefore have to be assisted. Aging veterans with disabilities are entitled to receive all services provided to senior citizens such as social insurance, national health insurance, and others. The key to optimal utilization of public aging services is to ensure that aging veterans with disabilities receive them on top of the MoD’s entitlements. The

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7

MoD is responsible for offering aging veterans case management services in how to navigate and utilize these additional entitlements. It is important that MoD staff serving aging veterans with disabilities receive gerontological and geriatric knowledge and training in how to offer better services to this population, including better understanding of how to navigate the system. There is ongoing development in technologies and screening and monitoring instruments for knowing how to prevent deterioration in functioning of the aging population. They must be utilized in both the public system and in the MoD’s system on behalf of aging veterans with disabilities.

Evaluation of the MoD’s provisions for aging veterans Table 5.1 presents the MoD’s strengths and challenges in providing services to aging veterans with disabilities. It is clear that MoD services are professional and comprehensive but are limited to the veteran’s recognized disability. In addition, they focus on the early years with regard to their functioning and career development needs and provisions. The challenges include increasing knowledge on aging, recognizing the interface between the veteran’s recognized disability and illnesses and disabilities related to the aging process, and adopting a proactive rather than a reactive approach to health and social conditions. In addition, there is a lack of infrastructure for monitoring aging veterans’ health and psychosocial conditions and for promoting better use of services available in the community. Table 5.1 The Status of the MoD’s Current Services Strengths

Challenges

Full health and benefits are restricted to veteran’s recognized disability (20 to 100% disablement).

Provisions are limited to recognized and approved disablement.

Veterans with 100% plus disablement receive non-restrictive coverage.

There is a gray area that falls between the MoD’s recognized disablement and secondary health conditions.

Veterans receive comprehensive vocational rehabilitation and career development provisions.

There is a lack of reference to unrecognized impairments and/or age-related illnesses.

Professional rehabilitation staff are available in all regions.

The general approach is reactive to veteran’s expressed needs and not proactive in preventing possible health risk and decline.

Many of the temporary internal instructions regarding benefits for aging veterans are supposed to be approved as amendments.

The MoD’s approach is limited to its own services, with minimal involvement in assisting veterans to navigate their rights as senior citizens.

Proposed policy to address unmet needs 109 In sum, it is clear that with respect to health and functioning there is a need to monitor aging veteran’s health conditions and particularly the gray area between the recognized disability and other secondary conditions related to other impairments or illnesses, including decline in functioning associated with aging. In the psychosocial dimension, efforts have to be directed toward veterans’ loneliness and lack of adequate social support in aging, and in assisting them to exercise their benefits and rights as senior citizens and in coordinating between the MoD and other available services. Based on evaluation of the MoD’s current approach toward aging veterans with disabilities, the Committee of Experts established the following core principles for its recommendations: Health promotion and proactive approach that is based on integrative monitoring of veterans’ health condition and psychosocial functioning. This perspective includes follow up and coordination of intervention according to monitoring outcomes and complexities. This approach implies the fulfillment and integration of all available units within the Division of Rehabilitation of the MoD (between central and regional administration) and with external community services for senior citizens. On top of the health promotion perspective, there is a need for a case management approach, including the provision of legal services, such as supported decision, guardianship, and wills frequently used by older veterans. There are two platforms for implementing these principles: (a) The Division of Rehabilitation in the MoD will provide all provisions. (b) The Division of Rehabilitation of the MoD will purchase all or part of the services from health and social welfare providers. It is evident that any alternative will need the inclusion of an aging unit in central and regional administrations.

The need for establishing quality of indicators for community care The need to improve care for the aging population leads specialists to search for instruments that can measure quality indicators. The latter are measurable elements of practice performance for which there is evidence or consensus that they can be used for assessing and changing the provided quality of care (Jones, 2005). Quality indicators can be related to process, outcome, and structure of care (Joling et al., 2018). There is a debate in the literature about the most useful types of indicators to assess quality of care. It appears that process indicators are the most sensitive in examining changes in health conditions and functioning. They can be translated to protocols to track risk factors and recommend intervention and service provision (Kajonius & Kazemi, 2016). The most common quality indicators for older population living at home are clinical and include falls and mobility disorders, pain, weight loss, dehydration,

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medications, injuries, infections, and hearing and vision loss. Given the wide variety of clinical aspects covered in this domain, these quality indicators are classified into subcategories according to need for follow up and risk assessment. However, there are other indicators that are included, such as cognition (cognitive loss and dementia) and mental health (depression and mood changes), psychosocial (social activities, loneliness), functional performance (instrumental activities of daily living and service utilization (number and length of hospitalization and use of emergency services). Although members of the Committee of Experts did not need to examine the preferred instrument for monitoring quality of care, they were impressed by interRAI’s second-generation home care quality indicators (HC-QIs). They are derived from two of interRAI’s widely used community assessments: the Community Health Assessment and the Home Care Assessment (Morris et al., 2013). The instrument consists of four groups of indicators: Functional Indicators – including monitoring improvement and decline of instrumental activities of daily living, activities of daily living, cognition and communication. Clinical Indicators – which include monitoring improvement and decline in bladder continence, follow up of falls, weight loss injuries, improvement and decline of mood, and improvement and follow up of pain. Social Indicators – follow up of caregiver’s distress, person being alone and distressed, and whether the person used to go out and socialize, but no longer does so. Utilization – including follow up of flu vaccinations and hospitalization and emergency care.

Committee of Experts’ recommendations on target subpopulation Aging IDF veterans with disabilities are entitled to receive rights and benefits from the MoD for their recognized and approved disability (the exceptions are those with 100% plus disablement who receive all services with no restriction). In addition, these veterans are also entitled to receive all benefits and services provided to senior citizens. The Committee of Experts debated whether to include all aging veterans with disabilities from the age of 60. However, this possibility has been ruled out because of the excessive cost of including 27,263 veterans in this recommendation, including those with milder disablements. An alternative approach was to include all 4,507 aging veterans from the age of 60 and with 50% disablement. The number is slightly lower (4,235) because all those with 100% plus disablement are deducted since they are already entitled to comprehensive services without any restrictions.

The proposed package of service Based on assessment of the current situation, the Committee of Experts’ core recommendation has been to propose a proactive health promotion package that

Proposed policy to address unmet needs 111 integrates monitoring and interventions to prevent declines in veterans’ functioning and wellbeing. The package is based on Wilber et al.’s (2002) public health and disability conceptualization which was examined in the Massachusetts Survey of Secondary Conditions. According to Wilber et al., as well as Lollar (1999) and Krause and Bell (1999), early professional work focuses on preservation of functioning among persons with disabilities instead of health promotion to prevent the development of secondary health conditions and functional decline. Therefore, a proactive integrative health promotion package needs to be developed, which includes ongoing monitoring of medical conditions and functioning, engagement in accessing health promotion or disease prevention activities, consistent and continuous primary care and social support, and reduction of risky behaviors. An additional recommendation is to provide aging veterans with disabilities with a psychosocial and legal assistance package. The package provides case management services to maximize their rights and benefits in the community and to integrate MoD services with other services to which they are entitled as senior citizens. The legal assistance package is based on a recent amendment to the legal capacity and guardianship law approved by the Israeli Knesset on March 29, 2016. It is intended to provide aging veterans with legal and notarized services from the MoD free of charge to assist them in making informed decisions about themselves, in granting powers of attorney, and in making wills regarding property and medical care. As proposed, the target population includes all 4,507 aging veterans from the age of 60 with 50% disablement and above. It defines needs according to age group and according to degree of disablement and types of disability to allow more refined monitoring. In addition, the population will be divided according to geriatric risk (falling, weight loss and obesity, depression, loneliness, polypharmacy) and proposed protocols. The core goals are as follows: 1 2 3 4

Promoting and conserving functioning and quality of life of aging IDF veterans Prevention of functional health decline in the recognized and approved disability Improving the abilities of Division of Rehabilitation in the MoD in establishing proactive and integrative protocols on behalf of aging IDF veterans with disabilities Improving coordination with national health providers and social welfare agencies on behalf of health and psychosocial issues of aging IDF veterans with disabilities

Secondary goals are: 1 2

Early detection of health and psychosocial risk factors Prevention of health and functioning decline in the interface between disability and secondary conditions relating to other disabilities and aging

112 3 4 5

Proposed policy to address unmet needs Supporting family caregiving resources Prevention of re-hospitalization and strengthening community resources Ensuring implementation of health and psychosocial protocols and improving compliance

The proposed plan Monitoring flow (see Figure 5.1).

1 2 3 4

Systematic integrative health and psychosocial monitoring will be on an annual basis. The monitoring and assessment instrument will track health and psychosocial problems according to aging and severity of disability. The monitoring can be translated to risk states and preventive protocol of health, function, and psychosocial perspectives. The flow chart starts from offering monitoring, referral, follow up, completion of monitoring, recommended protocol, and an initial need assessment that ends in a health and/or psychosocial path.

Planning and follow up 1 2 3 4 5

Based on monitoring and assessment, the case manager can plan recommended protocols and interventions according to agencies that can provide it. There will be mapping of MoD (and non-MoD) services that can correspond to different risk groups of aging veterans with disabilities. MoD case managers will be assigned to each aging veteran with disabilities. The case manager will allow, when applicable, in-house follow up sessions between health and psychosocial units. The veteran will receive a letter supporting his or her preventive health behavior and encourage him or her to comply.

Coordination and control It is the MoD’s responsibility to coordinate between all services (health and psychosocial) to offer the optimal services for each veteran by using community services primarily to prevent prevalent cases of loneliness and depression among aging veterans. In addition, all coordination processes will need control and correction of mistakes that occur in real time. Furthermore, the MoD will offer legal services for each aging veteran with disability, including supporting decisions, guardianship, and wills. These legal services reflect the appreciation of and commitment of the MoD to older veterans with disabilities stemming from the 1967 and 1973 wars.

Referral

Figure 5.1 Monitoring Flow Chart

Offer monitoring

Follow up

Perform monitoring Recommend protocol

Initial need assessment

Psychosocial path

Health path

Proposed policy to address unmet needs 113

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The pilot phase The decision of the MoD was to begin with a pilot phase in two regions, using an outsourcing agency that will handle the monitoring and coordination. Based on outcomes and lessons from the pilot project, the intention of the MoD is to incorporate the project as a regular service for all older veterans with disabilities. The MoD will appoint a manager at the national level and in two regions selected for the pilot phase. Their role will be to supervise the process and to generate implementation reports. The process and outcomes will be followed up by an external evaluation agency.

Conclusions This chapter focuses on the MoD’s approach toward aging IDF veterans with disabilities and the recent efforts to revise the current policy. A review of current benefits and services for older veterans with disabilities reveals that most of them were injured in the 1967 and 1973 wars. The majority of older veterans are in their late 60s and 70s; there is a portion of very old veterans injured prior to the 1967 war. It is evident that the MoD has been responsive to the growing needs of older veterans with disabilities since the late 1980s, and pension benefits have been increased by 10% for those who became senior citizens. Most of the internal benefits approved by the MoD have been medical and were approved in the 21st century. The MoD has recognized accelerated aging, beyond the letter of the law (Instruction 50.04), in veterans with certain moderate to severe physical disabilities (from 50% disablement) which may develop into secondary health conditions as early as the age of 40. They are entitled to medical treatment (ambulatory, prescriptions, medical and rehabilitation devices, nursing, and reimbursement for transportation for treatment). Another recognition of veteran’s pre-term aging is seen in Instruction 85.04. Pre-retired veterans with disabilities (aged 55–59 and above) are entitled to additional compensation for an accompaniment fee as related to their medical disability. However, these generous internal benefits, as well as others, were awarded after requests and pressures and do not reflect comprehensive and systematic policies. In fact, most of these benefits are provided at different ages, but only for veterans with moderate to severe disabilities. The MoD has been aware of the lack of knowledge regarding the needs, and in particular the unmet ones, of mid-life and aging veterans with disabilities and therefore funded the first survey about this population. The study, carried out by Shnoor et al. in 2011 and published in 2017, revealed that older veterans with disabilities exhibited many more secondary medical conditions related to their recognized disability than a parallel sample of senior citizens did. Furthermore, the oldest veterans (aged 75 and above) reported greater rates of loneliness and lack of support than younger age groups. The most vulnerable aging veterans with disabilities are those with PTSD and psychiatric disabilities, primarily depression.

Proposed policy to address unmet needs 115 They reported a greater rate of diabetes than those with physical disabilities, a higher rate of smoking, and limited social networks. The survey was a catalyst for establishing the Committee of Experts to examine the current status of benefits and services for aging veterans with disabilities. The committee, headed by the author of this book, found that the most serious concern is not the lack of services but is centered on the gray area between the recognized disability and other secondary conditions related to other impairments or illnesses, including decline in functioning associated with aging. In the psychosocial dimension, efforts have to be directed toward veterans’ loneliness and lack of adequate social support in aging, in assisting them to exercise their benefits and rights as senior citizens, and in integrating between the MoD and other available services. Therefore, it recommended the carrying out of a pilot project of proactively monitoring aging veterans with disabilities in two regions and providing coordination between MoD services and other services that veterans are entitled to like all senior citizens. The project will enable the MoD to gradually study the matter and to establish the most preferable policy.

References Angrist, J., & Krueger, A. B. (1994). Why do World War II veterans earn more than nonveterans? Journal of Labor Economics, 12(1), 74–97. Araten-Bergman, T., Tal-Katz, P., & Stein, M. A. (2015). Psychosocial adjustment of Israeli veterans with disabilities: Does employment status matter? Work, 50(1), 59–71. Bennett, J. T. (2017). Paid patriotism?: The debate over veteran’s benefits. Routledge. Clarfield, A. M., Manor, O., Nun, G. B., Shvarts, S., Azzam, Z. S., Afek, A., . . . Israeli, A. (2017). Health and health care in Israel: An introduction. The Lancet, 389(10088), 2503–13. Committee of Expert’s Recommendations to MoD. (2019). Responding to unmet needs of aging IDF veterans. (In Hebrew) Doron, A. (2016). Sixty-two years of national insurance in Israel. Israel Affairs, 22(1), 1–19. Doron, I. (2008). Law and older people: The rise and fall of Israel’s senior citizen’s act. Journal of Aging & Social Policy, 20(3), 353–75. Dwolatzky, T., Brodsky, J., Azaiza, F., Clarfield, A. M., Jacobs, J. M., & Litwin, H. (2017). Coming of age: Health-care challenges of an ageing population in Israel. The Lancet, 389(10088), 2542–50. Fletcher, K. L., Albright, D. L., Rorie, K. A., & Lewis, A. M. (2016). Older veterans. In J. Beder (Ed.), Caring for the military: A guide for helping professionals (pp. 54–71). Routledge. Gal, J., & Bar, M. (2000). The needed and the needy: The policy legacies of benefits for disabled war veterans in Israel. Journal of Social Policy, 29(4), 681–3. Israeli Retirement Age Law 5764–004 number 1919. (in Hebrew) Joling, K. J., Van Eenoo, L., Vetrano, D. L., Smaardijk, V. R., Declercq, A., Onder, G., . . . van der Roest, H. G. (2018). Quality indicators for community care for older people: A systematic review. PLoS One, 13(1), e0190298. Jones, R. (2005). Oxford textbook of primary medical care (Vol. 2). Oxford University Press.

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Kajonius, P. J., & Kazemi, A. (2016). Structure and process quality as predictors of satisfaction with elderly care. Health & Social Care in the Community, 24(6), 699–707. Krause, J. S., & Bell, R. B. (1999). Measuring quality of life and secondary conditions: Experiences with spinal cord injury. In R. Simeonsson & L. McDevitt (Eds.), Issues in disability and health: The role of secondary conditions and quality of life (pp. 237–61). University of North Carolina Press. Lafortune, L., Martin, S., Kelly, S., Kuhn, I., Remes, O., Cowan, A., & Brayne, C. (2016). Behavioural risk factors in mid-life associated with successful ageing, disability, dementia and frailty in later life: A rapid systematic review. PLoS One, 11(2), e0144405. Lollar, D. (1999). Clinical dimensions of secondary conditions. In R. Simeonsson & L. McDevitt (Eds.), Issues in disability & health: The role of secondary conditions and quality of life (pp. 41–50). University of North Carolina Press. Malisoff, H. (1952). The British Disabled Persons (Employment) Act. Industrial and Labor Relations Review, 5(2), 249–57. Mettler, S. (2002). Bringing the state back in to civic engagement: Policy feedback effects of the GI bill for World War II veterans. American Political Science Review, 96(2), 351–65. Morris, J. N., Fries, B. E., Frijters, D., Hirdes, J. P., & Steel, R. K. (2013). interRAI home care quality indicators. BMC Geriatrics, 13(1), 127. Ohry, A., Sullway, C., Broe, G. A., Tennant, J. A., & Ohry, S. Y. (2015). Premature aging: A danger to life expectancy and quality of life of the disabled. Tel Aviv University. Schmid, H. (2005). The Israeli long-term care insurance law: Selected issues in providing home care services to the frail elderly. Health & Social Care in the Community, 13(3), 191–200. Settersten Jr, R. A. (2006). When nations call: How wartime military service matters for the life course and aging. Research on Aging, 28(1), 12–36. Shnoor, Y., Ziv, A., Brodsky, J., & Naon, D. (2017). Research report: Aging IDF disabled veterans: Implications for service delivery. Myers-JDC Brookdale, Jerusalem. Spiro III, A., & Settersten Jr, R. A. (2012). Long-term implications of military service for later-life health and well-being. Research in Human Development, 9(3), 183–90. Stanford, E. P., & Dolson, J. V. (1972). The older disabled veteran. The Gerontologist, 12(4), 325–29. Stevens, R. (1991). Can the government govern? Lessons from the formation of the veterans administration. Journal of Health Politics, Policy and Law, 16(2), 281–305. Wilber, N., Mitra, M., Walker, D. K., & Allen, D. (2002). Disability as a public health issue: Findings and reflections from the Massachusetts survey of secondary conditions. The Milbank Quarterly, 80(2), 393–21. Zucker, I., Laxer, I., Rasooli, I., Han, S., Cohen, A., & Shohat, T. (2013). Regional gaps in the provision of inpatient rehabilitation services for the elderly in Israel: Results of a national survey. Israel Journal of Health Policy Research, 2(1), 27.

6

Closing remarks Insights regarding cross-national policies towards aging veterans with disabilities

Post-World War 2, the United States and the United Kingdom have seen the expansion of social welfare programs, although they reflect significantly different policies regarding ideology, economy, and political forces. The 1948 War of Independence in Israel intersected with the crystallization of social welfare policy, particularly for veterans with disabilities and bereaved families. It is evident that warfare by itself cannot explain the development of the welfare state, and that other factors, primarily domestic, political, and economic circumstances had their impact, as well (Obinger & Schmitt, 2011). Historically, the United Kingdom’s welfare policy during and after World War 2 is characterized by solidarity and therefore led to the offering of universal services to all citizens who contribute to national efforts (Titmuss, 1958). The establishment of military charities marks the appreciation and recognition of the general public to veterans. However, in recent years, due to economic and political changes, there has been an erosion in the government’s commitment to the welfare state and an increase in the number of charities that have stepped in to fill the gap. Compared to the United Kingdom, the United States’ approach is toward a strong warfare/weak welfare governance paradigm (Waddell, 2001). It reflects “target compensation” that supports the selective approach only to those who are “truly needy” and poor and excludes the rest of the population. Veterans are handled preferably in comparison to non-veterans, reflecting the commitment of American society toward those who sacrificed their lives and bodies for the sake of the nation (Gifford, 2006). This approach of supporting veterans was expanded after World War 2 by offering career development programs that cover higher education and training through the GI Bill of Rights, also called the Servicemen’s Readjustment Act of 1944 Public Law 346, chapter 268, S.1767 (Foust, 1945). The act enabled veterans to obtain grants for school and college tuition, low-interest mortgages and small-business loans, job training, hiring privileges, and unemployment benefits. Amendments to the act provided for full disability coverage and the construction of additional VA hospitals. Israel’s legislation regarding veterans with disabilities was the first legislation the government enacted after the War of Independence. It marked society’s commitment to and appreciation of those who have paid with their bodies; therefore

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their rights and benefits are considered generous in comparison to others (Rosenheck, 2004). According to the law, veterans with disabilities receive priority in hiring in the public sector by using employment quotas (Holler, 2014). However, it appears that over the years, the sense of commitment has eroded. The impression is that the policy of prioritizing veterans with disabilities in hiring has been replaced also in the United Kingdom and the United States with a sense of disappointment (Duel, Truusa, & Elands, 2019; Tal-Katz, Araten-Bergman, & Rimmerman, 2011). This book sheds light on the paradox of the 21st century, as most of the veterans with disabilities are older while current legislation, policies, and budgets are still aimed at young veterans and their integration in society (Shay & Yoshikawa, 2010). Most of the government’s budget is allocated to providing medical rehabilitation and career development programs for younger veterans who were recently disabled rather than to the older war veterans. It is evident that the peak of spending is during the early years after injury and that it declines with age. Part of the reason has to do with veterans’ subculture; older veterans, for example, tend to apply less for mental health services than younger ones do (Cheney et al., 2018). In this regard, the United Kingdom’s policy is non-selective, and veterans have to find their health care within the NHS with the rest of the public. They are supposed to receive priority within the health system, but the impression is that it is not fully recognized by NHS practitioners. These is no preference for older veterans with disabilities, and they have to satisfy their unmet needs through charities. One of the newer funding entities is the Aged Veterans Fund financed by LIBOR fines. The Aged Veterans Fund supports non-core health services for veterans born before 1950. It funds four areas: (a) practical support and companionship to improve older veterans’ wellbeing; (b) the provision of services to assist individuals in the completion of personal paperwork; (c) projects to build or enhance access to centers where aging veterans can meet and avoid isolation; and (d) the promotion of education of aged veteran’s needs. The US VA provides medical care to older veterans, including non-institutional geriatric services. However, these services are not accessible to those living in distant locations, primarily rural areas. In addition, it is less effective in identifying aging veterans with mental health needs and delayed PTSD or those with complex medical needs. The other two benefits relevant to aging veterans, A&A and Housebound allowances, are intended to cover the costs of home, assisted living, or nursing homes. However, these benefits are less recognized and underutilized by older veterans and their families (Kaye et al., 2015). Israel’s MoD policy has been quite responsive to older veterans’ unmet needs in comparison to the United Kingdom and the United States. However, their rights are limited to the recognized disability, and veterans have to look for their nonmilitary health needs in the general services. Among the generous services are: (a) an additional 10% pension paid to those reaching retirement age; (b) coverage of medical treatment beyond the letter of the law for secondary health conditions associated with certain disablements that were expressed prior to aging; and

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(c) provision of additional compensation for an accompaniment fee as related to disability for pre-retired veterans. There are additional benefits such as a distress button, scooters for mobility, additional spa services, and reimbursement for housing rental in the case where the veteran does not own a home. However, the most striking problem is that older veterans are torn between the MoD’s services, which are linked to their recognized disability, and other health and psychosocial needs. This situation is unfortunate and causes confusion and underservice, in particular for older veterans with depression or PTSD with a lack of family social support. The new pilot project proposed for aging veterans with disabilities intends to offer active monitoring and may solve the division in services experienced by many older veterans with disabilities. The challenges in these countries is how to better respond to the growing number of older veterans with disabilities, and in particular those with mental health problems, primarily PTSD (Cook & Simiola, 2018), who are at high risk of developing dementia (Qureshi et al., 2010). Depression is often worsened as a result of medical conditions including neurocognitive illnesses, uncontrolled pain, vascular risk factors, substance abuse, and insomnia (Chang & Chueh, 2011). In addition, older veterans with disabilities report problems of isolation and loneliness (Findlay, 2003), especially among frail veterans living on their own without a spouse or companion. It appears that the most important issue that requires additional attention is PTSD among older veterans with disabilities. So far, no clinically validated biomarkers have yet been detected to assess and treat PTSD. Therefore, researchers have to continue their studies of such biomarkers in order to improve their clinical knowledge. Clinicians need to examine better treatment models for older veterans with PTSD or those who express delayed PTSD symptoms and the most effective care delivery framework. Researchers also have to study the association between PTSD and suicide. However, it seems that older veterans are frequently marginalized in research and treatment studies (Cook & Simiola, 2018; Dinnen, Simiola, & Cook, 2015). Finally, a core concern is the complexity of care needs in aging veterans with PTSD. Physical and mental health have a strong bidirectional relationship, and a lack of care in one domain may result in a worsening of the other. Special efforts have to be made to continue the research on PTSD and aging and particularly in developing special protocols to identify delayed PTSD in aging. The United Kingdom, the United States, and Israel have to continue the efforts to identify older veterans who suffer from depression, loneliness, and are lacking mental health services (O’malley et al., 2020). A controversial issue is the existence of accelerated aging or pre-term aging, in particular veterans with serious physical and mental disabilities (Tamman et al., 2019). One of the areas explored in recent years is the association between PTSD and dementia prior to veterans’ retirement years and the presence of secondary conditions in younger veterans with severe physical disabilities. However, there is a lack of evidence in empirical studies regarding the clinical linkage between the two (Yaffe et al., 2010). Although Israeli policy recognized accelerated aging

120 Closing remarks by compensating pre-retired veterans with secondary conditions associated with certain disablements, these processes have to be studied further. Should older veterans with disabilities receive health care and psychosocial support separately from the general aging population? The merits of older veterans receiving separate services like the younger veterans is the uniqueness of their medical needs and their potential preference to receive services where they feel comfortable. Integrated services offer better selection and expertise of health care and may be provided locally and at a cheaper cost for the government. The United Kingdom’s health care services are integrated within the NHS. Although veterans are supposed to get priority, in reality most of them are denied this right (Hancock, 2018). There are areas that require special care like mental health services, and they are provided separately. The special non-medical care for veterans is provided by charities like the Aged Funds. While the US health care services for veterans, the VHA, runs separately, aging veterans with disabilities are often covered by Medicare or other health insurance, and they prefer to use them because they are available locally (Ysasi & McDaniels, 2018). The Israeli case is unique, as veterans with disabilities, including aging ones, can receive separate services for their recognized disability. They are entitled as citizens and senior citizens to obtain medical care from one of the providers of national health care, as well as other social welfare services. What the most desired model for service delivery is one of the core questions that need to be addressed. Finally, an interrelated question is the cost of aging services for veterans with disabilities. Can the United Kingdom, the United States, and Israel expand these services in an era of decreasing public spending and a decline in public appreciation of the status of veterans in society? The United Kingdom incorporates an interesting approach to offer older veterans integrated services with few exceptions and supplements them with the services of military charities. The United States is different, as veterans can choose between the VA and services offered to senior citizens such as Medicare and other health providers (Nelson et al., 2007). The problem is lack of coordination between the VA and others, which is not only inefficient but can leave the older veteran without adequate health care. The same applies to Israel: veterans with disabilities are caught between receiving health services for their recognized disability from the MoD and the national health insurance for their other health needs. The Israeli policy proposal introduced in Chapter 5 intends to solve the division in health services by offering proactive monitoring and case management. It seems that the United Kingdom, the United States, and Israel in the next decade will need to systematically address future policy toward older veterans with disabilities. As the aging veterans’ population is growing steadily, governments will be required to examine current legislation and provisions and offer revisions to both. While wrapping up the final chapter, the first cases of the novel coronavirus (COVID-19) pandemic were being reported from Wuhan, China. COVID-19 is an unprecedented, dangerous virus that spread rapidly to more than 190 countries, including the United Kingdom, the United States, and Israel. One of the most susceptible groups to be infected by COVID-19 were aging veterans with

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disabilities. Among the reasons for being life threatening for this population are the physiological changes associated with aging with disabilities, including decreased immune function and multi-morbidity. There is no doubt that among the most vulnerable populations were veterans with severe disabilities residing in long-term care facilities. The number of older veterans with disabilities who were infected by COVID19 is not clear. An early report from the VA reported 571 confirmed veteran cases of COVID-19 and nine veteran deaths in the United States (US Department of Veterans Affairs, 2020). These numbers could rise, likely being concentrated among older veterans and those with underlying conditions that made them especially vulnerable. Policymakers in the United Kingdom, the United States, and Israel, as well as in other countries, responded immediately to the increased challenges of the COVID-19 pandemic in aging veterans with disabilities. The first step was to recommend for them to practice self-isolation for a very long time in order to minimize the spread of infection. However, social isolation is a well-known serious public health concern among older veterans with disabilities because of their heightened risk of cardiovascular, autoimmune, neurocognitive, and mental health problems, particularly depression. This will be probably one of the challenges that World Health Organization (WHO) as well as countries need to address until a vaccination is available.

References Chang, T. Y., & Chueh, K. H. (2011). Relationship between elderly depression and health status in male veterans. Journal of Nursing Research, 19(4), 298–304. Cheney, A. M., Koenig, C. J., Miller, C. J., Zamora, K., Wright, P., Stanley, R., . . . Pyne, J. M. (2018). Veteran-centered barriers to VA mental healthcare services use. BMC Health Services Research, 18(1), 591. Cook, J. M., & Simiola, V. (2018). Trauma and aging. Current Psychiatry Reports, 20(10), 93. Dinnen, S., Simiola, V., & Cook, J. M. (2015). Post-traumatic stress disorder in older adults: A systematic review of the psychotherapy treatment literature. Aging & Mental Health, 19(2), 144–50. Duel, J., Truusa, T. T., & Elands, M. (2019). Public support for veterans leaving the armed forces. In C. Castro & S. Dursun (Eds.), Military veteran reintegration (pp. 215–44). Academic Press. Findlay, R. A. (2003). Interventions to reduce social isolation amongst older people: Where is the evidence? Ageing & Society, 23(5), 647–58. Foust, H. L. (1945). The educational and training provisions of the so-called ‘GI bill.’ Iowa State University Veterinarian, 7(4), 228–30. Gifford, B. (2006). The camouflaged safety net: The US armed forces as welfare state institution. Social Politics, 13(3), 372–99. Hancock, D. (2018). Become a veteran-friendly practice. Practice Management, 28(9), 20–2. Holler, R. (2014). Disability and employment policy in the Israeli welfare state: Between exclusion and inclusion. Disability & Society, 29(9), 1369–82. Kaye, L. W., Shay, K., Singer, C. M., Petzel, J. B., Middleton, J., Crittenden, J. A., & Osborne, G. (2015). Maximizing the health and well-being of older veterans. In C. J. Cress (Ed.), Handbook of geriatric care management (p. 270). Jones & Bartlett Learning.

122 Closing remarks Nelson, K. M., Starkebaum, G. A., & Reiber, G. E. (2007). Veterans using and uninsured veterans not using Veterans Affairs (VA) health care. Public Health Reports, 122(1), 93–100. Obinger, H., & Schmitt, C. (2011). Guns and butter? Regime competition and the welfare state during the Cold War. World Politics, 63(2), 246–70. O’malley, K. A., Vinson, L., Pless Kaiser, A., Sager, Z., & Hinrichs, K. (2020). Mental health and aging veterans: How the veterans health administration meets the needs of aging veterans. Public Policy & Aging Report, 30(1), 19–23. Qureshi, S. U., Kimbrell, T., Pyne, J. M., Magruder, K. M., Hudson, T. J., Petersen, N. J., . . . Kunik, M. E. (2010). Greater prevalence and incidence of dementia in older veterans with posttraumatic stress disorder. Journal of the American Geriatrics Society, 58(9), 1627–33, esp. 797–8. Rosenheck, Z. (2004). Social policy and nationbuilding: The dynamics of the Israeli welfare state. Journal of Societal & Social Policy, 1(1), 15–31. Shay, K., & Yoshikawa, T. (2010). Overview of VA healthcare for older veterans: Lessons learned and policy implications. Generations, 34(2), 20–8. Tal-Katz, P., Araten-Bergman, T., & Rimmerman, A. (2011). Israeli policy toward veterans with disabilities: A snapshot and insights of the proposed reform. Journal of Social Work in Disability & Rehabilitation, 10(4), 232–46. Tamman, A. J., Montalvo-Ortiz, J. L., Southwick, S. M., Krystal, J. H., Levy, B. R., & Pietrzak, R. H. (2019). Accelerated DNA methylation aging in US military veterans: Results from the national health and resilience in veterans study. The American Journal of Geriatric Psychiatry, 27(5), 528–32. Titmuss, R. M. (1958). War and social policy. In R. M. Titmuss (Ed.), Essays on ‘the welfare state’ (pp. 75–7). Allen & Unwin. US Department of Veterans Affairs. (2020, March 24). Novel coronavirus disease (COVID19). www.publichealth.va.gov/n-coronavirus Waddell, B. (2001). Limiting national interventionism in the United States: The warfarewelfare state as restrictive governance paradigm. Capital & Class, 25(2), 109. Yaffe, K., Vittinghoff, E., Lindquist, K., Barnes, D., Covinsky, K. E., Neylan, T., . . . Marmar, C. (2010). Posttraumatic stress disorder and risk of dementia among US veterans. Archives of General Psychiatry, 67(6), 608–13. Ysasi, N. A., & McDaniels, B. W. (2018). Challenges faced by veterans residing in rural communities. In D. A. Harley, N. A. Ysasi, M. L. Bishop, & A. R. Fleming (Eds.), Disability and vocational rehabilitation in rural settings (pp. 139–50). Springerlink Online.

Index

Note: Page numbers in italics indicate a figure and page numbers in bold indicate a table on the corresponding page. abilities: to adapt to challenges 63; autonomy and wellbeing, maintenance 38; cognitive 35; to develop preventive interventions 36; functional 38, 41; to make choices 39; physical 35; to pursue legal action 12; quality of life, maintenance 56; spinal cord 41 “accelerated aging” 40–1; challenging concept 48; complexity 48; evidence 44; experience 33; longitudinal research 42; MoD 95; of organ systems 44; posttraumatic stress disorder (PTSD) and 46–7 acquired disabilities 33, 40–1; see also disability “active aging” see “successful aging” active engagement 34–6 activity theory 34 Adult Day Health Care (ADHC) 88 Affordable Care Act (2010), US 13 age/aging: adults 34; benefits 104; biological 39; with care needs 37; cellular 46; chronological 39, 42, 46–7, 69; comorbidity and 44–6; conceptualization of 36; disability 1, 40; distribution 57; healthy 37; identity 39, 69; mid-life 57; old 33–4, 37, 57; for pensions 5; physical 42; population 34; pre-retirement 48; psychological 39; retirement 21, 34, 57, 63, 93, 95, 104, 118; secondary conditions and 41–4; subjective 39, 69; transition to 36; with visible care needs 36; of welfare 6; working 62; younger 41, 103, 114 Aged Veterans Fund, UK 78–9, 118

Aged Veterans Healthy Living Program, UK 79 Agent Orange Act (1991), US 17 “age-related conditions” 41 age-related losses 34 aging veterans: ex-servicemen and women (UK) 56–8; health and psychosocial concerns 55–71; Israel Defense Forces (IDF) 60–1, 62; military service 56; needs of 56; secondary conditions by age group 67; serving by charities 80; in US 57–60; see also policies aging with disability 33–48; “accelerated aging” 40–1, 44; defined 33; posttraumatic stress disorder (PTSD) 44–7; “premature aging” 40–1; secondary conditions 40–4; spinal cord injury (SCI) 41–4; “successful aging” 34–40 Ahmadi, N. 46 Aid and Attendance (A&A) 19, 80–1 Aldwin, C. M. 56 Americans with Disabilities Act (1990) (ADA) 13, 90 annual population survey 63 anxiety: comorbid 68; depression and 68, 80; disorder 44, 63; mental health services 21; symptoms 64 Armed Forces Act (2011), UK 10 Armed Forces Compensation Scheme (AFCS), UK 11–12, 57 Armed Forces Covenant, UK 7, 10, 76, 79 Armed Forces Independence Payment (AFIP), UK 11–12 Armed Forces Pension Scheme (AFPS), UK 10 Ashworth, J. 56

124 Index Asquith, H. 5 “associated conditions” 40 automobile allowance 19 autonomy 37–9 avoidance 44, 64 Baltes, M. M. 34 Baltes, P. B. 34 Bar, M. 24 Barras, D. 44 Bedroom Tax see Removal of Spare Bedroom Subsidy (RSBS) behaviors 34; health 41; regulation 36; risky 111; suicidal 45 beliefs: among clinicians 33; during and after wars 24; model of selective optimization 37; negative 45; wars stimulate economy 4 Bell, R. B. 111 Ben-Gurion, D. 23 Berridge, C. 36–7, 39 Beveridgean welfare 6 Beveridge Commission (1941), UK 5 Beveridge Report, The 5–6 Beveridge, W. 5, 7 biological age 39; see also age/aging Birren, J. E. 39 border conflicts 22 Boscarino, J. A. 65 Brenner, H. 47 British Legion 9 British Limbless Ex-Servicemen’s Association 64 British Mandate 23 British Nuclear Test Veterans Association 79 Brodet, D. 24 budget: allocation 79; defense 13, 24; expenditure 103; government 118; national 4; personal health 77; priorities 90; problems 24; public health 106; for services 89; spent 25; state 7; veterans 13; welfare spending 13 Bureau of Pensions (US) 13–15 Bush, G. W. 12–13 Campbell, M. 40–1, 44 cancer 67, 92–3, 102 cardiovascular disease (CVD) 42, 56, 67 career development: counseling 25; disabled IDF veterans 25; medical rehabilitation and 118; needs 108; programs 76, 101, 117–18; vocational rehabilitation and 91, 103; work and 91

care needs see needs Cecil, R. 8 cellular aging 46 Centers for Disease Control and Prevention (US) 40 cerebro vascular accident (CVA) 67 challenges 22; ability to adapt 63; of COVID-19 pandemic 121; difficulties and 64; MoD 108; older veterans 62, 119; strengths and 108, 108; World War 2 veterans 85 changes 24; age-related 35; cardiometabolic 65; conceptualization 36; during and after World War 2 9; economic 7, 22, 117; government spending 6; health 109; in mental disability rates 62; in military spending 5; pensioners mental health 57; physical health 34; physiological 121; political 7, 22, 117; in skin elasticity 43; social 22; in social spending 5; structural 21; veterans 18, 26; welfare policy 7 charities: Aged Funds 120; armed forces 71; for assisting truly needy 7; dedicated health programs 77–8; funds 79; for mental health services 78; military 7, 26, 96, 101, 117; NHS 77; post-traumatic stress disorder (PTSD) 80; role of armed forces 79–80; serving aging veterans 80; state 7, 26, 76, 96, 101, 117; as supplemental services 78; welfare 79 Chen, Y. 44 chronic illness 34, 36, 56 chronic pain 43 chronological age 39, 42, 46–7, 69 Civil War 12, 15, 18, 26 clinical indicators 110 Clinton, B. 13 clothing allowance 19 Code of Federal Regulations (Title 38), US 55 cognitive abilities 35 cognitive disability 33 cognitive functioning 35 Coker, J. 42 Cold War 10 Cole, S. 80 Colello, K. J. 87, 89 Combat-Related Special Compensation (CRSP) 19 Combat Stress 78 Committee of Experts 102–3, 104, 106–8, 110 Community Health Assessment 110

Index Community Living Center (CLC), VA 89 Community Nursing Home (CNH), VA 89 Community Residential Care (CRC) 88 comorbidity(ies) 40; aging and 44–6; mental disorders 45–6; post-traumatic stress disorder (PTSD) 45–6, 63, 68; quality of life 90; secondary medical 33; social support and 91; with trauma 45; triple 68 compensation 58, 57–60, 61; aging veteran 93; amount of 82; automobile allowance 19; clothing allowance 19; disability 19, 21, 81; eligibility 18; model 34; policy 5; schemes for veterans with disabilities 11–12; schemes in UK 11–12; serviceconnected disability 82–3; targeted 26 Complex Treatment Service (CTS) 78 Comrades of Great War (organization) 9 conceptualization 24, 34–6, 38, 111 Concurrent Retirement and Disability Payments (CRDP) 19 Confederation of Service Charities (COBSEO) 79–80 conflicts: border 22; military 8, 22; wars 18 Congress 13, 15–18, 86 Congressional Budget Office 21 Consolidation Act (1873), US 15 continuity theory 34 Cook, J. M. 65 Cost of-Living Allowance (COLA) 82 COVID-19 120–1 Craig, A. 43 cross-national policies 117–21 Cunningham, W. R. 39 defense budget 24; see also budget Department of Defense (DoD), US 21, 81, 81, 82, 84–5 Department of Health and Social Security (DHSS), UK 9 Department of Medicine and Surgery, VA 85 Department of the Interior (US) 15 Department of Veterans Affairs (US) 17–18, 47, 81 Department of War (US) 15 Dependent Pension Act (1890), US 15 depression 21, 43; anxiety and 68, 80; loneliness and 57, 112; major 21, 44–5, 62; older veterans 70; physical health 43; post-traumatic stress disorder (PTSD) and 45, 56, 69–71, 96–7, 102, 119; prevalence 63; psychosocial

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problems 70; rates 43; suicide and 27; veterans 15 Derwinski, E. J. 17 Desmond, D. M. 64 DeVivo, M. J. 44 diabetes mellitus 27, 35, 41, 42, 60, 66, 67, 68, 102, 115 Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 44 disability: acquired 33, 40–1; aging 1, 40–1; benefits 21, 59, 60; compensation 19, 21, 81; disease-related 35–6; elimination 37; forestalling disease and 35; medical 25; mental 2, 33, 55, 62, 68, 100, 119; orthopedic 25; payments 15, 19, 21; permanent 8, 19; physical 33–4, 40; prevalence of 36–7; primary 40; rating 19; service-connected 19; in US 1; see also aging veterans; specific disabilities Disability Compensation, VA 19, 21, 81, 81–2, 83, 84–5 Disability (Compensation and Rehabilitation) Law 5719–1959, Israel 23 disability pension, VA 83, 84–5 Disabled Persons (Employment) Act (1944), UK 9 Disabled Veteran’s Rehabilitation Act (1943), US 16 disablement pensioners 59 disablement percentage 57, 58, 59, 60, 60, 62 Disablement Service Center (DSC) 78 Discharged Soldiers (Reinstatement in Employment) Law (1949), Israel 25 discrimination 13, 36 disease-related disability 35–6 diseases see specific diseases disengagement theory 34 dissociation 45 Division of Rehabilitation, MoD 93 Doherty, R. 80 Dolson, J. V. 100 domestic expenditure 22 Doron, I. 95 Dryzek, J. 5 Earned Income Tax Credit 13 economic infrastructure 22 education and training 20 Ein-Dor, T. 68 El Alamein 5 electronic health record 21 emotions: arousal 46; negative cognitions and 45–6; negative trauma-related 45; problems 27

126 Index employment: investment 13; needs of veterans 5; quotas 9; rights of veterans with disabilities 25; sheltered 9 endocrine diseases 42 Enhanced Compensation Scheme (UK) 12 equality 4 Europe 4 expectations 24, 106 expenditure 22, 103 Ex-Servicemen’s Unemployment Compensation Act (1958), US 16 ex-servicemen/women 8; compensation 9; defined 55; disabled 9, 11, 55; in UK 56–8 family 43–4; allowances 6; contacts 67; immediate 42; social life 39; social problems 63; social support 66, 119 Fear, N. 63 Federal Advisory Committee (US) 85–6 federal benefits 21 federal funding 13 Fletcher, K. L. 100 Foraker, R. E. 46 Forbes, D. 45 forestalling disease and disability 35 free market policies 7 Full Time Reserve Forces Pension Scheme (FTRSPS 97), UK 10 Fulton, L. V. 70 functional abilities 38, 41 functional impairment 36 functional indicators 110 functional survival skills 39 Gal, J. 5, 22, 24 Garcia, H. A. 66 gastrointestinal system 43 General Pension Act (1862), US 15 genitourinary system 43 Geriatric and Extended Care (GEC) programs, VHA 87, 87–8 Geriatric Research, Education and Clinical Center (GRECC) 86 Geriatrics and Gerontology Advisory Committee (CGAC) 86 GI Bill of Rights 100, 117; see also Servicemen’s Readjustment Act (US) Ginzburg, K. 68 Girton, R. A. 46 Goldberg, J. 65 Goodin, R. 5 Gooding, P. A. 45 Goren Committee (2010) 25–6, 103

government spending 6 Gradus, J. L. 46 Greater Manchester 79 Guaranteed Income Payments (GIPs) 11 Gulf War 59, 64, 66 “Gulf War Syndrome” 9 guns vs. butter trade-off logic 5 Hajsadeghi, F. 46 Hallam, B. J. 42 health: aging 37; care services 77–8; disparities 34; long-term care policy 85–7; promotion 36; social care 77; spending 5 health and psychosocial concerns: for aging veterans 55–71; findings from Israel 67–9; findings from UK 63–4; findings from US 64–7; post-traumatic stress disorder (PTSD) 65; research on 62; social and economic problems (US) 65–6; utilization of health care services 66 Hearing Veterans Fund (HVF) 78 heart attack/heart failure 46, 67 Heflin, C. M. 66, 70 Helvitz, H. 69 hidden variable 56 Hodgkin’s disease 17 Holder, K. A. 64 Home-Based Primary Care (HBPC) 86, 88 Home Care Assessment 110 home care quality indicators (HC-QI) 110 Hoover, H. 15 Houk, V. N. 40 Housebound Benefits 19 Hudson, M. 56 hypertension 35, 41, 66, 67 immigrants/immigration 22 inequality, social 37 infrastructure and services, MoD 102–4 Institute of Medicine (IOM) 40 institutional care, VA 89 Insurance Act (1911), UK 5 International Code of Functioning of Disability and Health (ICF) 40 Intrator, O. 90 Invalids Law, Israel 22–5, 91, 102–3 Israel 1; benefits to mid-life and aging veterans 94; economic infrastructure 22; government policies in 91–5; Knesset 22–4, 91–2, 103, 111; labor infrastructure 22; legislation 117–18; MoD policy 118; policies toward

Index veterans with disabilities in 23–4; social welfare policy 22; study on aging veterans 67–9; veterans 33; veterans with disabilities provisions in 24–5 Israel Defense Forces (IDF) 2; aging veterans, in Israel 60–1, 62; allowance 25; disability association 103; disabled veterans 22, 24–5; distribution by age 62; prisoners of war 92; responsibility towards veterans with disabilities 23; veterans 55, 60–1, 62, 101–2, 110–11, 114 Israeli Central Bureau of Statistics 67 Israel Police Force 24 Israel Prison Service 24 Jensen, M. P. 42 Jewish immigrants 22 Joseph, K. 11 Kahn, R. 35 Kemp, B. 42 Kessler, R. C. 44 King’s Roll see National Scheme for Disabled Ex-Servicemen (1919), UK Kishon River 93 Kishon veterans, Israel 92; see also aging veterans Knaevelsrud, C. 70 Korean GI Bill see Veteran’s Readjustment Assistance Act (1952), US Korean War 16, 46, 59–60, 64, 66 Krause, J. S. 42, 111 Kuwert, P. 70 labor infrastructure 22 Labour Party (UK) 6 Lafortune, L. 41 Lebanon War 68–9 Lewis, M. W. 66 Liberal Party (1908), UK 5 LIBOR see London Interbank Offered Rate (LIBOR) Aged Fund, UK life insurance 17, 20–1 lifespan theories on successful aging 34–5 limbless veterans 64 Lockwood, E. 45 Lollar, D. 111 London, A. S. 66, 70 London Interbank Offered Rate (LIBOR) Aged Fund, UK 78, 80, 118 longevity 33 Long Parliament (UK) 8

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long-term care 38 Long-term Care Insurance Law, Israel 95, 105–6 long-term care provisions, VA 89–91 long-term economic cost, British amputees 64 long-term services and supports (LTSS) 89–90 losses: age-related 34; earning capacity 11; independence 1; of life 15; of limbs 23, 56, 63; memory 18; vision 41 lump sum payments 11 Lunney, C. A. 45 MacLachlan, M. 64 MacLeavy, J. 12 magnetic resonance imaging (MRI) 65 Malam, S. 56 Marge, M. 40 Marshall, T. H. 6 Martinson, M. 36–7, 39 Massachusetts Survey of Secondary Conditions 111 Medicaid 21 “medical complications” 40 medical disability 94; accompaniment grant 104, 114; compensation 92, 104, 114; exception of veterans 96; military 107; percentage 25; permanent 25; recognized 71 medical disablement 60, 62, 102 Medical Foster Home (MFH) 88 medical impairment 25 medical rehabilitation 23 Medicare 21 mental disorders/disability/illness 2, 33, 55, 68, 100, 119; avoidance 44; pensioners 57; rate 62; relationship with post-traumatic stress disorder (PTSD) 45–6; supplemental payments to veterans 21; traumatization 45; treatment 91; in UK 9; unemployment 9 mental health 1, 19, 21, 40, 42 Middleton, J. 43 mid-life veterans 33, 44, 60–1, 66, 67 mild traumatic brain injury (mTBI) 65 military charities 7 military conflicts 8, 22 military disabilities 68, 84, 92, 107 military retirees 19 military service, veterans 56 military spending 5, 12, 22 Miller, E. A. 90 Miller, M. W. 45–6

128 Index Ministry of Defense (MoD), UK 68, 71, 76, 78, 94; “accelerated aging” 95; benefits to mid-life and aging veterans 104; bereaved families 23; challenges 108; Committee of Experts 101; compensation 11; current services 108; Division of Rehabilitation 93, 101, 103, 107, 109; health services 104; infrastructure and services 102–4; medical care 101; medical needs 25; medical services 92; pilot phase 114; policies 24; provisions for aging veterans 108–9; strengths 108 Ministry of Health 105 Ministry of Housing 105 Ministry of Labor and Social Affairs 106 Ministry of National Insurance (UK) 9, 26 Ministry of Pensions (UK) 9, 26 Ministry of Social Security (UK) 9 Mistry, R. 67 Mofaz, S. 93 Molton, I. R. 39 Monetary Long-Term Care Benefit 106 Montgomery GI Bill 18, 20 mortgage life insurance 17 Mueser, K. T. 45 Müezzinler, A. 47 Murphy, D. 63 Murrison, A. 78 musculoskeletal diseases 42 musculoskeletal pain 43 National Assistance Act (1948), UK 6 National Association of Discharged Sailors and Soldiers (organization) 9 National Federation of Discharged and Demobilized Sailors and Soldiers (organization) 9 National Guard (US) 20 National Health Insurance Act, Israel 95, 105 National Health Insurance Law 105 national health policy (NHP) 79 National Health Service (NHS) 6–7, 64, 101; dedicated health care services 77–8; health and social care 77, 118; Long-Term Plan 77; personalized care 77; priority services in 77 National Health Service Act (1946), UK 6 National Home for Disabled Volunteer Soldiers (NHDVS) 15 National Insurance (UK) 9 National Insurance Act (1946), UK 6

National Insurance (Industrial Injuries) Act (1946), UK 6 National Insurance Institute (NII), Israel 22, 24, 104–5 national military service (Israel) 55 National Scheme for Disabled Ex-Servicemen (1919), UK 8 National Service Life Insurance (US) 16 National Spinal Cord Injury Association 42 Naval Home (US) 15 Navy Secretary (US) 15 needs: adjustment 35; care 36–8; career development 108; challenges of older veterans and 62; citizens 6; domestic social 26; employment 5; geriatric 89; health 19, 68, 91, 101; long-term mental health 71; medical 25, 26, 68, 101; psychosocial 26, 68; rehabilitation 92; social care 79; unique clothing 19; veterans 10, 26, 48, 56; visible care 36; see also unmet needs (proposed policy) negative cognitions and emotions 45–6 negative life events 68 nervous system arousal 44 neurology 43 neuropathic pain 43 “New Strategy, The” (UK) 7, 76 non-core health services 118 non-institutional care, VA 88–9 non-service-connected (NSC) disability 83 Nursing Home Care Units to Community Living Centers 89 Obama, Barack 13 Obamacare 13 Obinger, H. 5 occupational rehabilitation 23 Office of Pensions (US) 15 Ohry, S. Y. 41 Old Age Pension (NII) 104–5 Olmstead v. L.C. (Supreme Court decision) 90 Omnibus Budget Reconciliation Act (1990), US 17 Operation Desert Shield (US) 17 Operation Desert Storm (US) 17 Operation Enduring Freedom (OEF) 19, 27, 65, 66 Operation Iraqi Freedom (OIF) 19, 27, 65, 66 Operation New Dawn 65 optimization 34–5 Oregon 15

Index orthopedic disability 25; see also disability outpatient clinic-based services 88 pain 33, 43 Palestine 23 Palliative Care Clinics 88 Panagioti, M. 45 Panangala, S. V. 87, 89 Paris, A. H. 65 Pearl Harbor 16 Pension Act of 1806 (UK) 8 pensioners 57, 59 pensions: age for 5; allocated to veterans 7; benefits to ex-servicemen/women 81, 81–2, 84–5; calculations 8; civilian retirement 12; Civil War 15; compensation and 79; county-based 8; eligibility 19; non-contributory meanstested 5; veterans 15; wartime-only 18 Peoples, C. 12 percentage of disablement see disablement percentage permanent disabilities 8 Persian Gulf 19 Persian Gulf Conflict Supplement Authorization and Personnel Benefits Act (US) 18 Persian Gulf War veterans 18 “personal age” 39 Personal Independence Payment (PIP), UK 11–12 personality disorders 45 personalized care, NHS 77 Philadelphia 15 physical abilities 35 physical activity 41 physical aging 42 physical and mental function, maintaining 35 physical disabilities 33–4, 40 physical functioning 35–6 physical health 34, 39–40 physical impairment 36 Pietrzak, R. H. 70 Plymouth General Court 13 policies: Aged Veterans Fund 78–9; armed forces charities role 79–80; benefits and pension to ex-servicemen/women 81, 81–2, 84–5; charities serving aging veterans 80; concerns and future direction 21; cross-national 117–21; dedicated health care services 77–8; free market 7; health and long-term

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care policy 85–7; health and social care 77; institutional care 89; in Israel 91–5; non-institutional care 88–9; pension 83; personalized care 77; priority services in NHS 77; provision of long-term care 89–91; service-connected disability compensation 82–3; social justice 5; social protection 4, 7; social security provisions 84–5; social welfare 22; special provisions, aging veterans 83–4; toward veterans with disabilities in UK 7–9, 76–80; toward veterans with disabilities in US 13–18, 14, 80–1; warfare and social welfare in UK 5–7; see also unmet needs (proposed policy) political institutions 4 porphyria cutanea tarda 17 Post-9/11 GI Bill 20 post-traumatic stress disorder (PTSD) 9, 19, 21, 24, 33, 41, 57, 65; “accelerated aging” 46–7; aging with disability 44–7; charities for 80; chronicity 47; criteria 44; depression 45, 56, 69–71, 96–7, 102, 119; diagnosis 44–5; impact on physical health 65; mid-life veterans with 92; prisoners of war (POW) with 92; relationship with mental disorders 45–6; secondary physical health conditions 46; symptoms 44, 46; veterans 39 post-traumatic syringomyelia 43 post-war welfare legislation 6 poverty 6, 12, 34 “premature aging” 40–1, 44, 48; see also age/aging prevalence of disability, stable and substantial 36–7 primary disability 40 prisoners of war (POW) 92 privatization 7 “productive aging” see “successful aging” psychological age 39 psychological distress 43 psychological wellbeing 36 psychology 43–4 psychosis 45 psychosocial adaptation 64 public disability benefits (PDB) 85 public management 7 public spending 22 Putnam, M. 40–1 quality of community living centers 21 quality of life 35, 40, 43

130 Index Radiation-Exposed Veterans Compensation Act (1988), US 17 Reagan, R. 12, 17 Rehabilitation Division (Israel) 25–6 re-hospitalization 44 Removal of Spare Bedroom Subsidy (RSBS) 7 Reprisal Operations 22 Reserve Educational Assistance Program (REAP) 20 Reserve Forces Pension Scheme (RFPS 05), UK 10 Reserve Service (US) 20 resilience and adaptation 39 respiratory diseases 42–3 retirees, military 19 retirement: age 21, 34, 57, 63, 93, 95, 104, 118; benefits 19; pay 21 Ridgway, J. D. 18 Rimmerman, A. 24, 102 risk-sharing 5 Robson, A. 80 Rodakowski, J. 44 Roosevelt, F. D. 16 Rowe and Kahn’s model of successful aging 35–9 Rowe, W. 35 Roy, S. S. 46 Royal Air Force Benevolent Fund 79 Royal British Legion 77, 79 Rural Action Yorkshire 79 Sadeh, N. 46–7 Schmitt, C. 5 Schnurr, P. P. 56, 65 secondary conditions 40–4, 67 secondary health 39, 44, 46 secondary medical comorbidities 33 Second Lebanon War 24 Segal, D. R. 56 Segal, M. W. 56 selection 34–5 Seliger, S. 84 Senior Citizen’s Law (Israel) 95, 106 service-connected disability 19–20, 82–3 Service-Disabled Veteran’s Insurance (S-DVI) 20–1 servicemen and women 16 Servicemen’s Group Life Insurance 17 Servicemen’s Readjustment Act (US) 16, 117 Settersten, R. A. Jr. 100 Shalev, M. 22 Shamgar, M. 92–3

sheltered employment 9 Shnoor, Y. 2, 60, 67, 102, 114 Simiola, V. 64 single persons 67 Six Day War (1967) 22, 93 skills, functional survival 39 skin 43 social age 39 social citizenship 6, 26 social class 36 social connectedness 33, 39 social contacts 34, 36, 41 social engagement 34, 36 social factors 69 social inequality 37 social institutions 4 social insurance 4, 6 Social Insurance and Allied Services (report) 5–6 social justice policies 5 social life 36 social networks 36 social participation 40 social protection 4, 7, 12 social security 6, 21–2, 81; provisions 84–5 Social Security Disability Insurance (SSDI) 21, 81, 81–2 social spending 5 social support 36 social welfare 5–7, 22, 117 socioeconomic disparities 34 Soldiers, Sailors, Airmen and Families Association (SSAFA) 79, 80 Solomon, Z. 68, 69 Soviet Union 22 Specially Adapted Housing (SAH) Grant 21 Special Monthly Compensation (SMC) 83 special provisions for aging veterans 83–4 Spielberg, J. M. 65 spinal cord (SC) disabilities 60 spinal cord injury (SCI) 2, 33, 41–4, 56 Spiro, A. III 56, 65, 100 stable and substantial prevalence of disability 36–7 Stanford, E. P. 100 state funding 13 State Veterans Home (SVH) 89 Stein, J. Y. 69 stigma 36 St. John and Red Cross Defense 79 stress 43; see also post-traumatic stress disorder (PTSD)

Index Subcommittee on Military Construction, VA 90 “subjective age” 39 “subjective old age” 69 subjective wellbeing 34 “successful aging” 34–40; achievement 35; failure 33; lifespan theories on 34–5; persons with disabilities 36–40; propositions 36–9; resources 38; Rowe and Kahn’s model of 35–6; theories 34–5 Suez Crisis 22 suicide/suicidality 21, 45 supplemental payments 21 Supplemental Security Income (SSI) programs 21, 81, 81–2 Supplementary Benefits Commission (UK) 9 Supporting Wounded Veterans Ltd. 78 Survey of Income and Program Participation (SIPP) 66 syrinx see post-traumatic syringomyelia target compensation 26, 117 Tarrier, N. 45 Teich, J. 91 Tesch-Römer, C. 36–8 Thacker, S. B. 40 Thatcher, M. 7 Titmuss, R. M. 4–5 Tomlinson Committee (1943), UK 9 total disability 19 totally disabled veterans 17, 21 training and education 20 Transition, Intervention and Liaison Service (TILS) 78 transition to aging 36 transition to community-based services 90 transparency 24 trauma 44; battlefield 78; comorbidity 45; dementia 65; stress-related disorder and 44; vertebral column 41 traumatic brain injury 19 traumatic combat 33 Trieschmann, R. B. 39 Trump, D. 13 Tsur, N. 69 unemployment: benefits 7, 21; insurance 16; rate 17; UK 6, 9 United Kingdom (UK) 1; being veteran/ ex-serviceman 55; compensation schemes 11–12; ex-servicemen/women in 56–8; government policies in 76–80;

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health and social care 77; older veterans integrated services 120; policies towards veterans with disabilities in 7–9; poverty prevention 6; schemes for veterans with disabilities in 9–10; social insurance 4; unemployment 6; veterans 33; welfare and warfare policies 5–7 United Nations 23 United States (US): aging veterans in 57–60; benefits and services for veterans with disabilities 18–21; disability 1; government policies in 80–1; people with spinal cord injury 42; poverty in 12; principles of policy 76; social insurance 4; VA 118, 120; veterans 33; welfare and warfare policies in 12–13 unmet needs (proposed policy): Committee of Experts 107–8, 110; coordination and control 112; goals 111–12; health services and benefits for senior citizens 104–7; MoD’s provisions 108–9; monitoring flow chart 113; need to improve care 109–10; pilot phase 114; planning and follow up 112; problems 101–2; proposed package of service 110–12; regulatory infrastructure 102–4; see also needs utilization 110 VA see Veterans Administration (VA), US Vaccarino, V. 47 Vardi Report (2002), Israel 92 Veteran-Directed Home and CommunityBased Services (VD-HCBS) 89 veterans: characteristics of 55; chronic disabilities 18; defined 55; disability 1; education and training 20; eligibility criteria 18; employment needs of 5; Israel 33; life insurance 20–1; limbless 64; Operation Enduring Freedom (OEF) 19; Operation Iraqi Freedom (OIF) 19; post-traumatic stress disorder (PTSD) 39, 47; rating 18; supplemental payments 21; totally disabled 21; UK 33; unemployment benefits 21; US 33; see also aging veterans Veterans Administration (VA), US 15–18, 118, 120; benefits 20–1; health care 20; nursing home care 20; Pension 19 Veterans Administration Medical Centers (VAMCs) 89 Veterans and Reserves Mental Health Program (VRMHP) 78 Veterans Bureau (US) 15

132 Index Veterans Health Administration (VHA) 86 Veterans Integrated Service Networks (VISN) 86 Veterans Millennium Health Care and Benefits Act (1999), US 86, 89 Veterans Mobility Fund (VMF) 78 Veteran’s Mortgage Life Insurance (VMLI) 21 Veterans Pension 81 Veteran’s Preference Act (1944), US 16 Veteran’s Readjustment Assistance Act (1952), US 16 Veteran’s Readjustment Benefits Act (1966), US 17 veterans with disabilities: allowances 23, 25; benefits and services in US 18–21; compared with civilian 19; compensation schemes 11–12; medical disability 25; policies in Israel 23–4; policies in UK 7–9; policies in US 13–18, 14; provisions in Israel 24–5; responsibility 8; schemes in UK 9–10 VHA see Veterans Health Administration (VHA) Victim of Hostile Acts (Compensation) Law (5730–1970), Israel 23 Vietnam Era Twin (VET) registry 65 Vietnam GI Bill see Veteran’s Readjustment Benefits Act (1966), US Vietnam War 17, 26, 59, 64, 66 “vital aging” see “successful aging” vocational rehabilitation 16, 25 Vocational Rehabilitation Act (1950), US 16 Vocational Rehabilitation and Employment (VR&E) 20 Vulnerable Elders Survey 86 Wahl, H. W. 36–8 “War and Social Policy” (Titmuss) 5 War Disablement Pension (UK) 11 warfare: centrality 22; defined 4; operations 100; spending 12 “warfarism” 12 War of Attrition 22, 93 War of Independence (Israel) 22–3, 26, 93, 100–1, 117

War Pensions and Industrial Injuries Division (UK) 9 War Pension Scheme (WPS), UK 11, 57, 58 War Pensions Department (UK) 9 War Risk law (US) 15 Washington, DC 15 Welfare and Health Committee of Knesset 91–2 welfare and warfare 4–27; Beveridgean 6; charities 79; connection 12; defined 4; investment 13; legislation 22–3; nexus 4–5, 22; policies in Israel 22–3; policies in UK 5–9; policies in US 12–13; spending 5, 12–13 Welfare Reforms Act (UK) 7 welfare-to-work programs 12 wellbeing 33; autonomy and 38; psychological 36; subjective 34 Wessely, S. 63 Widows, Orphans, and Old Age Contributory Pensions (1925), UK 5 Wilber, N. 111 Williamson, V. 64 Wilmoth, J. M. 66, 70 Wolf, E. J. 45–7 women’s health 21; see also ex-servicemen/women Wood, D. 63 work-based programs 13 “workfare state” 12 “workfarism” 12 World Health Organization (WHO) 121 World War 1 8–9, 12–13, 15, 18, 57, 79 World War 2 2, 4–5, 7, 9, 12–13, 16, 18, 26, 46, 56, 59–60, 64, 76, 79, 85–6, 91, 117 Wu, L. 66 Yom Kippur War (1973) 22, 24, 69 Yorkston, K. M. 39 Zahal Disabled Veterans Organization (ZDVO) 23–4, 92 Zaineddin, A. K. 47 Zerach, G. 69 Zionist Labor movement (Israel) 22