Wounding Warriors

A new book addresses how a disability program, though well-intentioned, can inadvertently lure veterans away from the worlds of work and community

By Sally Satel, MD

In 2005, Army Lieutenant Colonel Daniel Gade lost his right leg and suffered other extensive injuries in an improvised explosive device attack in Iraq. As he spent months recuperating at Walter Reed Medical Center in Washington, D.C., Gade began to think about the nation’s approach to wounded veterans.

From 2007-2008, he refined his ideas as he worked on veteran issues and military health care in the Bush Administration. He went on to earn master’s and doctoral degrees in public administration from the University of Georgia at Athens and then taught at West Point for six years before retiring from the Army in 2017 after more than 20 years of service. 

During these years, Gade continued to think deeply about ways in which the Department of Veterans’ Affairs could better serve veterans who were physically and mentally disabled.

The culmination of his analysis appears in his new book, Wounding Warriors: How Bad Policy Is Making Veterans Sicker and Poorer, co-authored with former Wall Street Journal reporter Daniel X. Huang. The book, which combines hard data with stories of veterans, VA clinicians, and administrator, describes how a well-intended system can inadvertently lure fragile veterans, step by step, away from the worlds of work and community. 

 “Economists have known for decades that disability insurance benefits create a disincentive to work,” they write. “Rather than foster resilience, the VA is responsible for breeding passivity.”

Gade’s goal in writing Wounding Warriors was not to destroy current systems but “to shine a light on their inner workings in hopes of finding solutions that are effective and moral for the taxpayer, the citizen, and the veteran.”

In what ways does the VA disability system harm veterans?

To this day, the nation stands overwhelmingly behind its veterans. When men and women are maimed in battle, they deserve the best care “we, the people” can muster, including compensation for losses and impairments that cannot be restored. Unfortunately, the path of care and compensation can lead into a quagmire of despair and dysfunction. First, too often disability compensation separates veterans from work, which we know is powerfully important to mental and physical health. Second, overly broad disability “labeling” causes veterans to adopt a disability-focused identity, which marks them as flawed and broken in their own eyes and the eyes of society. Finally, the VA’s laser-like focus on compensation neglects the critical support of re-skilling, up-skilling, and transitioning that our veterans need and deserve. 

When did you realize that these dynamics were at play?

I served in the Army for 25 years and was wounded in action twice. I lost my right leg in combat in Iraq early in 2005, and spent the rest of that year in the hospital. While I was fighting to get better and return to duty, I often saw my fellow soldiers embracing the ‘sick role’ and fighting to get as many free things as they could. Later, while working at the White House and earning my PhD, I began to see that there are powerful interest groups colluding with passive, cowardly legislators to let these bad policies proliferate. Often the medical system is partly complicit: VA doctors we interviewed describe vets who “perform symptoms” and internalize ailments in response to the incentives offered for being disabled—even as they fear the backlash from speaking out. “There’s a great many veterans pretending to have fictitious conditions,” one VA claims professional told us. “And a great many doctors pretending to treat them.”

What are the key policy and philosophy changes you propose?

First, the goal of any system of veterans benefits and care should be to return the veteran as closely as possible to the life situation he or she would be in but for the service rendered. This requires an approach customized for individual veterans, whose background and experiences vary as with any large population. Employment should be the goal of any system of benefits—hopefully to a level that results in the veteran being weaned off of whatever temporary assistance was required.

Second, the system should incentivize desired outcomes by linking treatment with the compensation associated with it. There might be financial incentives too: perhaps a “BMI Bonus,” i.e., if the veteran keeps his body mass index within a certain range, he gets a cash bonus that is some portion of the calculated financial cost of obesity. 

Third, the system needs fundamental reform in the nature and types of disabilities compensated. Those injuries not directly caused by military service might be good targets for treatment but not compensation. The two most common disabilities last year were tinnitus and diminished hearing—neither one seriously disabling. Many other VA-compensated disabilities likely result from the normal wear and tear of daily life and aging than any particular incident during military service. Such a change would allow the VA to spend more on, for example, the veteran whose brain is damaged due to a firefight injury rather than on the (many) veterans who present, say, adult-onset diabetes.

What are the barriers to these improvements?

Serious government reform is difficult and reform of the VA might be the most difficult of all—past attempts have been quickly sunk by vested interests. Rethinking our approach to veterans’ care and compensation threatens the lifeblood of advocacy groups and the politicians who bow to them in order to be re-elected. A close look at past changes shows that what survives the legislative and rule-making process are usually additions to existing programs or the creation of new programs; in effect, the VA grows like a coral reef, adding a little bit here and a little bit there. These accretions over time have created a VA system that is huge, unwieldy, and illogical, as well as being politically protected and exceptionally expensive. And, as we show in Wounding Warriors, the system hurts our veterans.

Have the VA or Congress been receptive to your suggestions?

Behind closed doors—yes. The book’s reviews tell the story: multiple former department Secretaries (Defense AND VA) and other high-level government officials back my approach and consider Wounding Warriors to be a “must-read.”  Unfortunately, until there’s a groundswell of public support, neither VA officials nor members of Congress will have the backbone to say what they privately admit to be true. That’s why we wrote this book: to tell the American people the truth about what is being done and how we can improve it.

Sally Satel is a Visiting Professor of Psychiatry at the Vagelos College of Physicians and Surgeons.