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Trump's VA chief to decide on new Agent Orange ailments

Bob McDonald won't be the VA secretary to decide if thousands more Vietnam War veterans  those with bladder cancer, high blood pressure, hypothyroidism or Parkinson's-like symptoms  should be eligible for VA health care and disability pay because of research associating the ailments with possible exposure to Agent Orange or other herbicides used in the war.

The decision to add any of these ailments to the list of 17 conditions VA already presumes are tied to herbicides will be left for President Trump's VA Secretary, department officials told us Wednesday.

"For this administration, the deadline for proposing new rules for potential new presumptions [of service connection to herbicide] has passed, and this will become work for the new administration to take to completion," VA officials explained in a written statement.

As reported here in March, McDonald convened a working group of VA senior scientists and health experts to study the tenth and final biennial review of health problems linked to Vietnam-era herbicides. The Institute of Medicine (IOM), a division of the National Academies of Sciences, conducted every review. The latest took account of medical and scientific literature published from Oct. 1, 2012, through Sept. 30, 2014.

The IOM concluded that the research supports changing the strength of association to herbicide exposure for several ailments. For bladder cancer and hypothyroidism, it found "limited or suggestive" evidence of a link, an upgrade from "inadequate or insufficient" evidence determined earlier.

Looking again at scientific literature on cardiovascular conditions and herbicides, the IOM didn't upgrade but it did affirm limited or suggestive evidence that herbicides can cause hypertension, or high blood pressure.

The IOM also considered whether conditions resulting in Parkinson's-like symptoms, apart from Parkinson's disease itself, should fall into the same limited or suggestive category of evidence. Yes, it concluded, finding "no rational basis" for the current exclusion.

The IOM also withdrew an earlier finding that herbicide exposure may have caused spina bifida in children born to Vietnam veterans. For 20 years VA relied on a preliminary finding of an association. Based on newer research the IOM says it no longer believes the evidence shows service connection.

Dr. Ralph Loren Erickson, chief consultant of post deployment health services for the Veterans Health Administration, has co-chaired the working group reviewing the recent IOM findings. He predicted last March that McDonald could get final recommendations in time to decide by August whether to expand the Vietnam-era list of presumptive diseases. That didn't happen, however. One official said the group got diverted to other work including VA's announcement in September of eight diseases linked to contaminants found in the water supply at Camp Lejeune, N.C., before 1988.

An Agent Orange law that Congress allowed to sunset last year would have required the VA secretary to take action on IOM recommendations within 60 days of receiving its report, in this case by last May

The VA technical work group now expects to have a draft response and action plan on findings of the IOM, renamed the National Academy of Medicine, by early December. The packet then will be given to a VA IOM Task Force before recommendations are made to the secretary. By then, Trump will be president and VA presumably will have a new secretary.

"Limited or suggestive" epidemiological evidence that a disease is associated with herbicide exposure means a link to increased risk for a health effect. But the term doesn't always produce a decision to presume service connection. For some ailments, including ischemic heart disease, VA secretaries have used "limited or suggestive evidence" to add to the presumptive list of Agent Orange diseases. For others, including hypertension, which is suffered by two thirds of Americans 65 and older, the same evidence hasn't been seen as strong enough.

VA APPEALS STAAB DECISION  We reported here last August that more two million claims for VA reimbursement of private sector emergency healthcare services since February 2010 could be allowed veterans enrolled in VA health care, under an July ruling from the U.S. Court of Appeals for Veterans Claims in the case of Richard W. Staab v. Robert A. McDonald.

In part because that decision, if allowed to stand, would cost VA as much as $10.6 billion, the department has filed an appeal to the U.S. Court of Appeals for the Federal District, which could take another year to resolve.

For many years VA has maintained that, by law, it can reimburse VA-enrolled veterans for outside emergency care only if they have no alternative health insurance including Medicare, TRICARE, employer-provided health insurance or contracted health plans. The practical effect has been that veterans with other health insurance get stuck paying hefty out-of-pocket costs their plans won't cover while veterans with no other insurance see VA routinely pick up their entire emergency care tab.

This irked Congress enough by 2009 that it tried to clarify the law on VA coverage of outside emergency care, adding language that VA could "reimburse veterans for treatment in a non-VA facility if they have a third-party insurance that would pay a portion of the emergency care."

The change took effect Feb. 1, 2010. But in preparing new regulations, VA officials interpreted the revised law as still preserving its old way of screening most emergency care claims. That was wrong, ruled the appellate claims court last April, citing "plain language" of the revised statute. Last July, the full court upheld the decision.

VA filed a motion to "stay the precedential effect" of the decision  that is, to not require payment of any previously denied emergency claims, given the "strong likelihood" the decision will be reversed. So VA hasn't yet paid any emergency care claims Staab would require, explaining that to do so requires new regulations to support a complex claims review process.

Meanwhile, VA has suspended consideration of tens of thousands of claims for emergency care that it previously would have denied.

VA estimates if Staab is not reversed, 68 million more claims for emergency care would be eligible for reimbursement over the next decade.

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