Military retiree benefits: did the government keep its promise

¶ … military retirees are entitled to the sheer enormity and the scope of the endeavor are so gigantic that it borders on the overwhelming. The United States government has a plethora of benefits that encompass the health, welfare and continued treatment of medical issues involving the service men and women throughout the Armed Forces. There are also numerous retirement benefits, for instance members of the U.S. military receive various health benefits, retirement and Social Security incentives and significant Cost of Living Adjustments. These benefits, among numerous others are part of an attractive package that military recruiters utilize to attract young men and women to serve in the armed forces.

The largest benefit of all is the G.I. Bill which provides for educational expenses for all active and retired military members. This Bill, passed in the 1940's essentially covers the cost of education for military members through the general revenue funds of the United States Government. The G.I. Bill in conjunction with the variety of benefits that military members retain due to their service constitutes promises and agreements that the Federal Government has made to the members of the military. These promises constitute a relationship between the Government and the military members. This portion of the Introduction will review the main benefits the Federal Government bestows upon those that serve in the Armed Forces.

Discussion

The main benefits of those that serve in the U.S. military extend from educational, financial and health care and medical benefits. There are numerous departments within the Department of Veterans Affairs that handle the plethora of benefits that all military personnel take advantage of. The first benefit is obviously, the pay the military retirees receive. According to the latest Department of Defense Military Officer Pay Schedule, those Military Officers that retire with significant service records and years of experience are eligible to retire with significant amounts of pay. Those retiring as officers with upwards of 20 plus years of service will receive approximately $11,000 in military pensions per month. This represents a significant amount of pension funds distributed to military retirees, in total; an individual qualifying for such amounts of retirement pay can aggregate upwards of over $130,000 in retirement pensions. In addition to the pensions that military retirees are entitled to there are other benefits in terms of insurance; the most important benefit is those that involve health and medical coverage.

In October 1996, Congress passed the Veterans' Health Care Eligibility Reform Act, paving the way for the Medical Benefits Package plan, available to all enrolled veterans. The Medical Benefits Package emphasizes preventive and primary care, offering a full range of outpatient and inpatient services. In addition combat veterans returning from active military service may be eligible to receive free health care services and nursing home care for up to two years, beginning on the date of separation from active military service. This benefit covers all illnesses and injuries except those clearly unrelated to military service (common colds, injuries from accidents that occurred after discharge, disorders that existed before joining the military). Dental services are not included. The important designation within this section is the idea of "combat related" injuries. To this end the Veterans Administration has published several guidelines regarding the benefits that military veterans and retirees are entitled to regarding these various conditions.

The Veterans Administration has adopted several medical packages they offer to retirees and veterans. Each package contains numerous benefits and policy restrictions. The most commonly offered package is the Military Benefits Basic Package. This package contains provisions for a variety of conditions and offers coverage within a variety of contexts. The most common provisions within this package is Outpatient medical, surgical, and mental health care, including care for substance abuse; Inpatient hospital, medical, surgical, and mental health care, including care for substance abuse; Prescription drugs, including over-the-counter drugs and medical and surgical supplies available under the VA national formulary system; Emergency care in VA facilities; Emergency care in non-VA facilities in certain conditions: This benefit is a safety net for veterans requiring emergency care for a service connected disability or enrolled veterans who have no other means of paying a private facility emergency bill. If another health insurance provider pays all or part of a bill, VA cannot provide any reimbursement ("Military Advantage," 2010).

The Basic Benefits Package also provides for preventative care including immunizations, periodic medical exams, health care assessments and medical screening tests ("Military Advantage," 2010). This is only one example of the myriad of benefits that military retirees are entitled to. One other important benefit aspect and one that will be discussed within the Literature Review, is the Civilians Health and Medical Program from the Veterans Administration. This program was adopted shortly after the creation of Medicare to provide for those veterans and retirees to young to qualify for Medicare. In general the CHAMPVA program covers most health care services and supplies that are medically and psychologically necessary. Upon confirmation of eligibility, beneficiaries will receive program material that specifically addresses covered and noncovered services and supplies in the form of a CHAMPVA handbook ("Military Advantage," 2010). In addition to the health care and medical insurance the military retirees are entitled to receive there is yet another benefit related to health coverage that military veterans are entitled to receive. The United States military offers Life Insurance to all of its veterans and retirees.

This insurance is referred to as the "Servicemen's Life Insurance Guarantee." SGLI is a VA program that provides low cost group life insurance to members of the Uniformed Services, including commissioned officers of the Public Health Service and the National Oceanic and Atmospheric Administration, cadets and midshipmen of the service academies. Members are automatically insured under Service members' Group Life Insurance (SGLI) for the maximum amount of $400,000 unless an election is filed reducing the insurance by $50,000 increments or canceling it entirely. In addition the SGLI coverage now includes Traumatic Injury Protection. This coverage provides service-members protection against loss due to traumatic injuries and is designed to provide financial assistance to members so their loved ones can be with them during their recovery from their injuries. The coverage ranges from $25,000 to $100,000 depending on the nature of the injury ("Military Advantage," 2010). These benefits are only a sampling of the many benefits military retirees receive, to devote space to discussing all of the benefits would ultimately lead to an entire dissertation simply discussing the benefits for military retirees and their dependents. The advent of all these benefits has been the saving grace for countless disabled veterans and retirees. However, the creation of these benefits has lead to some to falsely claim they were "promised" certain benefits-namely, the access to free health care and that this access is "guaranteed." This is the problem that is the cornerstone of this dissertation. The main premise of these groups that argue from this standpoint is that the government "promised" that all veterans would have access to "free" healthcare after they served in the United States military.

However, after examining the massive body of work devoted to explaining the benefits as promulgated by the United States Veterans Administration it can be logically deduced that nowhere in any of the information does it say that access to "free" health care is in fact "guaranteed" and furthermore, it does not contain any language that creates or establishes the existence of a "promise" or "contract" between the military member and the various branches of service. However, this does not prevent these so-called "Veterans' Advocacy Groups" from filing suit, rallying veterans and falsely claiming the government violated its promise to all veterans. The remaining portion of this chapter will focus on the nature of this problem and what will be done to analyze it.

Nature of the Problem

The very nature of the problem presented within this thesis is the entire definition of the word "promise." The term "promise" typically has a universal connotation inherently expressed. However, there are some that are bent on continuously modifying this simple word in order to achieve a certain goal or objective. Currently within the United States there are numerous groups that are couching themselves as "Veteran Advocacy Groups" that are encouraging veterans-their target audience is disable veterans-to engage in litigation against the various branches of the United States Military and the Department of Defense under a "breach of contract" theory claiming the Defense Department was willfully negligent in their violation of the "contract" that was established between the military and the service member to provide for certain benefits after their time of service was completed.

These group's typically produce claims that convey the story of an individual who most likely served upwards of 20 years in the Army, Navy or Air Force and is significantly disabled and ultimately was denied access to a physician under the auspices of "free" health care from the Veterans Administration. Although these arguments are emotional and pull at the very fabric of which we are as Americans, they lack the legal, logical and evidentiary support necessary to be deemed a credible argument.

First of all only a scant few of these Veterans groups will acknowledge the "promise" of free health care; for the most part these groups will tout the benefits already promised by the Veterans Administration and assert that cuts in these benefits are the same a broken promise-or contractual breach in legal terms. The idea of the United States military making a "promise" or forging a legally binding agreement between individual veterans or groups of veterans is barred by the United States Constitution. As will be demonstrated in the Literature Review, specific Constitutional language from Article I give Congress and only Congress the express authority to make laws and regulations pertaining to the armed forces. Therefore, the idea the military breached a contract with service members is, ultimately, inherently inaccurate. Combining the lack of specific language within the materials provided by any governmental agency with the clear language of the Constitution, it becomes readily apparent that there is no validity to the claim of the Government breaking any contractual relationship with veterans, either individually or collectively.

Some of these groups are also fraudulently acting on behalf of veterans-although the data suggests that the overwhelming amount of such groups are legitimate and are pursuing legitimate causes; however the need for examining these fraudulent groups is imperative for a comprehensive analysis. The most recent example of a fraudulent veterans group is seen in the case of the United States Naval Veterans Association -- a group that raised upwards of $40,000 this past fiscal year in donations (Birkey, 2010). The lynchpin, however, is that the group is a fraud. No money has ever gone to one veteran, hospital, charity, clinic or center. In total, nearly $100,000 in fraudulently obtained donations went into the pocket of the group's founder Robert Thompson (Birkey, 2010).

Groups such as this are at the root cause of the problem when it comes to veteran's advocacy groups, it is extremely difficult to distinguish between the legitimate, and cause oriented group and those who are only after the innocent donations of Naval Veterans. Focusing on the legitimate veterans groups brings the nature and complexity of this issue into stark reality. One such group referred to as "The Retired Military Advocate" goes into great detail as to the nature of the promises that have been broken between the military and the veteran.

On their website, the group states the following:

"The breaking of the military retiree medical care promise:

In the process of down sizing the United States Military, a large number of military bases and military treatment facilities have been closed. This has created a situation where inadequate space is available to accommodate the military retiree community. As a result, the medical care that was promised to the military retiree is being denied by the United States Government." (2010).

Language such as this begins to lay out the nature of the problem. There are those whether they be individuals or groups that continue to think the closure of various VA facilities and the inability to service all veterans who seek "free" health care is a breach of the promises that Congress and the Department of Defense has made to veterans and retirees. Where do these individuals and groups ascertain the information necessary to formulate the attitude that a promise was conveyed in the first place? The answer to this question requires a bit of historical purview. This purview is also stated on "The Retired Military Advocate" website. The group states the following:

"In November of 1951, because of the military draft, I had to make a choice. I could volunteer to join or be drafted into the military. At that time I did talk to a military recruiter and I volunteered to join the military. I was told by the military recruiter that medical care would be provided for me and my wife while I was on active duty, and medical care after retirement was mentioned. I was very interested in the immediate medical care since I could not afford insurance based on what I would be paid. In November of 1951 I was not concerned about medical care after retirement because I had no interest in a military career, but because of later promises I changed my mind" (2010).

This text is the relaying of an experience by a member of the group detailing their experience as a young, eager recruit who was informed of the prospect of medical care after service. Again what is not mentioned in any of this language is that the medical care will be "free" and be provided "on-demand." This is further evidence that supports the premise the Government has indeed fulfilled its promise to its veterans and retirees. How can this research conclusively prove the premise, that seems so readily apparent, that the United States Government has kept its promise, did not breach any contracts with veterans?

This question will be answered by the use of statistical analysis and integration of predictive models to demonstrate the causal relationship between various variables. Through the use of advanced

Quantitative methodology techniques, the data compiled from a variety of government and Veterans Affairs databases will be used to compare and establish both positive and negative correlated relationships. This analysis will examine the data stemming from the Veterans Administration's facilities in what is defined as the Western Region of the United States, consisting of Montana, Oregon, Washington and Idaho. These states will provide the data to construct a predictive model for the level of care, quality of care and the relationship between these data points and the degree of severity of the physical, mental, psychological and behavioral disorders that are plaguing veterans.

There will be a variety of statistical tests that will be utilized to determine the very nature of the relationships and whether the data is correlated or suffers from a high degree of variations which in turn will increase the margin of error. These tests include the Linear Regression Model, Chi-Square and ANOVA Tests. The formulas for each of these tests are presented in the Methodology Chapter. The predefined level for determining significance of these tests is .05, this indicates that if any of the critical test statistics are greater than .05 then the results are statistically significant and based on a viable relationship and not random chance.

Through the analysis of the raw data and the incorporation of a variety of statistical analytics it will be determined that there is no validity to the hypothesis that over the years the Government has broken any promise to any military retiree; furthermore, it will be shown through data examination that the enormous amount of patients and cases that are diagnosed is indicative of the ever present, cognizant relationship the government has with the veterans of the armed forces.

Chapter 2: Literature Review

Theoretical Constructs

There are numerous theories that are present within the body of literature that discusses the current status of military benefits directed toward military retirees. However, many of these theories deal with the issue itself at a more detailed, policy orientated vantage point. Therefore, the main theory that is at hand within this literature review is the military has kept its promise to military veterans and military retirees in terms of benefits that have been promised. This literature review will examine the massive body of work that revolves around this theory to create a framework that substantiates the main premise of this research: the government has honored its commitment to military retirees in providing the vital benefits they deserve and were guaranteed.

Literature Review

Each year hundreds of veterans and military retirees' claim they experience a continuing decline in their military medical benefits and further assert the governments' promise of guaranteed health coverage and physician access has been violated. They generally use as precedents that medical care that is previously available to them is no longer present. A contention, they claim, that substantiates their premise that the "promise" made to them by the Federal Government has indeed been broken. Another common argument is that the larger medical institutions that existed during the Cold War provided more access to health care and medical services.

These individuals assert that the regular cuts exacted upon the Department of Defense and the resulting reduction in size of the Defense Department is the core reason for the reduction in military benefits for veterans. The coalescent of these events have lead to the popular uprising of groups that portend to work for veterans under the auspices of "broken promises" that seek to reclaim those benefits the government "promised" but fail to deliver. In certain instances, organizations representing military retirees have alluded to "broken promises." Some individuals have claimed that these benefits include "free" health care for life, or more liberally, "free care for life in military health care facilities." As emotional as these contentions are, the body of literature shows these arguments are not supported by the vast amount of legislative history regarding this issue.

The vast amount of literature on this issue involves, inevitably, the growing body of bills introduced into Congress to expand medical care for military veterans and retirees. Numerous bills introduced into the Congressional Record seek to both increase applicability of existing protocols and also to enhance funding for medical care and benefits for military veterans and retirees.

Reports accompanying both House and Senate defense authorization bills (H.R. 1588/S.1050) include provisions encouraging better access to health care providers as part of Tricare Standard (Best, 2003). . These provisions were included in response to reports that civilian health care providers in some areas are not accepting new Tricare patients (Best, 2003). The Senate-passed version of H.R. 1588 includes provisions offering Tricare to certain Ready Reserve personnel, with annual enrollment fees ranging from $330-$610 (Best, 2003).

However, in a floor statement on July 16, Senator Graham of South Carolina indicated the likelihood of a compromise entailing a study of the best way to provide Tricare coverage to Guard and Reserve members in terms of cost, affordability, and availability (Best, 2003). Further action would be envisioned next year. Medicare reform legislation (S. 1/H.R. 2473) currently in conference contains provisions that would waive penalties for military retirees who enroll late in Part B of Medicare to become eligible for Tricare for Life (Best, 2003).

Further evidence of the commitment between the Government and military retirees was demonstrated within the 108th Congress when the 108th Congress, at least two of these bills (H.R. 58 and S. 56) cite a "promise" or "commitment" as the rationale for provisions that would "restore health care coverage to retired members of the uniformed services." Although previous attempts to pass such legislation have failed, Congress substantially expanded the military retiree health care benefits via the FY2001 National Defense Authorization Act (Burreli, 2008).

The premise underlying the rights of the Congress to dictate the regulations governing the military has its roots in the United States Constitution. Pursuant to Article 1, Section 8, Clause 14 the United States Congress has the authority to make rules for the Government and Regulations for the land and naval forces. Therefore any "promise" of health care on behalf of the military can only come from the United States Congress and only the United States Congress. The military cannot under any circumstances make any promise or create any "contract" with its service members and retirees to provide any entitlement for health care or medical coverage.

The idea of the United States Government providing for the welfare of the military men and women is not a novel concept. This ideal has been promulgated since the early days of the Republic. In 1799, the United States Congress enacted a law authorize the federal government to provide for the health and welfare of all land and naval officers fighting on behalf of the United States (United States House Armed Services Committee, 1974). However, there is no evidence in any of the case law or literature that suggests or even implies a contractual agreement between the armed forces and its members that establishes some sort of "entitlement" to medical benefits for military retirees.

This logical construct however, does not dissuade those "veterans' advocacy groups" from taking advantage of the situation. Many-if not all-of these groups claim that a contract was made between the military and its members when the military promised free health care to all of its members upon retirement and the denial of these benefits or reduction of them is a violation of their contract with military members ("The Retired Veterans Advocate," 2010). These groups contend, vigorously, that a contract does exist and provides for terms that express a level of care guaranteed to all service members-however despite repeated court cases and appeals, the courts continue to assert that no contract exists and if it did it would be in direct contrast to the well established Constitutional provisions as stated previously. Some of these cases are explained in the following sections.

In 1956, Congress made the provision of medical care to members of the military a federal law. This law states, in part:

"a member or former member of a uniformed service who is entitled to retired or retainer pay, or equivalent pay may, upon request, be given medical and dental care in any facility of any uniformed service, subject to the availability of space and facilities and the capabilities of the medical and dental staff"( 10 United States Code, sec. 1074(b))

The critical aspect of this provision is the words "may" and "subject to availability." The presence of these words indicates that there is no "entitlement" for an "entitlement" suggests that an individual is "entitled" to receive something, a good or service, regardless of the availability and capacity. However, this portion of the governing U.S. Code does not make such a guarantee. The further evolution of this provision and the increased development of the commitment of the Federal Government to the military's welfare is seen in the development of CHAMPUS in 1965 as a result of the Congress and the Johnson Administration enacting Medicare that guaranteed health care coverage for those over the age of 65. The problem emerged regarding those members of the military that were retiring at younger ages, younger than 65.

Those military veterans retiring before the required age for Medicare were not guaranteed health care or medical coverage during the "doughnut hole" period. As a direct consequence, the United States Congress passed a bill creating the Civilian Health and Medical Program of the Uniformed Services (Burrelli, 2008). This program was modeled after the Blue Cross Blue Shield private insurance model that was a fee-for-service benefit model (Burrelli, 2008).

Although there was no premium associated with this plan, there was a form of cost-sharing that each participant was required to undertake, CHAMPUS was not free by any means however it provided a critical stop-gap measure to ensure those veterans retiring before they became Medicare eligible did not go without health care. The enactment of CHAMPUS further serves to demonstrate the main theory within the literature and that is the U.S. government has done everything in its power to ensure those entitled to health care that have served the United States receive it.

The advent of CHAMPUS has further fueled so called Retired Veteran Advocate groups to further assert their claims the government is violating their promise to veterans. One such group calling itself "The Military Retirees Grass Roots Group" makes bold claims on its website. These claims assert that "those who served a minimum of 20 years in the U.S. military during the 1940's and 50's were promised; free medical care for life after their retirement... For themselves and their dependents" ("The Military Retirees Grass Roots Group," 2010). Furthermore, this group goes a step beyond this claim and makes another, even bolder predication. They state "those who retired after 1957 were made similar promises [with conditions]... But were still promised free lifetime medical care on a space available basis. This promise was made to all members of the Air Force, the Army, the Navy, the Marines and Coast Guard and continued into the 1990's when it was stopped by the massive BRAC effort of the Clinton Administration" ("The Military Retirees Grass Roots Group," 2010).

As emotional as these claims are they lack substantive support. Throughout the entire body of literature, including the majority of which, is United States Case Law and Judicial Opinions there is no factual basis to assert the proposition the U.S. Government provided any sort of contractual agreement with members of the military either active duty or retirees to establish an entitlement to free health care. Many groups however assert that representations were made by military recruiters and these representations constitute a binding promise to fulfill certain obligations once the military member retires.

In a memo to Congress, Richard Best of the Congressional Research Service, stated in 1997, that the provisions of the 1956 statute did not create an express entitlement to health care and therefore even if the recruiter made verbal representations, the written statutes supersedes any verbal representations or promises made by the recruiter and therefore, there is no binding contract between the military and the veteran or retiree. It also observed that this de facto availability was, without question, a useful tool for recruiters. The end result appears to be that, regardless of the lack of statutory entitlement, many active duty personnel and their dependents, and retirees and their dependents, erroneously came to believe that they were guaranteed free health care in military facilities for life (Burrelli, 2008).

In 1993, the United States Congress held hearings to ascertain a level of clarity as to what exactly had been promised to the retiring veterans once their time of service was completed. In response to Vice Admiral Hagan's testimony, Rear Admiral in Charge of Benefits and Administration Harold Koenig stated before Congress the following clarification statement regarding promised benefits:

"There is a problem here of interpretation. [Vice Admiral Donald Hagen, Medical Corps Surgeon General, U.S. Navy] said medical care for life. That is true. We have a medical care program for the life of our beneficiaries, and it is pretty well defined in the law. That easily gets interpreted to, or reinterpreted into, free medical care for the rest of your life. That is a pretty easy transition for people to make in their thinking and it is pervasive. We spend an incredible amount of effort trying to reeducate people that that is not their benefit" (U.S. Congress. House. Committee on Armed Services, National Defense Authorization Act for Fiscal Year 1994, H.R. 2401, Hearings, 103rd Cong., 1st Sess., H.Rept. 103-13, April 27, 28, May 10, 11, and 13, 1993: 505)

The clarification offered by the Rear Admiral in charge of benefits and administration makes abundantly clear that free medical care for life for military retirees and their dependents are not part of their retiree benefits; therefore the construing of the benefit programs available to military members as somehow providing free medical coverage for life is unfounded and lacks basic support either in law or fact. This lack of evidentiary support is found in the numerous court cases that have arisen out of the misguided attempts of various veterans' groups to assert that such a cause exists.

In 1997, the United States District Court of Appeals dismissed a case filed on behalf of a class of disaffected veterans who were asserting the logical premise that they had been denied free health care and medical coverage that was promised to them by their recruiters and the entire United States military as a precondition of their years of service. These plaintiffs were asserting their supposed legal "right" to free heath care from the military. The U.S. Court of Appeals stated the following in denying the plaintiffs' claim and dismissing the suit:

"The court must reject plaintiffs' contention that [10 United States Code sec.

1074(b)] confers authority on the military branches to guarantee free lifetime medical care to retirees and their dependents. First, plaintiffs cite to no regulation under sec. 1074(b) guaranteeing such care, but only cite to recruiting materials that make general representations as to eligibility for continued health care for retirees and their dependents.

Even if the military departments had promulgated regulations under sec.1074(b) that make an unequivocal promise of lifetime medical care for retirees and their dependents, the language of sec. 1074(b) itself is clearly conditional. Any regulations purporting to guarantee free and unconditional lifetime health care to retirees and their dependents would be inconsistent with the statute and therefore invalid. Larionoff, 431 U.S. At 873

n.13 ("A regulation which ... operates to create a rule out of harmony with the statute ... is a mere nullity.") (citing Manhatten General Equip. Co. V.

Commissioner, 297 U.S. 129, 134 (1936)).

Furthermore, under sec. 1074(b), "a retired member of a uniformed service is not entitled to medical care as a matter of right," Lord v. United States, 2 Cl. Ct. 749,

756 (1983), and "retired personnel who fail to receive such care cannot successfully maintain an action for money damages based on such failure." Id.

At 757; see also Watt v. United States, 246 F. Supp. 386, 388 (E.D.N.Y. 1965 )

("furnishing [medical care in a military facility] to a retired soldier is discretionary, not mandatory"). Because the law states that retirees are not entitled to health care as a matter of right, the representations upon which

plaintiffs rely are to no effect" (Coalition of Retired Military Veterans, et al. v. United States of America).

The first paragraph of the Court's opinion clearly states the no legal basis within the Congressional Statute to provide any member of the United States military with free health care for life. The Court in Coalition of Retired Military Veterans discussed the issue of the proposed "promise" that many of these veterans' groups portend was made at the outset of their service. The Court states that "employers who hire individuals for a specific role or job and make verbal representations and then proceed to disappoint their employee or employees do not create a prima facia case of contractual breach and subsequent contractual liability" (Coalition of Retired Military Veterans, 1997). A similar case came before the United States District Court in 1999.

This case, Shimer and Reinlie v. The United States, asserted that the Department of Defense had created a contractual obligation to provide free health care to all veterans on an "on-demand" basis. The court in its ruling stated:

"Nothing in these regulations provided for unconditional lifetime free medical care or authorized recruiters to promise such care as an inducement to joining or continuing in the armed forces. While the Retirees argue that the above mentioned section 4132.1 gave those of them who served as officers in the Navy

and Marine Corps the right to free unconditional medical care, we cannot agree.

The [1922 Manual of the Medical Department of the United States Navy]

Manual provided guidelines for the Navy's Medical Department, but did not create any right in such officers to the free unconditional lifetime medical care they claim. It related only to hospital care, not the broader services that these

Retirees seek, and covered only the period when it was in effect. In any event, in view of the general pattern of the military regulations that provides medical care to retirees only when facilities and personnel were available, we decline to read into the creation of such an enduring and broad right to unconditional free lifetime medical care.

In sum, we conclude that the Retirees have not shown that they have a right to the health care they say was "taken" by the government. Since the basic premise of their claim fails, their taking claim necessarily also fails" (Reinlie, 1999).

This is yet another example through the literature regarding the lack of plain, evidentiary support for those claims that assert any type of legally binding, contract was ever established at anytime between the Government, Department of Defense or individual branches and veterans.

Chapter III: Methodology

Introduction

The main method of data analysis for this thesis will involve the use of Quantitative Methodologies. This methodology encompasses a variety of specific, statistically derived techniques. Throughout this analysis, various statistical calculations, derivations and mean comparisons will be conducted in order to gauge the level of access and its relation to veterans' benefits for those veterans living in the Mountain West. This chapter of the dissertation provides a brief overview of the methodologies that are to be implemented within this research. Furthermore, this chapter will provide a general overview of the nature of Quantitative methodologies. Finally, this chapter will conclude with an overall review of the methodology, population sampling and process used to measure the data contained within this thesis.

Discussion

In order to fully appreciate the nature of Qualitative Analysis, a working framework must be established in order to adequately the intricate nature of Quantitative Analysis and the various factors that go into constructing statistical models. Furthermore, the formulations use in constructing the various statistical predictors and measures of data variation will also be included in this section.

The field of Social Science research demands that researchers construct models and predictive analysis that can provide the vital information that is necessary to determine if something, a relationship, phenomena, occurrence is statistically significant. If something is defined as being statistically significant, it is usually determined the relationship, variables or data in question is not predicated on random chance but rather is based on a relationship, be it causal or otherwise. Traditionally, there are three various levels of statistical analysis that are utilized within social science research. Normally, it is customary to only include one of these statistical methods; however some researchers dealing with difficult problems may find it necessary to include more than one or even all three methods. These methods are: (1) Descriptive Statistical Analysis; (2) Inferential Statistics and (3) Relational Statistics.

Differential Statistics can be further broken down into two sub-categories, measures of central tendency (mean, median and mode) and measures of dispersion (standard deviation and variation). This is the more common form of statistical analysis utilized within Quantitative Methodologies. In part this will be the form of analysis utilized within this research in terms of utilizing the Chi-Square and ANOVA calculations. Relational Statistics include three categories of variables, univariate, bivariate and multivariate.

As the names suggest, uni, bi and mulit refer to the number of variables these analysis tools are examining. In social science research it is common for researchers to examine the relationship of two variables revolving around constant phenomena or on variable in relation to a given stimulus. The final form of statistical analysis is Inferential Statistics. These statistics which includes, Chi-Square and ANOVA is usually divided into two further subcategories of analysis, test for differences of means and tests for statistical significance, this category can be further broken down to parametric vs. non-parametric statistics. The purpose of the difference of means test is to determine the level of correlation between related variables and furthermore, to test the strength of a hypothesis that has been constructed to explain why certain variables are behaving in a specified manner. The most common tests for mean difference is the Student's T-Test or the "Z"test; however the most common test for statistical significance, which will employed within this research is referred to as the "F-Test" or more commonly known the "Chi-Squared Test." This test is useful for determining the relationship between variables is a valid relationship or if the correlation between these two variables is based on random chance. Furthermore, another more common Inferential Statistical test is the ANOVA. ANOVA is an acronym for Analysis of Variation Analytics. This test statistic determines the level of variation in the data which could impact Chi-Square Testing. The formula that will be used for the Chi-Square and ANOVA analysis are given below.

The formula that will be used in this Quantitative Analysis for Chi-Square is presented as:

The chi-square test for contingency is interpreted as strength of association measure, while the chi-square test for independence (which requires two samples) is a nonparametric test of significance that essentially rules out as much sampling error and chance as possible. The ANOVA formula is a bit more complex and is presented below. This formula will be used through the Quantitative Analysis.

At the outset of this quantitative analysis is the issue of data mining. Where is the data regarding access to quality health care for veterans in the more remote western portions of the United States coming from? In order to ascertain this information, it was necessary to engage in a qualitative review of the documentation related to the issue of veterans' access to health care. These documents included, the Combined Assessment Program of the Veterans' Administration for Montana, Idaho, Washington State and Oregon; the 2003 OMI Report Veterans' Administration HealthCare System as analyzed within Montana; Review of the Quality of Care within the Veterans' Administration and the Uniform Mental and Physical Services in Western State Veterans' Administrations Centers and Clinics. These documents provided the requisite information and data regarding the current state of access to both mental and physical health care for those military veterans and retirees within the Western region of the United States. Additionally, statistical data was compiled from the Veterans' Administration itself regarding the number of western veterans' seeking health care for both mental and physical disorders. This dissertation does not make any distinctions between mental and physical health disorders. The main principle is that veterans suffering from a wide variety of disorders (both physical and mental) seek access to quality care and according to some groups the "promise" of free access to adequate health care has been broken. Therefore, it did not make any rational sense to segregate the two forms of disorders.

Once the appropriate standards for review were established by using these documentary supports, the Veterans' Administration's Database was utilized to ascertain the appropriate sample population. This database provided the information pertaining to the number of veterans who retired between July 1, 2009 and July 1, 2010 and were currently living in the Western United States. This geographic area was defined as encompassing the states of Montana, Idaho, Washington and Oregon. The personal information of these veterans was not included in this database and not relevant to the research. This database provided the number of veterans who were actively seeking or who had sought access to health care through the various Veterans' Administration centers, hospitals or clinics. To ensure accuracy, this database is monitored and maintained by the Office of the Inspector General for the Veterans Administration to ensure that not personal data related to military retirees and veterans is used for illicit purposes. This database receives its information from the Department of Defense and combines with the Veterans Affairs to form the first and only comprehensive database of its kind to effectively monitor the number of veterans currently seeking access to health care through the Veterans Administration.

The OIG's descriptive report on the LC database, Quantitative Assessment of Care Transition: The Population-Based LC Database, was published in September 2007. The report describes the LC database in detail, including an overview of its structure, the methodology used to create it, data confidentiality issues, and the opportunity it provides for VA to make decisions using an evidence-based approach. Now that the validity of the database used to ascertain the raw data used, it is time to discuss the data derived from specific aspects of care provided by the Veterans Administration.

Disability Compensation (DC) is an extensive component of the Veterans Administration's benefit policy for military retirees and their dependents. One could logically assert that the overwhelming majority of services offered to military retirees and veterans have something to do with DC. If one were making this assumption, one would ultimately be correct. According to a recent study conducted by the Veteran's Administration, close to 75% of all claims paid out and reasons for seeking quality care involves some form of disability. Therefore, it is imperative this data be analyzed in regards to the main thesis of this research.

Disability Compensation has the aim of compensating veterans for lost income as a result of either their mental or physical disability sustained from events related to serving in the United States Armed Forces. There is an extensive process that veterans must embark upon in order to secure their disability payments. First, the veteran must submit a disability claim form to their Regional Veterans Affairs Office. Once this claim has been submitted, the RVAO schedules a physical to determine the severity of the condition and what the extemporaneous factors related to the condition entail. There is a three tiered system for "coding" the degree of disability the veteran is claiming. These tiers include: (1) What specific Body Systems are involved, i.e. heart, liver, brain, etc.; (2) What are the Specific Conditions-hypertension, jaundice, depression and (3) What is the severity of the disorder. Based on this system of evaluation, the veteran seeking disability will receive compensation in the range of 0% (in theory, although data demonstrates this is not the case) and 100% (again, mostly in theory although the data does predict this does happen in certain cases).

In order to incorporate this data into the overall statistical analysis related to the thesis of this research, several disabilities were added into the analysis. These specific disability "ratings" were included and compared to the overall disability "ratings" for the individual conditions at the end of the time period being analyzed. The theory predicating this inclusion was that it would bring into focus the extensive nature within which the Veterans Administration must operate to ensure that all military retires and veterans receive adequate care. It was determined that working with disabilities directly and showing a causal relationship between the degree of disability and the coinciding level of funding a veteran received from the Veterans Administration would demonstrate, in fairly stark terms the extent to which the government has kept its promises to veterans by providing access to quality medical services. This information was procured from the Benefits Delivery Network Database -- a database that encompasses the entire spectrum of disabilities and benefits paid out to veterans depending on "rating" and specific disability.

Thus far the data and methodology demonstrated thus far have involved information regarding specific numbers of veterans seeking care and the type of disorder, diseases and afflictions they are seeking treatment for. However, the remaining portion of the data discussed and the methodology used to analyze it will focus on the core of what this dissertation has predicated its thesis on-access. The access to quality health care provided by the Veterans Administration for those veterans living in the Western United States; this section will discuss the data used in this portion of the research and the methodology incorporated into the analysis.

The Veterans' Administration requires compensation at the time of services, otherwise known as "Fee for Service." This fee agreement is carried out either by contractual agreement between the doctor and the patient or through the more traditional "fee basis." This methodology did not discriminate between either of these two methods as they do not have any bearing on the issue of access, this dissertation leaves the policy meaning of access for another time. However, this dissertation does segregate out the three various types of treatment that veterans seek access to health care for. These three variations in treatment are: (1) Medication only; (2) Therapy only and (3) a combination of Medical treatment and therapy. According to the data analyzed, those veterans with Post-Traumatic Stress Disorder are the most likely of veterans to seek the third option, a combination of both medication and therapy.

All veterans within the Western United States were incorporated into the quantitative analytical model by using what is referred to as "geo-coding." This type of coding within the social sciences utilizes software to translate a veteran's address into a specific geographical location-therefore ensuring their continued privacy and maintaining compliance with all federal and state laws and administrative regulations. This type of "coding" is imperative to establishing the "dependent variables" that can impact the access to quality of care. If there is an impediment to veterans receiving adequate care as promised by Congressional statute then it should be determined that exigent factors beyond the control of the United States Government play a role in this determent.

This information was procured from the Department of Policy Analysis and Forecasting within the Department of Veterans Affairs. Their information translated the address of all veterans within the Western States, as previously defined, and translated their specific locations into longitudes and latitudes. This assisted greatly in the construction of the data representation graphs that will demonstrate the impact of the dependent variables.

The PA&F Department within the VA further created a series of time-bands representing the travel time of specific groups of veterans related to where they were located within the Western States. These time bands were delineated along traditional lines; five separate time bands indicating the various travel times: (1) 15 minutes to the VA center or clinic; (2) 30 minutes to the VA center or clinic; (3) 60 minutes to the VA Center or clinic; (4) 90 minutes to the VA center of clinic and (5) 120 minutes to the VA clinic. These time bands represent the inclusion of the dependent variables that could be used in an argument to support the premise that the government has broken its promise to provide free, accessible health care to retirees by causing them to travel upwards of 120 minutes or longer to receive care. This data will demonstrate that these dependent variables do not impact their ability to receive care based on the treatment received predicated on their specific condition.

In analyzing the specific conditions, both mental and physical, that veterans sought treatment for, a total of eleven (11) various disorders were included in this statistical analysis. In order to alleviate confusion during the statistical analysis, the standard guidelines were used to determine the appropriate "codes" for various physical conditions. The International Classification of Diseases, 9th Edition, Clinical Modification was ultimately used to establish the appropriate codes for physical disorders. Furthermore, those mental disorders whose data was included in this analysis were also assigned codes. Again, the clinical standard for disorder coding was derived from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised, more commonly referred to as the DSMM-IV-R. The DSMM-IV-R was used also to incorporate those disorders that are classified as both "psychological" and "behavioral" in order to minimize inaccurate exclusion of disorders that veterans seek access to medical care and treatment to remedy.

Conclusion

The methodology described in this chapter involves in-depth quantitative analysis of a variety of factors that contribute to the access veterans have towards quality health care. The required data was gathered from a variety of sources including Veterans Affairs databases. All personal information was removed before the data was implemented into the statistical modeling and projections utilized to establish the level of access veterans receive for health and medical care. The premise of this dissertation is not to draw any distinctions between physical and mental care; they are both broad categories of afflictions that veterans seek treatment for. This dissertation is more concerned with demonstrating the level of access and availability veterans have to quality health care.

The data is broken down into specific diseases and disorders in order to cultivate a cumulative and exhaustive paradigm that allows for an in depth examination of the level of care and access that veterans can expect from the Veterans Administration. This comprehensive analysis that will be presented in the following chapters, does segregate the data out by age and gender, however through Chi-Square analysis is demonstrated that neither of these two variables have any impact whatsoever. Ultimately, the data will demonstrate that despite external, dependent variables, including extensive time and driving distance and severity of injury or psychological condition, the data proves that the United States Government has more than kept its promise to veterans in offering access to quality care.

Data Analysis

Introduction

This chapter will focus on the raw data and its analysis in the quest to conclusively determine the level of access that veterans are able to receive for their many disorders, both physical and mental. Before the data is presented along with the various statistical analyses, there are some important qualifiers that must be addressed in order to accurately present and analyze this data. The data is segregated along several different categories. These categories are: (1) Age; (2) Gender; (3) Branch; (4) Discharge Status and (5) Pay-Grade. These distinctions were made in order to provide the most comprehensive data analysis and to further ensure that no representations or references could be made based on the data that the government "promise" was applied or kept in a discriminatory manner, that is to say, the purpose of showing the government kept its promise to all veterans regardless of age, gender, service rank, pay grade or discharge status. The data presented herein will also demonstrate there is a positive relationship between those veterans who seek access to quality health care through the Veterans Administration and those who actually receive it, the data and the analysis will ultimately substantiate the premise that the Government has kept is promise to the veterans of the United States.

Data Presentation and Analysis

The first table presented within this chapter details the number of VA sites, including centers, hospitals and clinics that are located within the Western States that provide a variety of services including treatments for mental afflictions such as PTSD, Depression and Anxiety. This table demonstrates the sheer number of clinics available. The amounts are measured in hundreds.

Table #1: Number of VA Locations within the Western States

Number of VA Sites 2009-2010

# of Sites With

# of Sites

# of Sites With

Only

With Only

Both Meds & Medication

Therapy

Therapy

Management

Mental health providers in the Western States

VHA Provider

VAMC

1

0

0

1

CBOC/Satellite

7

4

0

3

Paid Service Provider

Fee-Basis

26

0

26

0

Contract

45

0

29

16

Total

79

4

55

20

As Table 1 demonstrates, the number of VA centers is numerous. This is the first indication that the data demonstrates, even without significant statistical evidence and analysis that there are a plethora of options available to members of the military wherein they can seek treatment. Table #2 presents further corroboration of this premise, demonstrating the raw number of diagnosis of certain health conditions made by VA doctors within the study period. This table provides information related to the percentage of diagnosis made before and after discharge.

Table #2: Percentage of Diagnosis made before and after discharge

Active Component Reserve/Guard

Physical Disorders Male (Active) Male (Ret.) Female RET

46.5

35.9

11.7

22.5

After Discharge

6.1

8.3

5.4

6.2

Mental Disorders (ICD"9"CM: 290-319)

Before Discharge

35.6

28.8

9.4

19.8

After Discharge

4.9

5.7

4.9

5.9

V-codes for Psychosocial/Behavioral Problems

Before Discharge

30.5

22.8

4.6

7.1

After Discharge

4.0

1.7

As this table demonstrates, there are numerous diagnosis of both physical and mental conditions during and after the veteran is discharged from the facility. As the table presents, the data indicates that the percentage of diagnosis between male and female both active duty and retired are roughly equivalent. This therefore, begins to demonstrate that there is no difference in access or receipt of quality care based on duty status and gender. This data dispels one argument; that access to quality care promised by the government is somehow delivered on a discriminatory basis. Further statistical analysis will demonstrate this premise to be wholly incorrect. The following table displays data that shows the specific physical conditions and diagnosis that were made between 2009-2010 within the various Veterans Affairs hospitals, clinics and centers. The purpose of this table is to provide raw data that demonstrates how many cases each VA clinic, center and hospital becomes involved in-creating further support for the premise that the government has honored its commitment to Veterans.

Table 3: Number of Physical Diagnosis with VA Centers, Hospital and Clinics

Active Component

Reserve/Guard

ICD?9 CM Categories

[1,758]

[1,466]

OIF/OEF

Not OIF/OEF

OIF/OEF

Not OIF/OEF

[593]

[1,165]

[1,142]

[324]

Infectious and Parasitic Disease (001-139)

42.0

32.4

20.3

26.2

Malignant Neoplasm (140-208)

1.7

1.0

0.9

Benign Neoplasm (210-239)

11.1

8.2

6.5

10.8

Endocrine, Nutritional and Metabolic Disease, and Immunity Disorders (240-279)

26.0

20.8

19.4

20.4

Diseases of the Blood and Blood Forming Organs (280-289)

2.5

2.7

2.3

Mental Disorders (290-319)

48.7

34.9

43.1

26.9

Diseases of the Nervous System and Sense Organs (320-389)

73.9

60.4

64.0

63.6

Diseases of the Circulatory System (390-459)

20.2

13.9

14.9

14.8

Diseases of the Respiratory System (460-519)

59.2

55.3

36.2

67.6

Diseases of the Digestive System (520-579)

37.3

26.4

34.8

29.9

Diseases of the Genitourinary System (580-629)

21.8

19.3

9.2

13.0

Complications of Pregnancy, Childbirth, and the Puerperium (630-677)

20.7

18.1

7.8

11.7

Diseases of the Skin and Subcutaneous Tissue (680-709)

39.6

31.7

19.6

25.6

Diseases of the Musculoskeletal System and Connective Tissue (710-739)

70.7

56.1

58.1

60.2

Congenital Anomalies (740-759)

7.1

5.0

2.2

Certain Conditions Originating in the Perinatal Period (760-779)

Symptoms, Signs, and Ill-Defined Conditions (780-799)

64.8

50.1

49.8

51.2

Injury and Poisoning (800-999)

72.3

50.9

43.9

55.3

V-Codes Indicating a Psychosocial or Behavioral Problem1

34.7

25.8

14.1

9.6

As Table #3 shows, in stark detail, there are an overwhelming number of cases and diagnosis that the Veterans Administration's various facilities address each year. This data is representative of only those facilities located within the four western states the formed the focus of this dissertation. Extrapolating this data into more populated cities and states and one can begin to get a sense of the enormity of the care that VA facilities provide on an annual basis. The following Table presents more data on additional physical conditions that are addressed annually by VA doctors. This continued data presentation further demonstrates the nature of the VA to provide in depth quality care to military retirees.

Table #4: Continued Data on Physical Diagnosis

Active Component

Reserve/Guard

ICD?9 CM Categories

[349,421]

[141,197]

OIF/OEF

Not OIF/OEF

OIF/OEF

Not OIF/OEF

[130,862]

[218,559]

[114,525]

[26,672]

Infectious and Parasitic Disease (001-139)

43.5

37.8

21.3

27.5

Malignant Neoplasm (140-208)

1.4

1.6

1.2

1.9

Benign Neoplasm (210-239)

11.0

10.3

6.9

11.1

Endocrine, Nutritional and Metabolic Disease, and Immunity Disorders (240-279)

28.0

24.1

22.1

27.1

Diseases of the Blood and Blood Forming Organs (280-289)

4.5

4.9

2.7

4.1

Mental Disorders (290-319)

44.7

37.1

33.3

28.2

Diseases of the Nervous System and Sense Organs (320-389)

67.7

60.6

47.4

55.1

Diseases of the Circulatory System (390-459)

20.9

18.5

17.2

23.5

Diseases of the Respiratory System (460-519)

60.3

61.3

41.7

49.9

Diseases of the Digestive System (520-579)

38.5

32.2

29.4

30.0

Diseases of the Genitourinary System (580-629)

22.8

22.5

13.3

20.8

Complications of Pregnancy, Childbirth, and the Puerperium (630-677)

20.8

20.6

10.2

16.1

Diseases of the Skin and Subcutaneous Tissue (680-709)

41.8

36.7

25.2

30.5

Diseases of the Musculoskeletal System and Connective Tissue (710-739)

69.5

61.9

52.9

58.8

Congenital Anomalies (740-759)

6.2

6.0

3.1

5.3

Certain Conditions Originating in the Perinatal Period (760-779)

0.3

0.3

0.1

0.2

Symptoms, Signs, and Ill-Defined Conditions (780-799)

66.0

58.5

48.8

56.1

Injury and Poisoning (800-999)

68.1

57.9

42.2

51.3

V-Codes Indicating a Psychosocial or Behavioral Problem1

35.7

27.5

21.8

17.7

Again, this table presents data that show, within the Western Region of the United States, how extensive the operations of the various VA facilities are. Each one of these patients represented in the data presented thus far is indicative of the premise that the VA has upheld its "promise" to military retirees. Table #5 is another data table that presents data related to Mental disorders; in order to demonstrate that one type of affliction is not subject to any treatment bias by VA officials.

Table #5: Mental Diagnosis

Active Component

Reserve/Guard

Mental Disorders (ICD"9"CM: 290-319)

[1,758]

[1,466]

OIF/OEF

Not OIF/OEF

OIF/

OEF

Not OIF/OEF

[593]

[1,165]

1,142

[324]

Alcohol and Drug induced mental disorders (Alcohol & drug psychoses) (291 & 292)

1.7

0.8

1.1

Episodic mood disorders (Affective psychosis) (296)

8.8

6.4

7.4

3.7

Anxiety, dissociative and somatoform disorders (Neurotic Disorders) (300)

12.0

9.0

9.6

4.3

Personality disorders (301)

2.7

4.3

0.8

Sexual and gender identity disorders (302)

2.5

1.6

1.5

Alcohol dependence syndromes (303)

8.9

2.8

5.3

Drug dependence (304)

2.0

1.2

Non-dependent abuse of drugs (305)

29.7

14.9

21.4

16.1

Special symptoms or syndromes, not elsewhere classified (307)

7.8

5.3

5.1

3.1

Acute reaction to stress (308)

2.7

2.0

3.0

Adjustment reaction excluding PTSD (309 excluding 309.81)

14.5

14.2

10.1

4.9

PTSD (309.81)

18.4

2.4

25.2

Specific non-psychotic mental disorders due to brain damage (310)

1.5

Depressive disorder, not elsewhere classified (311)

18.0

11.0

19.7

7.1

Disturbance of conduct, not elsewhere classified (312)

Other mental disorder diagnoses1

6.1

3.7

4.3

Table #6: Further Presentation of Mental Diagnosis

Active Component

Reserve/Guard

Mental Disorders (ICD"9"CM: 290-319)

[349,421]

[141,197]

OIF/OEF

Not OIF/OEF

OIF/OEF

Not OIF/OEF

[130,862]

[218,559]

[114,525]

[26,672]

Alcohol and Drug induced mental disorders (Alcohol & Drug Psychoses) (291 & 292)

1.6

1.1

0.9

0.9

Episodic mood disorders (Affective psychosis) (296)

7.9

6.3

5.7

4.5

Anxiety, dissociative and somatoform disorders (Neurotic Disorders) (300)

12.5

10.0

9.1

7.1

Personality disorders (301)

2.8

4.3

1.0

1.3

Sexual and gender identity disorders (302)

2.1

1.9

2.3

2.9

Alcohol dependence syndromes (303)

6.4

3.4

2.8

2.2

Drug dependence (304)

1.9

1.3

1.0

0.9

Non-dependent abuse of drugs (305)

24.0

15.5

16.1

13.5

Special symptoms or syndromes, not elsewhere classified (307)

5.8

6.2

3.4

3.9

Acute reaction to stress (308)

2.8

1.9

2.0

1.4

Adjustment Reaction Excluding PTSD (309 Excluding 309.81)

14.2

13.7

11.0

7.7

PTSD (309.81)

13.8

2.5

13.6

3.4

Specific non-psychotic mental disorders due to brain damage (310)

1.6

0.6

1.6

0.7

Depressive disorder, not elsewhere classified (311)

13.0

10.1

10.2

7.5

Disturbance of conduct, not elsewhere classified (312)

0.6

0.5

0.4

0.3

Other mental disorder diagnoses1

4.7

4.1

3.4

2.8

Table 5 and 6 are further evidence of the voluminous amount of patient cases the VA facilities within the Western Region take in on an annual basis. The data presented thus far raises an interesting question: "If the Western Region of the VA takes in these cases each year is there any correlation between various variables and access to quality care?" This question will be addressed using the Linear Regression Models, Chi-Square and ANOVA analysis later in this chapter. However the larger question or point rather, raised by the data presented thus far is that given that evidentiary support for the sheer enormity of the cases and patients cared for by the doctors at the various VA clinics, how can one logically assert that the "promise" of the quality health care has been broken by the Federal Government?

The answer does not stem from complex statistical analysis or predictive modeling; rather one only need to examine the nature the 6 or so data tables presented that provide the raw statistical data demonstrating the actual number of diagnosis and patients the VA hospitals within this region take in an examine on a yearly basis. Predicated on this logic it can be safe to assume, inherently, that if there were any validity to the claim that decrease in defense spending or the reduction in the size of the pentagon negatively influenced the access and quality of care, there would be a substantial downward trend within these numbers. The following section takes this raw data and integrates it into the complex statistical tests and models that were described in the Methodology chapter. These tests will demonstrate the correlation between access to care available to veterans and the level of treatment, diagnosis and quality of care offered at the various facilities within the Western region. The following figure represents the Linear Regression model when Age and Gender of the veteran are examined to see if there is any correlation between these variables and the access to care and diagnosis levels.

Figure #1: Linear Regression using Age and Gender of the Veteran

As this figure conclusively demonstrates there is no correlation between these two variables and the access of care nor quality of care. This data was measured using a 95% Confidence Interval, the average age (mean of the patient) and the percentage of both male and female patients. The formula for calculating the Linear Regression Model is

The Confidence Intervals are represented within the dotted lines and the value of Beta is the solid line going through the middle of the graph. As it appears, the Confidence Intervals are not even close to Beta; therefore it can be deduced there is no correlaive relationship between age, gender and access to quality care through the VA.

This relationship was further proven when a Chi-Square test was conducted, using the formula previously described in the Methodology chapter. The results of the Chi-Square Test are found in Figure #2 below.

Figure #2: Chi-Square Analysis of Age in relation to access

This figure presents the results of the Chi-Square Test. The blue columns represent the probability that the patient will receive the same quality treatment as other patients within their cohort. The Red Bar demonstrates the probability that the patient will not receive the same quality of care as another patient within their Cohort. As it can be readily observed the "blue" probability is significantly greater than the "red." Therefore, once again, there is no correlative relationship between age and access to care. The following Linear Regression model is the representation of the calculations pairng the variables of diagnosis, treateable condition and quality of care. This model was calculated, again within a 95% Confidence Interval. Beta, was the result of the calculations that measure the degree of relationship between the nature of the condition and the quality of care. The ultimate premise of this model was to show a positive relationship between nature of the condition and quality of care-more serious the condition, the better the care.