Veterans Affairs department officials said Monday they have launched a study to determine how removing race from widely used lung function tests may affect disability benefits for veterans, and they expect the impact to be much smaller than predicted in a study published earlier this year.
They also said veterans who may have heard about the issue should not be concerned about any sudden changes to their benefits. Any changes, said Olumayowa Famakinwa, who oversees implementation of the VA’s rating schedule for disabilities, would come with ample notification and the ability for veterans to appeal.
“If I was talking to a veteran, I’d say, give us some time, but we’ll figure it out for sure and you can remain confident you will get the benefits you’ve earned,” he said.
In 2023, in response to outcries that using race in pulmonary function tests can underestimate the extent of disease in Black patients, and to a smaller extent in Asian patients, the American Thoracic Society released new guidelines stating that the use of race was contributing to health disparities and should be ended. A race-based equation had long been used to guide interpretations of results from spirometry tests and over time were built into the software of the machines.
The tests are used to help diagnose lung disease and guide treatment decisions, as well as in determining disability payments.
A study published in May in the New England Journal of Medicine analyzed how a race-free equation might affect patients. Using data from a large population study, the authors estimated that the change could affect more than 400,000 veterans and lead to redistribution of nearly $2 billion dollars, with 17% more overall going to Black veterans and just over 1% less going to white veterans.
In an interview with STAT, veterans officials said they thought the study had vastly overestimated the number of veterans who were entitled to benefits and the amount that benefits might change for individuals, because the researchers did not use VA numbers but extrapolations from population-wide data.
“As far as I can tell, there was no VA engagement in that manuscript,” said David Au, a pulmonologist who directs the Veterans Health Administration’s Center for Care and Payment Innovation. “We would have been happy to help contribute.”
Au said he appreciated the attention the study had brought to the issue, but hoped the study could be corrected or revised or that the authors would work with the VA in the future to create more precise estimates.
The study’s lead author, Arjun Manrai, an assistant professor of biomedical informatics at Harvard, said he appreciated the VA’s comments and agreed the populations were not as precise as they would have been had the authors used VA data directly.
But he said he believed the larger finding, that Black veterans might be due additional benefits if pulmonary function tests, or PFTs, employed race-free equations, was not likely to change. “Ultimately, we are confident in our estimates of the direction and magnitude of changes expected with widespread adoption of race-neutral PFTs,” he told STAT, adding that he would like to see the VA’s data.
VA officials said potential changes to disability payments were not likely to be as large as the study estimated for a number of reasons. First, pulmonary function tests are only one factor in determining lung disability. A wide range of tests and other factors, such as whether people need bronchodilators to control asthma or have been prescribed outpatient oxygen, are also used.
Furthermore, Famakinwa said, most disability claims include a number of service-related disabilities, so altering the amount of lung disability among myriad other claims might reduce or increase a disability award very little or not at all.
The VA began studying the issue after the ATS recommendation was released and it hopes to determine a new policy by September 2025, said Au, who added he was fully on board with the larger issue of removing race from clinical algorithms but said removing them in pulmonology was not straightforward. “This is really an implementation problem,” Au said. “It’s messy and it’s complex.”
He said VA officials do not want to make a change that may introduce a new health disparity. “Ten years ago, 15 years ago, there were disparities in care delivery in the VA. The most recent data has shown we’ve eliminated most disparities in terms of treatment and outcome between Black and white veterans,” he said. “What we were concerned about is if we implemented this wholesale, would we induce new disparities.”
As an example, he cited a JAMA Surgery paper published last year that showed Black patients might be less likely to receive a more aggressive and more effective lung cancer surgical option if their lung function was assessed using race-neutral equations. “That was alarming to us,” Au said.
Another issue is that if relatively simple PFT tests are replaced by more complex tests that are not offered at every VA hospital, it could create access barriers for veterans with transportation issues or other complications. “Every time you add a layer of complexity to testing, you drop out a population,” Au said.
Au said decisions about how to administer the tests were up to individual VA centers, and 30% had begun to use the race-free equation, while the rest had not, causing some problems for continuity of care. The VA has paused roll out of the changes for the time being, he said. “We really want [changes] to be consistent and equitable across the system,” he said.
The VA moved more quickly to implement race-free tests for kidney function, but Au said that was a simpler decision because nephrologists had a gold-standard test in that case and data modeling showed a race-free equation had a similar performance. Pulmonary function tests, he said, have no gold standard or new data analyses and are affected by a wide variety of factors including ancestry, poverty, and air pollution, making the issue far less clear. “I wish we were nephrologists,” he said.