Introducing - Intention to Treat: Money and Misdiagnosis

Why It Matters

Accurate lung‑function testing directly affects veterans’ health outcomes and determines billions of dollars in federal disability payments, making the race‑correction debate a critical equity and fiscal issue.

Key Takeaways

• Race‑corrected spirometers underestimate lung disease in Black veterans
• VA hospitals that switched to race‑neutral testing saw more diagnoses
• New study projects over $1 billion extra annual benefits for Black veterans
• VA’s 2024 ban blocks further adoption of race‑neutral tests
• Misdiagnosis costs veterans up to $370 more per month in compensation

Pulse Analysis

The legacy of race‑adjusted spirometry dates back to the 19th‑century belief that Black bodies have inherently lower lung capacity. Modern devices still embed this bias, applying a correction factor that reduces predicted values for Black patients. In practice, the adjustment can shift a COPD diagnosis from moderate to mild, effectively masking disease severity and limiting access to treatments, specialist referrals, and disability benefits. For veterans exposed to toxic burn‑pit smoke, such misclassification compounds existing health burdens and erodes trust in the VA health system.

At the Jesse Brown VA in Chicago, pulmonologists Peter Sporn and Cheryl Connor led a pilot transition to a race‑neutral equation in 2022. Within months, they identified a surge in moderate‑to‑severe lung disease among Black veterans, prompting seven additional Midwestern VA facilities to adopt the same methodology. The shift not only improves clinical accuracy but also translates into higher compensation; moving from a mild to a moderate COPD rating can raise monthly VA payments from roughly $180 to $550. A recent NEJM‑sponsored analysis warns that nationwide adoption could increase annual benefits for Black veterans by more than $1 billion, while potentially reducing payouts for White veterans by about $500 million.

The controversy underscores a broader reckoning in American medicine: algorithms that encode race can perpetuate health inequities and fiscal distortions. While the VA cites concerns about over‑diagnosis and surgical eligibility, the preponderance of evidence suggests that race‑based adjustments are scientifically unfounded and financially punitive for marginalized groups. Policymakers, clinicians, and advocacy groups must weigh the ethical imperative of equitable care against bureaucratic inertia, recognizing that removing race from diagnostic tools is both a clinical correction and a step toward reducing systemic disparity in veteran health services.