Costs of care for veterans: high and rising

Veterans of the wars in Iraq and Afghanistan will be much on the minds of their countrymen this Independence Day weekend. Marching in town parades. Lauded in speeches.

But the pride and the bunting are also a reminder that the price - and cost - of war go on many years after the fighting stops, that "to care for him who shall have borne the battle and for his widow and his orphan," as Abraham Lincoln put it, is as much an issue of national security today as are armored Humvees and trustworthy translators of Arabic.

The Senate got into a bipartisan snit over funding for veterans this week, Republicans and Democrats both raising alarms over a $1 billion shortfall for the Department of Veterans Affairs this fiscal year. On Wednesday, the Senate approved $1.5 billion in emergency funding for the VA. But the funding issue raises questions about the VA's ability to handle an increased workload as a result of the war.

With nearly 240,000 employees, the VA is larger than all other federal departments except the Pentagon. But even before the "war on terrorism" began, it had to scramble in dealing with the needs of 7.5 million enrolled vets, including a large number of homeless - 33 percent of homeless men in the US are veterans.

Now, thousands of Iraq war vets are being added to the rolls, including many who have been wounded and will require lifelong care.

"Clearly, VA is not ready for this," says Dan Smith, a retired US Army colonel and Vietnam veteran.

Since the US-led invasion of Iraq began, an average of 474 US service members a month have been wounded, injured, or become ill in the war zone. As of last week, the Defense Department put the total at 13,074.

But the total number of vets who still need help is much larger than that, and it's growing. As of February, VA officials reported, 85,857 of the 360,674 veterans of the wars in Afghanistan and Iraq who had separated from active duty - 24 percent - had sought healthcare from the VA. This included treatment for both physical injuries and mental health problems.

"The bottom line is there is a surge in demand in VA services across the board," Veterans Affairs Secretary James Nicholson told a House panel this week.

Earlier this year, Mr. Nicholson told lawmakers the VA had used 2002 estimates when assuming that 23,553 veterans of Iraq and Afghanistan would need medical care in 2005. Since then that number has been revised upward more than fourfold to 103,000. Part of the reason is the changing nature of war and the casualties it produces.

As helicopters did so prominently in Vietnam, new means of transporting and treating the wounded in Iraq are saving lives. But this also means a higher portion of overall casualties will need extended government benefits. During the wars of the 20th century, the ratio of wounded to killed in action was about 3 to 1. In Iraq that ratio is more than 9 to 1.

Another new factor is the relatively large number of women who've been in combat, who now face what some experts think are different kinds of post-traumatic stress disorder - called "soldier's heart" during the Civil War.

"I'm no psychologist, but my understanding of the perceptual and psychological differences between men and women suggests the likelihood that PTSD reactions will be different, requiring nuanced treatment for a devastating condition when extensive clinical experience doesn't exist for women," says Colonel Smith, now a military analyst with the Friends Committee on National Legislation in Washington. "This in itself will add to costs."

PTSD for all returning vets - men and women - may be of particular concern because of the nature of a counterinsurgency fought among, and in some cases against, civilians. Another unknown is the long-term effects of exposure to depleted uranium, suspected of causing the "Gulf War Syndrome" ailments experienced by veterans of the 1991 war in Iraq. Thousands of rounds of armor-piercing shells made of depleted uranium were used by US and British forces in the 2003 invasion of Iraq.

Given that some 26 million Americans have served in the military, support for veterans comes from across the political spectrum. Liberal Senator Patty Murray (D) of Washington and her conservative colleague Larry Craig (R) of Idaho led the charge for more VA funding - the emergency $1.5 billion came at Sen. Murray's bequest. Groups from the American Legion to Vietnam Veterans Against the War have weighed in on the issue.

At the same time, says national security analyst Ivan Eland of the Independent Institute in Oakland, Calif., "Veterans' benefits are like any other government program - that is, they are a result of politics." For example copayments on prescription drugs are lower through the VA than private health plans and Medicare.

Others point to waste and abuse in an agency with a $68 billion annual budget meant to provide services for millions of people. "The Inspector General of the [VA] estimates that program overpayments exceed $800 million per year, mostly because of fraudulent benefit claims," notes a report by the Heritage Foundation. "While the VA is working to reduce these overpayments, significant opportunities remain. In addition, the VA has not been sufficiently diligent in collecting the $3 billion in debt owed to the department by loan program recipients."

Since taking office President Bush has hiked spending for veterans' medical care by more than 40 percent. More veterans are enrolled in healthcare services, the waiting time for such care has been shortened, and the backlog of disability claims has been reduced.

At the same time, the administration has attempted to reduce costs in certain areas. For example, it tried to double the copayment veterans are charged for prescription drugs (from $7 to $15), and impose a new $250 annual fee for using government health care services.

Under pressure from veterans' groups, Congress refused to go along.