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Caring for Veterans on the Cheap
How the Veterans' Administration has been shortchanging soldiers who come back wounded.
April 28 , 2006
On the eve of his Marine unit's assault on Falluja in November, 2004, Blake Miller read to his men from the Bible (John 14:2-3): "In my father's house, there are many mansions: if it were not so, I would have told you. I leave this place and go there to prepare a place for you, so that where I may be, you may be also."
A photograph of Miller's blood-smeared, filthy face, so reminiscent of David Douglas Duncan's photos of war-weary Marines in Vietnam, is one of the Iraq War's iconic images. Over a hundred newspapers ran it. But as the San Francisco Chronicle reported recently, Miller, a decorated war hero, has been shattered psychologically by Iraq. Disabled by flashbacks and nightmares, he continues to pay daily and dearly for his service there.
His eloquent commitment to his fellow Marines is the highest value in military life. But the Bush administration, which sent Blake Miller, his fellow Marines, and 1.3 million other Americans (so far) to war in Iraq and Afghanistan apparently does not share this commitment.
Much has been written about how President Bush and Secretary of Defense Donald Rumsfeld waged war on the cheap, sending too few ill-equipped young soldiers -- 30% of them ill-trained Reservists and National Guardsmen -- into battle. But little has been reported about how shockingly on-the-cheap the homecomings of these soldiers have proved to be. The Bush administration awarded Blake Miller a medal, but it has fought for three long years to deny soldiers like him the care they need. While Miller and his men were being thrown into the fire in Falluja, the White House was proposing to cut the combat pay of soldiers like them. (Only an outburst of outrage across the political spectrum caused the administration to back off from that suggestion.)
The Veterans Administration, now run by a former Republican National Committeeman, has been subjected to the same radical hatcheting that the White House has tried to wield against the rest of America's safety net. Cutbacks, cooking the books, privatization schemes, even a proposal to close down the VA's operations have all been in evidence. The administration's inside-the-beltway supporters like the Heritage Foundation and famed anti-tax radical Grover Norquist like to equate VA care with welfare. Traditionally, however, most Americans have held that the VA's medical care and disability compensation was earned by those who served their country.
Unfortunately, in our draft-free country, the fight to protect the Veteran's Administration and to fully fund it has gone on largely out of public sight. Other than the Washington Post and the Associated Press, relatively few journalistic organizations have bothered to regularly cover the VA. The fight over it that White House hatchet men, VA political appointees, and their allies in Congress have had with Congressional critics (Democratic and Republican) along with veterans' organizations has been monitored closely only by veterans' websites like Larry Scott's VAWatchdog.org, veteransforcommonsense.org and military.com.
While national deficits soar, thanks in part to skyrocketing war costs, veterans of Iraq and Afghanistan are flooding into the increasingly underfunded VA system. The Pentagon says that 2,389 Americans have died and 17,648 have been wounded in combat in Iraq (and another 285 have died in Afghanistan). But these casualty figures seem to be significant undercounts. After all, 144,424 American veterans have sought treatment from the VA system since returning from those wars, not including soldiers actually hospitalized in military hospitals.
These figures were wrested only recently from the Veteran's Administration after years of fruitless demands from Democrats on the House Veterans' Affairs Committee. The 144,424 figure includes not only many of those 17,648 reported wounded in combat by the Pentagon -- if that figure is, in fact, accurate -- but those wounded psychologically, those injured in accidents, and those whose ailments were caused or exacerbated by service in the war. (Think of war, in this sense, as an extreme sport in its toll on the body.) Of course, neither Pentagon, nor VA figures for the wounded include estimates of those soldiers or veterans who don't show up at a Department of Defense (DoD) or VA facility. Among these casualties are post-combat-tour suicides (who obviously can't show up) and the victims of diseases like leischmaniasis, caused by the ubiquitous sand flies in Iraq, who often suffer on their own.
Nonetheless, the VA has admitted -- and it's been confirmed by an Army study -- that a staggering 35% of veterans who served in Iraq have already sought treatment in the VA system for emotional problems from the war. Add this to the older veterans, especially from the Vietnam era, pouring into the VA system as their war wounds, both physical and emotional, deepen with age or as, on retirement, they find they can no longer afford private health insurance and realize that VA health care is -- or, at least in the past, was -- more generous than Medicare.
Just as the Pentagon failed, after its March 2003 invasion of Iraq, to plan for keeping the peace, guarding against looting, fighting a resilient insurgency, or handling a civil war, so has the Veterans Administration failed to plan for caring for casualties of the war. The VA admitted recently that 33,858 more vets showed up for treatment in just the first quarter of FY2006 than were expected for the entire year. Do the math yourself. Multiply times 4, assuming that the war goes on injuring Americans at current levels, and you get a possible underestimate of 135,000 casualties for the year.
Even more distressing, the San Diego Union recently reported that mentally ill soldiers are being sent back to war armed only with antidepressants and anti-anxiety drugs. The Union quotes Sydney Hickey of the National Military Family Association as saying that "more than 200,000 prescriptions for the most common antidepressants were written in the last 14 months for service members and their families." According to the Union, an Army study also found that 17% of combat-seasoned infantrymen suffer from major depression, anxiety, or Post-Traumatic Stress Disorder (PTSD) after a single tour in Iraq. California Sen. Barbara Boxer has called for an investigation.
Are such chronic underestimates merely the result of incompetence? Not according to the Government Accountability Office (GAO), Congress's investigative arm. In a series of reports on the Veterans Administration over the last three years, the GAO found that the VA's top officials submitted budget requests based on cost limits demanded by the White House, not on realistic expectations of how many veterans would actually need medical care or disability support.
In repeated testimony before Congress, top VA political appointees have opposed demands by veterans' groups like the American Legion and the Disabled Veterans of America to increase significantly funds for medical care and disability payments for the new patients now flooding the system. Top VA officials assured Congress that more money wasn't needed because the agency had stepped up "management efficiencies." But the GAO found that, from 2003-2006, there were no obvious management efficiencies whatsoever to offset the increased treatment costs from the Iraq War, nor did the VA even have a methodology for reporting on such alleged efficiencies.
While the GAO's findings, when describing the VA's budget manipulations, were couched in such relatively polite bureaucratic euphemisms as "misleading," "lacked a methodology," and "does not have a reliable basis," the conclusions nonetheless were striking. "The GAO report confirms what everyone has known all along," American Legion National Commander Thomas L. Bock commented. "The VA's health-care budget has been built on false claims of 'efficiency' savings, false actuarial assumptions and an inability to collect third-party reimbursements -- money owed them. This budget model has turned our veterans into beggars, forced to beg for the medical care they earned and, by law, deserve. These deceptions are especially unconscionable when American men and women are fighting in Iraq and Afghanistan."
Some veterans are calling it fraud. Rep. Lane Evans (Dem.-Ill.) of the House Veterans' Affairs Committee calls it "Enron-styled accounting."
The economic realities of the wars the Bush administration has taken us into are, in truth, budget busting. A recent study by Nobel prize-winning economist Joseph Stiglitz and Harvard management expert Linda Biones -- that actually factored the costs of "coming home" into war expenditures -- sets the total cost of the Iraq War between $1 and 2 trillion, including $122 billion in disability payments and $92 billion in health care for veterans.
Pentagon health-care costs for soldiers still in the military have doubled in the last five years and are projected to total $64 billion or 12% of the official Pentagon budget by 2015, according to William Winkenwerder, Jr., Assistant Secretary of Defense for Health Affairs. Soaring American medical costs are only partly to blame. Advances in combat medical care have also meant that far more wounded soldiers are being kept alive than in earlier wars, many of them with serious brain injuries and/or multiple amputations. Taking care of these tragically maimed soldiers for life will be extraordinarily costly, both in terms of medical care and their 100% disability payments. (The VA rates disability on a scale of 0 to 100%, which then determines the size of the monthly disability payment due a veteran.)
Even before recent veterans began flooding the system, the VA was already underfunded and being criticized for poor services. Then, three years ago, Rep. Evans and Rep. Chris H. Smith, (Rep.-NJ), Chairman of the House Veterans' Affairs Committee, raised the alarm that the VA, already short of funds, would face a catastrophe as the troops began returning from Iraq.
Smith was rewarded for his efforts to sound the alarm by being removed not just from his chairmanship, but from the committee altogether, by the House Republican leadership. Similarly, in November 2004, VA head Anthony Principi was forced out by the White House because of his opposition to the VA being shortchanged in the budget the White House demanded -- so lobbyists for veterans believe. But Principi seems not to have suffered from his VA experience. The Los Angeles Times reported recently that a medical services company Principi headed, and returned to after running the VA, earned over a billion dollars in fees, much of it from contracts approved while Principi was VA chief.
The VA admits its disability system was overburdened even before the administration invaded Iraq; and, by 2004, it had a backlog of 300,000 disability claims. Now, the VA reports that the backlog has reached 540,122. By April 2006, 25% of rating claims took six months to process -- no small thing for a veteran wounded badly enough to be unable to work. An appeal of a rejected claim frequently takes years to settle. One hundred twenty-three thousand disability claims have been filed already by veterans of Iraq and Afghanistan. Yet, in its budget requests, the administration has constantly resisted congressional demands to increase the number of VA staffers processing such claims.
The True Cost of Coming Home
Congress has fought the White House over its low VA budgets for several years. In the FY 2006 budget, all Congress could finally grant the VA was $990 million above the agency's already meager request -- an increase of just 3.6% over the previous year despite the rise in casualties to be treated. In fact, top VA officials now admit it would take a 14% increase in the present budget simply to keep up with the inflation in medical costs.
Rep. Evans estimates that there has been a $4 billion shortfall in VA funding in the years 2003-06. In 2005, the White House admitted that, for medical services alone, the VA was short $1 billion for the year -- and another estimated $2.6 billion in 2006.
What may ultimately swamp the Veterans Administration's ability to cope is the emotional toll of combat -- unless it jettisons thousands of returning soldiers. Nearly one in three veterans has been hospitalized at the VA, or visited a VA outpatient clinic, due to an initial diagnosis of a mental-health disorder, according to the VA itself. Its numbers are consistent with a recent Army study on soldiers who served in Iraq or Afghanistan. Such a rate might add up over time (depending on how long these wars last) to almost half a million veterans in need of treatment -- or more. A 2004 study of several Army and Marine units returning from Iraq and Afghanistan that appeared in the New England Journal of Medicine found only 23-40% of those with PTSD had sought treatment. And post-traumatic stress is called "post" for a reason -- its most serious symptoms usually emerge long after the trauma is over.
Listen to the VA's own national advisory board on PTSD in a report released in February, 2006:
"[The] VA cannot meet the ongoing needs of veterans of past deployments while also reaching out to new combat veterans of [Iraq and Afghanistan] and their families within current resources and current models of treatment."
The VA is now paying out $4.3 billion a year for PTSD disability to 215,871 veterans. The report also found that a returning war veteran suffering from emotional illness now has to wait an average of 60 days before he or she can even be evaluated for diagnosis, let alone treated. Forty-two percent of VA primary care clinics had no mental-health staff members and 53% of those that did had only one. Eighty-two percent of new patients needed to be in the most intensive PTSD treatment programs, the VA report found, but 40% of those programs were already so full that they could only take a few more patients; 20% said they were too full to take any at all.
"VA's data show a 30% increase in the number of [Iraq and Afghan War] veterans who have an initial diagnosis of post-traumatic stress disorder from the end of FY 2005," says Rep. Michael Michaud (Dem.-Me). "I applaud the courage of these veterans who have sought help, but the administration refuses to acknowledge fully the demand and need for mental health services."
Further down the line: How many Iraqi veterans will eventually join the ranks of the 400,000 homeless vets on the streets of American cities? (Right now the VA takes care of only 100,000 such vets, according to the National Coalition for Homeless Veterans.)
This dire situation has only encouraged the budget cutters and anti-government radicals like Norquist, who once joked that he hoped to shrink the government enough so that he could drown it in a bathtub. With PTSD rates soaring among vets, the hatchets have been out not just when it comes to treating them, but even when it comes to the diagnosis of PTSD itself. In 2005, the VA, under White House pressure, announced that it was reopening 72,000 long-approved PTSD disability claims for review, many of them for Vietnam veterans. Right-wing columnists quickly swung into action with op-ed pieces insisting that many PTSD claims were fraudulent. The VA backed off -- but only after a New Mexico newspaper reported that a troubled Vietnam veteran with a 100% PTSD disability killed himself upon fearing that the VA might review his case and a firestorm of criticism from Congress and veterans' organizations followed.
Other White House ideas for cutting back the VA, including making vets pay insurance premiums, higher co-pays and doubling Vets' costs for prescription drugs, have also been beaten back by Congress. One VA response to its huge backlog of claims has been to limit enrollment for its services. In January 2003, the White House ordered the VA to create a new temporary cost-cutting category of "affluent" vets who would not be eligible to use the VA. But the new category seems headed for permanency. And it sets the cut-off level for eligibility for VA care so low -- around $30,000 for a so-called "affluent" family of four -- that many vets who have been cut off can't possibly afford health insurance and medical care on the private market.
In World War II, 12 million Americans fought on behalf of a nation of 130 million. Twenty-five percent of American men served in that war. They came back heroes to a country more than willing to give them the latest medical care, compensate them for their wounds, send them to college, and help them buy homes.
Fifty years later in Iraq -- an unpopular war -- only 1.3 million are fighting for a nation of 300 million. "Never have so few sacrificed so much for so many," one Desert Storm veteran said recently. Iraq may be the wrong cause for sacrifice. But Vietnam veterans taught us that once war starts we must be willing to take care of everyone who gets hurt in it.
Judith Coburn has covered war and its aftermath in Indochina, Central America, and the Middle East for the Village Voice, Mother Jones, the Los Angeles Times, and Tomdispatch, among other media outlets.
Copyright 2006 Judith Coburn
This piece first appeared, with an introduction by Tom Engelhardt, at: http://www.tomdispatch.com/indexprint.mhtml?pid=80291