"Beyond The Battlefield" is a 10-part series exploring the challenges that severely wounded veterans of Iraq and Afghanistan face after they return home, as well as what those struggles mean for those close to them. Learn how you can help here. Other stories in the series can be found here. Listen to reporter David Wood discuss "Beyond The Battlefield" with NPR's Terry Gross here. Wood and wounded veteran Bobby Henline will hold a live video chat this Friday. See more details and send them questions.
Three days after Sept. 11, 2001, Congress met to authorize giving the president the power to respond with "all necessary and appropriate force" to the terrorist attacks in New York and Washington, D.C. It was, in effect, a declaration of the war that has now lasted a decade. In a rhetorical cascade that went on for five hours, hundreds of politicians of both parties joined the war fervor, demanding that troops be sent to "crush" the perpetrators and their supporters.
Only one person, a now-retired Democratic congresswoman, took time to observe that war would create a new generation of wounded veterans who would need lifetime care, and that Congress ought to agree to pay those bills before sending young Americans into battle.
"There will be casualties, both physical and psychological," said Rep. Darlene Hooley of Oregon. "Let us ensure that when they come home Congress honors their sacrifice, not solely with parades, but for the rest of their lives."
Former Rep. Darlene Hooley, D-Ore., urged Congress in 2001 to set aside money for wounded veterans.
There would be more casualties than anyone at the time could imagine -- 53,000 dead and wounded -- and there would be more severely wounded among them as well, roughly 16,000 so far. Moreover, the cost of caring for these young, severely wounded combat survivors for a lifetime would also rise exponentially.
In a report that the Congressional Budget Office issued last summer, economist Heidi L. W. Golding said future costs for the Department of Veterans Affairs to treat veterans "will be substantially higher (in inflation-adjusted dollars) than recent appropriations for that purpose, partly because more veterans are likely to seek care in the VA system but mostly because health care costs per enrolled veteran are projected to increase faster than the overall price level."
Responsibility for caring for veterans could add at least another half-trillion dollars to the U.S. debt, according to Harvard economist Linda Bilmes. Yet there is at present no long-term strategy on how to pay for it. Money for veterans' care emerges from the annual budget squabbles in Congress. Unlike a pension fund or even Social Security, Congress doesn’t actually set aside funds for future obligations to veterans.
And given the current budget-ax climate in Washington, it's unlikely that Congress will begin setting aside money for the future care of veterans who are being wounded this year.
So far, politicians generally have been loathe to cut funds for veterans. But the uproar this year over the budget and debt squeeze suggests that even annual appropriations for severely wounded and disabled soldiers such as Tyler Southern and Todd Nelson could be vulnerable.
Politicians of both parties vow to protect veterans' funding, and the White House has directed that $25 billion be stripped from the Pentagon's 10-year spending plan and set aside for veterans' medical costs. The Department of Veterans Affairs projects that its costs will drop as the generation of Vietnam veterans require less support.
But VA funding remains an enticing target as tempers fray over the ballooning deficit.
Rep. Michele Bachmann (R-Minn.), for instance, a GOP presidential candidate, proposed early this year a package of federal spending cuts that included a $4.5 billion cut in veterans' health benefits. Veterans organizations screamed in protest. The measure would, said Veterans for Common Sense, leave the war's wounded "twisting in the wind."
"While the country is at war, there's a lot of positive feeling about those who fight," said economist Bilmes, who has studied and written about the cost of veterans programs. "But it is quite conceivable to me that over a period of time, when the wars are over and the U.S. is involved in other things and budget resources are very scarce, the desire to support veterans will change."
LIFETIME CARE
At the close of 2001, with the war in Afghanistan barely underway and the Iraq war still 18 months away, the VA was paying compensation to 172,254 veterans who had a disability rating of 100 percent from service in prior conflicts. By the end of last year, the VA had 295,529 veterans with 100 percent disability ratings on its books, an increase of 123,275 disabled veterans in just a decade.
The increase in costs was also substantial. In 2003, the VA paid $18 million to care for veterans of Iraq and Afghanistan. By 2013, the VA projects that cost will be $3.5 billion -- and that figure will continue to grow by $1.5 billion a year.
Why?
Among many reasons -- more wounded veterans, more generous allowances and more veterans who are aggressively seeking help -- is this: The growing number of severely wounded soldiers and Marines coming off the battlefield require more expensive services and compensation over the five decades or more of their lifetimes.
Because Iraq and Afghan war casualties are more severely wounded than veterans of past conflicts, the cost of their lifetime care may be underestimated. A recent Army study reported that the severely wounded experience "prolonged and profound dysfunction (physical and emotional) that is oftentimes underestimated by health care providers."
As President Obama observed in a speech last summer to the American Legion: "Thanks to advanced armor and medical technologies, our troops are surviving injuries that would have been fatal in previous wars. So we're saving more lives, but more American veterans live with severe wounds for a lifetime. That's why we need to be there for them for their lifetime.”
Prosthetic legs, for instance, have grown in sophistication and capability in the past decade. Instead of the "dumb" peg-legs seen in pirate movies, today's powered legs come with microprocessors, accelerometers and gyroscopes to mimic the complex motions of walking, as well as a carbon-fiber foot that enables amputees to run.
One such prosthesis, the Otto Bock X2, costs $30,000 for the knee joint alone. Tyler Southern has two of them. Otto Bock HealthCare of Duderstadt, Germany, developed the joint working with the Defense Advanced Research Projects Agency and the U.S. Army Telemedicine & Advanced Technology Research Center.
The entire powered leg, from hip to toe, can cost up to $100,000 -- and most amputees are given three or four of them for different uses. The prostheses have to be replaced after three to five years, depending on how much they are used.
Still in the experimental phase is a mind-controlled arm that will replace the static hook commonly seen today. The new arm, a collaboration between Otto Bock and U.S. researchers funded by the Defense Department, uses signals from the brain, re-routed through nerves transferred from chest muscles to the arm stump, to rotate and open and close the hand and to flex the elbow. A prototype has advanced sensors implanted into the prosthetic index finger to feel heat and cold, judge the strength of the grip and, it is said, feel the difference between a grape and a raisin.
Such devices are developed to deliver maximum benefit to military amputees, not necessarily to control costs. "We'll do everything we can to return you to the highest level of function," is the way Chuck Scoville, chief of amputee patient care at Walter Reed National Military Medical Center, describes his work.
Each new generation of a prosthetic limb has been "radically more expensive" than the device it replaced because of its increasing complexity, said David McGill, a board member of the Amputee Coalition and a prosthetics industry official. "With increased sophistication of the device you see an increase in the cost," he says.
Aside from hardware, the cost of caring for veterans is rising because veterans are increasingly demanding mental health services and disability payments, among other benefits. According to Army studies, the levels of acute stress among combat troops deployed in Afghanistan is "significantly higher" than in previous years, suggesting the demand for mental health services will continue to grow for years.
Past wars have shown that the cost of caring for the wounded rises and peaks long after the war is over and largely forgotten by the general population. Disability payments for veterans of World War I didn't peak until 1969, according to Harvard economist Bilmes, who teaches public finance at the Kennedy School of Government.
The VA is still making disability payments to a dependent of a soldier who fought in the Civil War 150 years ago, according to VA officials who declined to provide details because of privacy guidelines.
QUESTION MARKS
Costs are already rising. Each year the VA enrolls new veterans for disability payments. In 2006 the VA signed up 32,838 veterans to begin receiving disability payments for mental disorders. Four years later, its intake of new veterans with mental health disabilities had almost doubled, to 60,535 veterans. Altogether, more than 1.2 million of the 5.2 million veterans seen by the VA in 2009 had a mental health diagnosis -- a 40 percent increase since 2004.
To care for these veterans, the VA has hired 7,500 mental health care staffers just since 2005, and has opened almost a thousand outpatient clinics across the country.
It still isn't enough to meet the demand, and for that reason the VA has to outsource some of its mental health work, senior VA officials said. The VA pays private psychologists and other mental health care providers to see VA patients, especially those with the most severe conditions.
"The system is just swamped now," says one psychologist in private practice who works with VA patients, and who requested anonymity because he is not authorized to speak publicly about his work with the agency. He said patients seeking a mental health appointment at VA facilities face a two to three-month wait.
VA officials themselves acknowledge that they expect this influx of mental health patients to increase over time, even as U.S. military operations in Afghanistan taper off. Symptoms of post traumatic stress disorder, for instance, often don't appear for years or even decades after the experiences that trigger them.
"Someone who seemed to be coping well initially may develop significant problems later on, even after several years," Dr. Robert Petzel, the VA's undersecretary for health, said in a written statement to The Huffington Post.
What will it all cost? How much should Congress -- if it wanted to fund future veterans costs -- put aside?
The VA doesn't know.
The agency doesn't have a good record of forecasting future expenses. In early 2002, after American troops were already fighting in Afghanistan, it estimated it would owe disability payments to veterans of $26.9 billion in 2010 and $36.3 billion in 2020. In fact, the VA has already hit the 2020 mark: Last year it made $36.5 billion in disability payments to veterans. Its annual report for 2010 does not forecast future costs.
Miscalculating the growing population of wounded veterans, the VA ran a $1 billion budget shortfall in 2005, and a $1.5 billion shortfall in 2006. In 2009 the Government Accountability Office concluded, after studying the VA's books, that the agency's budgeting was "unrealistic" and "raises questions about both the reliability of VA’s spending estimates and the extent to which VA is closing gaps in non-institutional long-term care services."
Senior VA officials say that the size of the veteran population and the services that veterans will require in the future is unknown and unknowable. "To look 20 years out is purely speculative. You just can't calculate what the cost of health care will be," Petzel says, noting that it's particularly difficult to foresee the cost of caring for the severely wounded.
"We don't have extensive experience, particularly with the most severely injured population," he says. "It's fair to say the cost of prostheses isn't going to go down. You can't predict at all how many people are going to need that." The VA budget projects three years into the future and Petzel says "that's the best we can do."
Long-term cost estimates, Petzel adds, "are just not possible."
Others disagree. Bilmes estimates the total cost of caring for the war's wounded veterans, in disability payments and medical care, will come to between $589 billion and $934 billion over 40 years -- almost a trillion dollars, depending on the length and severity of the fighting yet to come in Afghanistan and Iraq. These numbers, developed with Nobel Prize-winning economist Joseph Stiglitz, are based on budget estimates by the Congressional Budget Office, the Congressional Research Service and data from the VA itself.
The Congressional Budget Office, in a study released last summer, estimates it will cost between $40 billion and $55 billion to care for all wounded Iraq and Afghanistan war veterans. The CBO study uses more narrow definitions of costs than Bilmes, who counts, for example, the cost of lost productivity by wounded troops unable to work.
While no one would argue that veterans don't deserve medical treatment and compensation, the long-term costs of caring for veterans remains unfunded, and that concern has prompted some to lobby for the creation of a Veterans Trust Fund. An unusual coalition of supporters, including peace groups such as Win Without War and conservative Republicans like Rep. Walter B. Jones of North Carolina, whose district includes the Marine base at Camp Lejeune, have gathered around the idea.
The sponsors say a key part of the plan mandates that Congress, in authorizing any U.S. participation in armed conflict, would also have to put money away for veterans wounded in that conflict.
"Even though you can't predict it exactly, you know if you are committing the country to a military conflict, there is going to be a long-term cost of providing medical care and disability benefits to those who are fighting the war," Bilmes says. She believes that without any mechanism to force Congress to set aside the money up front, "there is a willful, deliberate underestimation of the cost of war."
A Veterans Trust Fund, she says, "might lead our elected representatives to make different decisions or at least ask more questions about whether the objectives [of war] are worth the costs."
For his part, Rep. Jones dismisses the current year-by-year funding of veterans as a "shell game" that "has to stop.”
At a recent congressional hearing he spoke passionately about why the issue matters to him.
"I've seen those kids at Walter Reed with their legs blown off. I’ve seen the moms crying, the wives crying," he said. "These kids are 19, 20, 21 years old. And it's 30 years from now that we really have to be careful."
He endorsed the idea of a Veterans Trust Fund as the way "to ensure that we keep our promise to those who have served this country …"
But at present, there is no draft legislation establishing a Veterans Trust Fund and there are no sponsors for it in Congress -- leaving future funding for the severely wounded in question, despite the frequent declarations of patriotism and support by politicians.
Will the money be there? Will Congress in 2051 still be willing to set aside billions of dollars for replacement prosthetic legs and traumatic stress treatment for Tyler Southern and Todd Nelson and thousands of their wounded buddies?
Among others, Adm. Mike Mullen, who retired last month as chairman of the Joint Chiefs of Staff, has his doubts and he made them clear before a Senate panel last June.
Mullen noted that the vast array of services for the wars’ wounded -- from suicide prevention to family counseling and medical research -- is "some of the first money that budget types like to take out, historically."
The reason for this is simple, he said. "We like airplanes before we would keep [these] programs intact." A tireless champion for upgrading care for the wounded, Mullen warned that "unless we watch that very carefully, it will not be there when we need it."
Darlene Hooley, who urged in 2001 that Congress begin setting aside money for veterans, retired from Congress in 2009 and went home to Oregon. But she is not pleased that her predictions have come to pass. "I knew we would have a lot of injuries and that the budget didn't have anything in there for newly injured soldiers," she recalls. "We were really not prepared -- and we are still way behind."
She knows firsthand. After she left Washington, she started a scholarship fund for returning veterans, those whose needs are not covered by the VA. The Darlene Hooley scholarships help them get the college courses and vocational education they need to get good jobs.
"We are fighting every day to catch up," she says. "I said 10 years ago that if people go over there and serve, we absolutely have to make sure they get treated fairly when they got home. And time eventually tells -- we needed to be a lot more prepared."