Six years into the "global war on terror," the Bush administration, Congress, and federal agencies are scrambling to address the health needs of battlefield veterans back from Iraq and Afghanistan.
President Bush acknowledges that the current means of caring for wounded and traumatized vets is "an antiquated system that needs to be changed." A bipartisan commission says the need for fundamental improvements in care management and the disability system "requires a sense of urgency and strong leadership."
As a result, Mr. Bush has proposed administrative action and legislation that would streamline the system for providing postwar medical services and disability compensation to wounded veterans and their families.
The numbers are daunting:
•Of the more than 1.4 million service men and women who have served in the two war zones, nearly 700,000 have become eligible for Department of Veterans Affairs (VA) medical care, of whom about 230,000 have sought such care since 2002.
• Depending on future force deployments, VA medical costs associated with Iraq and Afghanistan could total between $7 billion and $9 billion over the next decade, according to Congressional Budget Office (CBO) projections. Disability compensation and survivors' benefits could add another $3 billion to $4 billion.
• A total of about 30,000 troops have been wounded in action. The survival rate of those wounded is higher than it was in Vietnam and much higher than World War II, due to body armor, advances in battlefield medical procedures, and more rapid evacuation.
Put another way, this means the number of those killed is a relatively smaller portion of overall casualties. It also means concern is growing about injuries and ailments that have come to mark this war: amputations, traumatic brain injuries (TBI), and the mental and emotional shock of combat.
"Of the [Iraq/Afghanistan] veterans who sought care from VA, about 38 percent have received at least a preliminary diagnosis of a mental health condition, and 18 percent have received a preliminary diagnosis for PTSD [post-traumatic stress disorder], making it the most common, but by no means, the only mental health condition related to the stress of deployment," Michael Kussman, undersecretary of the Veterans Health Administration, told a House Committee on Veterans' Affairs hearing last week.
According to the Congressional Research Service, between 2003 and 2007 about 60,000 troops were diagnosed with either PTSD or TBI.
The VA is one of the largest federal bureaucracies, operating more than 1,500 facilities providing help for veterans and their families and employing about 200,000 people, including some 13,000 doctors and nearly 55,000 nurses.
Despite this, one concern is the growing need for medical specialists to help war veterans.
In recent congressional testimony, Joseph Wilson of the American Legion cited federal studies showing that by 2020, projected retirements will create a shortage of about 24,000 physicians and almost 1 million nurses nationwide.
"Another challenge [is] acquiring staff trained in certain specialty fields … physical medicine and rehabilitation, blind rehabilitation, speech and language pathology, physical therapy, and certified rehabilitation nursing," warned Mr. Wilson. "Given the special rehabilitative and long-term care needs of combat wounded veterans returning from Iraq and Afghanistan – especially those residing in rural areas – shortages in these specialty fields will have a lasting impact on these veterans as they attempt to resume independent functioning."
Linda Bilmes, who teaches at of the Kennedy School of Government at Harvard University, estimates that the long-term costs of disability compensation and medical care to veterans of Iraq and Afghanistan could be as high as $700 billion.
"The cost of providing such care and paying disability compensation is a significant long-term entitlement cost that the US will be paying for the next forty years," professor Bilmes wrote in a research paper earlier this year. Reports early this year of inferior treatment and bureaucratic bungling at the Walter Reed Army Medical Center highlighted problems that still have not been fully solved despite steps to reform the massive and complicated system.
The Government Accountability Office (GAO) last week cited "fundamental system weaknesses" on the part of both the Defense Department (DOD) and the VA in how they treat wounded vets – including not enough staff and staff training.
"Delayed decisions, confusing policies, and the perception that DOD and VA disability ratings result in inequitable outcomes have eroded the credibility of the system," the GAO reported.
It is these criticisms that Bush addressed last week in meeting with the "Wounded Warriors" commission headed by former Sen. Bob Dole and former Secretary of Health and Human Services Donna Shalala. The President's proposals include:
•New procedures for evaluating disabilities and compensating injured military personnel, including pensions for those who cannot return to active duty.
•Greater emphasis on diagnosing and treating PTSD – especially addressing any stigma associated with the disorder.
•Assignment of patient advocates to monitor progress, guide wounded vets through government bureaucracies, and help in the transition to civilian life.
•Providing six months unpaid leave for family members who want to help aid the recovery of wounded GIs.
As the fighting in Iraq and Afghanistan continues, policy makers – like most Americans – say it's vital to separate a divisive war from those who fought.
"No matter where we stand on the war in Iraq, we all stand together in our desire to make sure that our returning service members get the healthcare they need, and the benefits they have earned," says Rep. Bob Filner (D) of California, who chairs the veterans' affairs committee. "We cannot fund the war, but fail to fund the warriors."