Him Who Shall Have Borne the Battle: The Complex Costs of War

April 09, 2007

"Support the troops" has become a mantra for US policymakers, political shorthand freighted with different connotations for those who seek an imminent military exit from Iraq and those who favor open-ended commitment of US forces. In this charged environment, media coverage describing the grim welcome -- from dilapidated housing to demoralizing bureaucracy -- awaiting some soldiers making the transition from combat to convalescence at Walter Reed Army Medical Center sent shockwaves through US public discourse. The revelations triggered Congressional hearings, internal investigations, high-level resignations, a military review panel and a blue-ribbon commission, and widening scrutiny on the Departments of Defense and Veterans Affairs.

Thorough investigations will doubtless add detail to early sketches: some defense and VA programs offer high-quality care, including cutting-edge prosthetics and unique rehabilitation for complex traumas. Others suffer from suboptimal funding and staffing and more facilities have fallen into neglect than those already marked for closure (such as Walter Reed). In the week marking the fourth anniversary of the war in Iraq, VA identified more than 1,000 deficiencies of varying seriousness in its 1,400 hospitals and clinics, GAO alleged serious neglect in a home for military retirees, and staff of the highly praised National Naval Medical Center warned that overwork and "compassion fatigue" could yet take a toll on services.

The reports rippling outward from Walter Reed may be shameful, but they should not be shocking. In 2003, reporter Mark Benjamin described shoddy living conditions for reservists and National Guard troops trapped in "medical limbo" prior to mobilization. A 1999 staff report initiated by then-Senate Committee on Veterans' Affairs Ranking Member John D. Rockefeller IV warned that budget cuts and a changing health care model might compromise VA's ability to serve combat-wounded veterans -- specifically those with spinal cord injuries, amputations, blindness, and post-traumatic stress disorder. GAO reports on the rocky transition from active duty to civilian life would fill a shelf.

Why did recovering soldiers still end up sleeping in moldering rooms while celebrities and political leaders visited other wounded troops in gleaming halls only steps away? Blame an ignoble history of budget woes and interagency conflicts, exacerbated by the current Administration's deliberate underestimates of the costs of waging war.

When the U.S. military shifted to an all-volunteer force in 1973, economists correctly predicted that active duty forces would become increasingly educated (high-school graduation rates among enlisted personnel exceed those of age-matched cohorts), professionalized (evidenced by high re-enlistment rates), and representative of the U.S. population (although the South is slightly over-represented, the military's racial make-up matches the general population more closely than ever). Economists inaccurately assumed that, as the military's payroll budget rose to attract qualified personnel, competitive wages would supplant programs such as the GI Bill. After a few hiccups in the late 1970's, the military met marketplace demands with a comprehensive package of healthcare, education, and retirement benefits. Over time, salaries for active duty personnel declined compared to civilian wages, but an increasingly generous benefits package compensated, and the military could recruit fastidiously.

Thus, diverse military and VA benefits programs, including health services, complement military recruitment and retention strategies. These programs compete for appropriated dollars against other force readiness priorities; recent increases in military budgets have been accompanied paradoxically by an erosion of health funding. The current Administration's annual VA budgets have relied upon curious assumptions: in 2006, the White House grudgingly admitted that VA's budget planning process had ignored the war, leading to a $1.3 billion shortfall for health care. An emergency supplemental appropriation closed the gap, but spurred Republican leadership to remove the House VA Committee chairman for advocating veterans' funding too passionately. Although the president's fiscal year 2008 budget proposes increasing VA's healthcare budget by about 6% to $34.2 billion, it also assumes that VA healthcare costs will freeze or shrink beginning in 2009, despite an anticipated influx of more than 250,000 veterans of Iraq and Afghanistan in 2008. Ignoring an ongoing war that makes more veterans eligible for VA services daily again appears more than disingenuous.

Walter Reed illustrates not only funding dilemmas (how many scarce dollars to spend on a facility designated for the scrap heap), but the onerous process of determining fitness for duty. A serious illness or injury should trigger an evaluation to determine whether a servicemember meets medical standards. If not, a physical evaluation board rates the degree of disability on a scale of 0-100%, determining whether the member will return to the home unit, assume alternate or limited duties, or separate or retire from service. Ratings also determine the level of any benefits to compensate for lost earning potential. The evaluation can be delayed or repeated if the disability is deemed "unstable." The Army's need to retain every soldier capable of serving in order to maintain troop levels, combined with an overburdened evaluation system scaled for peacetime separation levels, cultivates a holding pattern for all but the most profoundly disabled. A high disability rating can translate into higher costs to the military, providing an incentive to "lowball" estimates for soldiers uncertain of their rights or willing to compromise to end a Kafkaesque paperwork process. Because VA depends heavily on military disability ratings when making decisions on pensions and healthcare access, soldiers may trade lifetime support for a quicker return to civilian life.

Media reports understandably focus on egregious facility defects, but the laundry list of leaks and stains cannot compare to stultifying interagency cooperation problems that delay care. The increased scrutiny has already prompted the military to examine the need to bolster "wounded warrior" regiments and provide better information to families of injured servicemembers. In contrast, years of laws, threats, and cajoling have failed to stir the Pentagon's interest in facilitating a seamless transition between military and VA services. Despite its stature as the second-largest Federal agency, VA has little leverage to force its still-larger counterpart to adopt common electronic medical records, exchange clinical information easily, or allow its case managers to explain veterans' services and benefits to injured troops before separation is incontrovertible.

As some decision makers have argued, demands on military and VA services continue to evolve. Improvised explosive devices favored by insurgents in Iraq and Afghanistan increase traumatic brain injuries and amputations. Advances in body armor, trauma care, and medical technologies mean that more desperately injured servicemembers survive than ever before and need intensive clinical management, some for months and some for the rest of their lives. The invisible symptoms of post-traumatic stress disorder, estimated to occur in up to 10% of troops returning from Iraq, can be difficult to diagnose and too easy to self-medicate with alcohol or drugs if no other relief is offered.

However, the absolute numbers of casualties (about 23,400 injured to date, according to icasualties.org, although accurate figures are elusive) should not have overwhelmed military and VA capacities if realistic assessments had been used to fund and staff these programs. When Congress enacted VA eligibility reform in the wake of the first Gulf War, streamlining the system for determining who had access to what type of facility, all combat veterans earned the right to access VA healthcare for two years post-discharge regardless of whether they sustained a service-connected injury. A decade's worth of data should make predicting the number of active duty forces, veterans, and their families seeking healthcare through either the military or VA a relatively straightforward actuarial exercise.

The comprehensive costs of redeployment -- from support services for re-integration into civilian life to the full range of needed medical care -- should be placed into the context of strategic planning for this and future missions. If moral obligations are not compelling enough, policymakers must consider whether military and VA health infrastructures can be divorced from their context as a downstream part of the U.S. war-fighting capability, contributing to recruitment and personnel readiness, in determining levels of funding. Legislation requiring already overtaxed staffs to complete "report cards" will not replace honest public discussion about national willingness to support the troops in more than sentiment alone. So far, the American public has shown little taste for nickel-and-diming those who placed themselves in harm's way to buttress theories about fighting a war on the cheap.

In the best-case scenario, the high-level commissions charged with looking to and beyond Walter Reed can cut through the political miasma surrounding the war and focus purely on meeting promises made to those deployed to Afghanistan and Iraq, and those who will don uniforms for the missions future leaders deem necessary. President Lincoln's words of the second inaugural, a portion of which are inscribed on the walls of VA headquarters, summarize the challenge best: "Let us strive on to finish the work we are in, to bind up the nation's wounds, to care for him who shall have borne the battle and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations."

Dr. Julie E. Fischer leads the Stimson Center's Global Health Security program which explores the growing demands on the world's public health infrastructure, from policies intended to contain transnational disease threats to a new role for international health interventions in defense and diplomacy.