Phillip Carter. Foreign Affairs. New York, Volume 96, Issue 5. September/October 2017.
Each year, the U.S. military recruits some 175,000 young Americans. At the heart of its pitch is a sacred promise to take care of those who serve-what President Abraham Lincoln described in his second inaugural address as the national duty “to care for him who shall have borne the battle and for his widow and his orphan.” Today, this promise is enshrined in the ethics of each service: members of the U.S. Army, Navy, Air Force, Marines, and Coast Guard pledge to never leave a fallen comrade behind. After their service, the Department of Veterans Affairs (VA) works to fulfill this same promise on behalf of a grateful nation, enabled by a budget larger than those of the State Department, the Department of Homeland Security, and the entire U.S. intelligence community combined.
Most national security discussions focus on strategy or policy. To the extent that ways and means get considered at all, the talk tends to center on weapons systems, budgets, bases, and buildings. These matter, but people matter, too. Service members are an irreplaceable component of U.S. national security. And because the United States relies on an all-volunteer force, how the country treats its troops during and after their service matters when it comes to sustaining this critical component of national strength.
The wars in Afghanistan and Iraq saw incredible advances in body armor, battlefield medicine, and medical evacuation, all of which dramatically improved the likelihood that soldiers would survive injuries. Deaths from nonbattlefield injuries and illnesses, historically far more deadly than combat, have also fallen greatly, thanks to aggressive public health efforts and fitness requirements for troops. In this respect, the United States is keeping its most sacred pledge to those it sends into harm’s way: to bring them home.
But despite some recent improvements, the VA and other federal agencies struggle to keep other promises to active service members and veterans after they come home. Aging bureaucracies struggle to meet the needs of a diverse and dispersed population. Educational and economic support programs fail to keep pace with the changing needs of veterans and their families. To fix these problems, the United States must rewrite the contract it strikes with its service members, building a support system that not only ameliorates their battle wounds and financial losses but also helps them thrive after their service in a twenty-first-century economy.
At Your Service
The social contract with veterans has changed considerably since the founding of the United States. For economic and political reasons, the framers of the Constitution envisioned a small standing military, supported in peacetime by a citizen militia. When wars did break out, white male citizens were expected to volunteer. Aside from small pensions for war widows or severely disabled veterans, the government offered little in return.
This model persisted through most of the eighteenth and nineteenth centuries. Then came the Civil War. Following the lead of the French during the Napoleonic Wars, both the North and the South eventually resorted to conscription for the first time in U.S. history. By the time the war was over, in 1865, some 3.3 million Americans had served, out of a total population of 35.2 million. Of these, nearly 500,000 were killed, with tens of thousands more wounded. During the war, each side set up battlefield hospitals; afterward, they established convalescent homes to rehabilitate the injured and veterans’ cemeteries to inter and memorialize the dead.
Civil War veterans dominated U.S. political life for the next half century. Veterans’ organizations, such as the Grand Army of the Republic and the United Confederate Veterans, became powerful domestic lobbies. They successfully campaigned for expanded government benefits, such as bigger pensions for disabled veterans and widows and more hospitals, veterans homes, and cemeteries. But Washington didn’t think to combine these services into a single federal agency, since the U.S. government wasn’t in the habit of providing social services at the time. Apart from these new benefits, support for veterans remained largely the province of charities and local governments.
This arrangement changed with the advent of industrialization, the experience of two world wars, and the implementation of the New Deal. During World War I, the United States mustered 4.7 million troops to fight, including 2.8 million conscripts. Over 115,000 died and 200,000 were wounded. Just as had happened after the Civil War, veterans’ organizations that formed in the wake of this war accrued tremendous political influence. This time, however, they used that power to secure more expansive health care, life insurance, vocational rehabilitation, and other programs. In 1930, President Herbert Hoover worked with Congress to create the Veterans Administration, the forerunner to today’s VA, consolidating health care, benefits programs, and cemetery administration into a single agency for the first time. After the Great Depression struck, President Franklin Roosevelt responded by fundamentally changing the role of the federal government in society, vastly expanding social welfare programs- eventually including those for veterans.
The government’s role in veterans’ affairs increased again during World War II, in which 16 million men and women served, 400,000 of whom died and 670,000 of whom were wounded. To prepare for the return of so many troops, in 1944, Congress unanimously passed the Servicemen’s Readjustment Act, better known as the GI Bill. It contained three main provisions: 52 weeks of unemployment compensation, a veterans’ home loan program offering zero-down-payment mortgages, and subsidies for higher education. It also appropriated $500 million for new VA hospitals, authorized the VA to take over existing military hospitals, created a veterans’ employment program, and established a small-business loan program. Together with Roosevelt’s earlier reforms, these benefits added up to a new social contract with service members. The government would not simply treat the wounds of war and compensate the disabled and the widowed for their suffering; it would recognize and reward military service, too.
The GI Bill helped the massive cohort of World War II veterans make the transition back to civilian life. One congressional study from 1988 estimated that for every $1 the government spent on educational benefits, veterans returned nearly $7 to public coffers in increased tax revenue or added economic output. In the ten years after the war, the government issued 4.3 million home loans to veterans, contributing to a housing boom that stimulated the economy and changed the postwar American landscape.
Even during these halcyon days, however, the VA labored to fulfill its expanded role. To address its various problems, in 1954, President Dwight Eisenhower appointed his former colleague, General Omar Bradley, to lead a study of the future of the VA. The Bradley Commission took a conservative view of what veterans were owed, concluding, “Military service in time of war or peace is an obligation of citizenship and should not be considered inherently a basis for future Government benefits.” Helpful as the GI Bill had proved to millions of veterans, Bradley saw it as unnecessary and unsustainable, particularly since new programs such as Social Security were intended to provide economic security for all Americans.
But Bradley ultimately lost the debate. Veterans fought back hard against the attempt to cut their cherished programs, and they found allies in broader society, which had benefited from the tidal wave of former soldiers buying homes, going to college, and starting businesses. As the Cold War took off, the Defense Department continued to recruit or conscript hundreds of thousands of young men, establishing the first large peacetime military in U.S. history (and contributing to a veteran population that would peak at over 28 million in 1980). That military would go to war in Vietnam. As the conflict began to wind down in 1973, President Richard Nixon ended the use of conscription, eliminating one of the great contributors to the antiwar movement. So began the era of the all-volunteer force, which remains in place today.
In the wake of Nixon’s decision, the demographics of the U.S. military began to shift dramatically. Although the military had been formally desegregated for decades, the military (and veteran) population became more racially and ethnically diverse as the self-selection dynamics of the all-volunteer force took root and as minorities increasingly saw service as a form of economic mobility. The military also began to include more women, who gained access to new roles across the force and now make up the fastest-growing demographic within the veteran population. Yet without conscription, which drew young Americans from all classes and regions, the military began to recruit disproportionately from certain parts of the country and society: the South, the Midwest, the middle and working classes, and military families. Among those, the military also recruited a relatively elite group, since not everyone could pass its rigorous entry requirements regarding education, health, and criminal history. The effect of these changes was to produce a military that has grown increasingly distinct from the population as a whole: a part of society, but also apart from it.
During this period, the social contract behind military service also shifted. Today’s promise to veterans still includes the core components provided to previous generations: health care and compensation for wounds and other injuries sustained in the line of duty, help with readjusting to civilian life, and support for indigent veterans and survivors of those killed in the line of duty. But now it also includes programs- from the Post-9/11 GI Bill’s educational assistance initiatives to the Small Business Administration’s programs for veteran entrepreneurs- that reward and encourage service by enabling veterans to outperform those who have not served.
Yet the shift to giving veterans a leg up in the workplace is not complete. The VA’s largest program, disability compensation, effectively encourages disability by paying veterans according to the degree to which they are disabled, offering no incentive for them to improve their conditions or leave the disability roster. A related VA program, aimed at vocational rehabilitation and education, aims to get disabled veterans back to work, but it serves a relatively small population and should be broadened to help all disabled veterans. The dissonance between these programs-with one compensating veterans for losses incurred during service and the other seeking to improve their performance after service-creates mixed incentives for veterans.
Get Well Soon
Of the three categories of veterans’ benefits-health care, economic aid, and crisis support-health care is the largest and most used. By law, nearly all of the country’s 21 million former service members are eligible for VA health care; of these, nine million have enrolled, and almost seven million used the system in 2016, at a cost of $63 billion. This system provides comprehensive coverage, not only for injuries and illnesses sustained in the line of duty but also for any other medical needs that may arise at any point. To do this, the VA runs 144 hospitals, 800 clinics, and 300 mental health Vet Centers and employs more than 300,000 people. In addition to treating veterans, the VA trains nearly half of U.S. doctors and two-thirds of U.S. nurses at some point in their careers and conducts more than $2 billion in research each year.
Generally speaking, the VA provides outstanding medical care. The problem, however, is that many veterans struggle to access it. The VA’s complex bureaucracy is hard to navigate, so many eligible veterans don’t receive care in a timely, convenient manner. The VA system erupted in scandal in 2014, when CNN discovered that employees at a VA hospital in Phoenix were manipulating recorded wait times to make it seem as though veterans were receiving timely care. The incident prompted Eric Shinseki, the secretary of veterans affairs, and Robert Petzel, the VA’s top doctor, to resign.
The VA also has difficulty maintaining quality and patient satisfaction. It relies on an antiquated health records system that once led the country in terms of innovation but now lags far behind those in the commercial sector. (In June, the VA announced that it plans to replace this system with commercial software, but doing so will likely take years.) Because of its size and geographic dispersion, the VA struggles to be good at all things in all places. Hardly a month passes without a scathing report from the VA’s inspector general about flaws in care or squalid conditions at some VA facility. In May 2017, for example, a report on the VA hospital in Hines, Illinois, described cockroaches on patient food trays and transportation carts.
Until the Phoenix scandal, proposals for reforming VA health care generally involved pouring more resources into the existing system. Afterward, however, conservatives, such as Arizona Senator John McCain, won a major debate over whether to rely more on the private sector to improve care. For years, McCain and others had called on the VA to privatize in a variety of ways, in part by relying more on contractors. In 2014, the VA contracted out ten percent of its appointments to private-sector providers; that figure rose to 32 percent by late 2016 and, if the Trump administration gets its way, will increase further. In the years to come, the VA will likely reshape its health-care system into a hybrid public-private model that current VA leaders hope will better and more cheaply serve the shrinking, dispersed veteran population. But this evolution is fraught with peril. It remains unclear whether the VA can maintain its high quality of care or large research and educational missions when a significant number of veterans receive services outside the system.
The Benefits of Service
The federal government runs a dizzying array of economic support programs for veterans. Some, such as disability compensation, trace their roots back to the Revolutionary War and the core idea of caring for those wounded in war. Others, such as offering veterans small-business loans or giving them preference in receiving government contracts, reflect the more modern aim to reward veterans and attract new recruits.
Of these various efforts, disability compensation and pensions are the most expensive: in 2016, the VA spent $77 billion on payments to roughly five million people eligible for such benefits. It devoted another $14 billion to educational and training programs, including the Post-9/11 GI Bill; these helped just over one million veterans attend college or receive vocational training. Alongside these forms of assistance, the VA also administers life insurance programs and home loans. Meanwhile, the Department of Labor runs a veterans’ employment service, the Small Business Administration offers support for entrepreneurial veterans, and every federal agency provides contracting and hiring preferences for veterans.
Like Social Security, most VA benefits programs run on autopilot. Unlike the VA’s health-care system, which is classified as discretionary spending, its benefits system is considered by Congress to be mandatory spending. Once a veteran earns a benefit, it is paid until it is exhausted, as with the Post-9/11 GI Bill (which runs for 36 months) and disability compensation (which generally lasts for a veteran’s lifetime). Controversy arises only when the system runs aground, as it did in 2011, when the disability claims backlog reached nearly one million, as veterans of all ages simultaneously pursued claims for disability from an overworked system. It also encounters problems if it makes systemic errors, such as denying claims for Agent Orange-related illnesses or posttraumatic stress disorder because the evidence of a causal link between military service and these ailments is tenuous (although, of course, battlefield conditions are not the best laboratories for randomized controlled trials). But veterans have come to accept a certain level of friction in the system, not unlike what they experienced in the military itself.
Yet many of these benefits fail to fully support modern soldiers’ transitions to civilian life. The VA’s disability compensation scheme, for example, matches neither the realities of contemporary service nor the American workplace. With longer terms of enlistment and more frequent deployments, service members often end their tours with at least some physical effects, from hearing loss to orthopedic injuries or worse. The current disability system treats every one of these injuries, no matter how minor or treatable, as a potentially lifelong disability, rather than as the normal wear and tear of service. Veterans have increasingly claimed these injuries as disabilities, taxing the VA’s resources. The system also primarily addresses physical injuries rather than cognitive or mental impairments, an outmoded approach.
In addition, over the past eight years, the unemployment rate for recent veterans rose above the overall national rate. By 2011, the unemployment rate for post-9/11 veterans was 12 percent, compared with just nine percent for the overall population. (The total veteran unemployment rate was lower than the national rate, owing to older veterans, who tend to do better than average in the work force.) Starting that year, the Defense Department, the VA, the Department of Labor, and other agencies worked to address this crisis by revamping the civilian transition training given to service members before discharge and working with companies to establish private-sector hiring goals. Those efforts, plus an improving economy, brought unemployment among recent veterans down to parity with the national unemployment rate by 2016.
But the unemployment spike highlighted a problem. Although the government provides substantial benefits in education and health, it can do much more to facilitate veterans’ transitions into the work force. For example, it should offer programs that subsidize vocational training, such as coding boot camps, and provide seed capital for startups, which could help veterans who want to start a business instead of going to college. The Trump administration has pledged to facilitate public-private partnerships to serve veterans and hold the VA accountable. Although such efforts will help, the continued gulf between the culture of the military and that of the civilian work force makes for a difficult shift no matter what services the government provides.
Remember the Neediest
Although crisis support-programs for homelessness, addiction, and legal problems-represents a small share of veterans’ benefits, it responds to an acute problem. The VA and other federal agencies provide billions of dollars to veterans living on the margins of society, offering a lifelong social safety net that far exceeds what is available to nonveterans.
For years, veterans have been chronically overrepresented in the nation’s homeless population. In 2009, Shinseki announced an audacious goal of reducing the number of homeless veterans to zero. From fiscal year 2009 to fiscal year 2017, the VA poured $65 billion into housing, mental health treatment, and other services for veterans in need. The effort made a huge dent, reducing the number of homeless veterans from 73,367 in 2007 to 39,471 in 2016. Shortly after Trump took office, David Shulkin, his secretary of veterans affairs, announced that the effort would continue, but that instead of simply counting the absolute number of veterans on the streets, it would instead aim for the more realistic target of “functional zero,” a goal that measures the number of homeless veterans against the housing capacity of a given community.
Veterans are also disproportionately afflicted by alcohol and substance abuse. Self-medication of posttraumatic stress appears to be one driver; another may be the tendency of VA and military hospitals to overprescribe medication for everything from sports injuries to combat stress and sleep disorders. The VA has set up clinics to treat addicted veterans, but these lack the resources to meet demand, and other veterans fail to seek any care at all.
Veterans have also historically been overrepresented in the nation’s courts, jails, and prisons, although less so in the era of the all-volunteer force. Across the country, local courts and law enforcement agencies have joined with social service agencies to form veterans’ courts, which resemble diversionary programs for other populations, such as juveniles. For nonviolent, nonserious crimes, these courts can match veterans with supportive services, such as substance-abuse counseling and job placement, in exchange for dismissing or expunging their charges when they complete these programs. The number of veterans entering these courts remains small, but they have no doubt helped many avoid a lifetime of dependency and incarceration.
Another previously marginalized group of veterans has risen to prominence over the past few years: those discharged with “bad paper,” frequently the result of minor misconduct while in service, for which the root cause is often posttraumatic stress. By statute, these former service members aren’t classified as veterans and are thus denied access to veterans’ health care and other benefits. But they are far more likely to struggle with unemployment, homelessness, substance abuse, and suicide than other veterans. Since they are ineligible for VA support, the burden of supporting these veterans falls on state and local governments and charities, often costing tens of thousands of dollars per veteran. In recent years, veterans’ groups, social service organizations, and public interest lawyers have argued that these veterans should at least have access to life-saving health care, if not the full benefits. Shulkin recently embraced this cause, too, although it will likely take action from Congress to make real headway.
Time to Rethink
In all these areas, change will undoubtedly prove slow and challenging. Each VA program has a constituency that depends on it and might oppose reform. Long-overdue adjustments to the system for disability compensation, for example, could include updates to the antiquated schedule used to rate disability percentages or changes to the process for evaluating disabilities. Because these changes would reduce benefits for some, however, for political reasons, current veterans would have to be grandfathered in. On the health-care side, increasing the VA’s use of private-sector doctors could shorten wait times, but it could also weaken the agency’s teaching and research capacity and thus lower the quality of care for those patients who continue to receive treatment from VA doctors. Those veterans who are generally satisfied with the status quo will look at any major changes with skepticism.
Cost must factor into the equation, too. The federal government already spends more on veterans now, in both absolute and per veteran terms, than at any point in history-but some reforms will cost even more. Trump requested a VA budget for 2017 totaling $186 billion, covering health care, benefits, cemeteries, and the administration of the VA. This represents a four percent increase from the previous year but may still fail to meet veterans’ needs through the existing agency structure. Over the past 15 years, even as the overall veteran population has shrunk, the VA budget has grown enormously, since veterans of all generations are increasingly using the system. And over the next 15 years, demand will no doubt rise, as the VA serves both the Vietnam-era cohort and the post-9/11 cohort. The Defense Department has reported that as of May 2017, 2,874,820 service members had deployed to Afghanistan, Iraq, or other theaters of war since 9/11. The Harvard scholar Linda Bilmes has estimated that the total cost of veterans’ support for the post-9/11 generation will likely exceed $4 trillion. The majority of this bill will come due sometime around 2050, because expenditures typically peak when a cohort reaches its 70s.
With the veteran population evolving and existing programs straining to meet its needs, it is time for the U.S. government to fundamentally rethink the social contract underlying service. If the goal of veterans’ programs is merely to compensate individuals for injuries, hardships, and the costs of service, then they are doing a decent job. But if the goal is to help veterans thrive, then the programs are faring poorly. And leaving veterans better off than their peers is crucial, since it will make service appear more attractive to future generations weighing the military as an option.
With that goal in mind, Washington should redesign the system for supporting veterans. Without scaling back programs such as disability compensation and health care, which primarily ameliorate the harms of service, the government should expand benefits such as the Post-9/11 GI Bill and small-business financing, which can create enormous economic opportunities for those who serve. It should also find ways to leverage the enormous social capital that veterans develop during their service for economic and societal gain. In Israel, for example, veterans of elite intelligence and special operations units move seamlessly into the technology and start-up world, drawing on their connections in much the same way that Stanford graduates do in Silicon Valley. Although Israel is much smaller and maintains conscription, both of which help build a tightknit entrepreneurial military community, the United States could replicate elements of that ecosystem within parts of its military, especially the intelligence and special operations fields, both of which rely on advanced technology. The Defense Department should also explore ways to more closely link active and reserve units with businesses, particularly those that provide critical infrastructure, such as telecommunications and energy firms. These service members could draw on their hard-earned experience to help defend the private sector against cyberattacks and economic espionage, while fostering a virtuous cycle of innovation between the military and the private sector.
Washington should also be mindful of the ways in which the increasing civil-military divide exacerbates the struggles of veterans—for example, fueling veteran unemployment because of the cultural gap between civilian employers and their veteran employees. This divide may also hinder veterans’ reintegration into communities and their willingness to seek mental health care, because of a fear of social stigma. Absent a foreign invasion or a crisis on the scale of World War II, the country is unlikely to return to conscription or increase the size of the military to the point where it would fundamentally change its relationship to the rest of society.
To repair the split, then, the military should seek greater geographic and socioeconomic diversity among its recruits. It should establish public-private partnerships to support veterans in the work force. And it should rely on reserve units so as to broaden the military’s geographic footprint to include communities away from major base towns such as Killeen, Texas, and Norfolk, Virginia. Veterans have a role to play, too. A recent study by the advocacy group Got Your 6 found that veterans are not always likely to self-identify as veterans after service, and civilians often think veterans are worse off than they are. Veterans, particularly those who succeed after service, must represent the military and explain their service to the wider population.
For the foreseeable future, the United States will rely on a relatively small, volunteer military. Its success depends on its ability to draw in high-quality recruits. And that, in turn, depends on the perception that service will benefit soldiers, their families, and their country.