The answer is more complicated than whether the Food and Drug Administration has approved it.

Inside the Department of Veterans Affairs, a treatment can pass one scientific hurdle and still face others before it becomes routine care.

VA says the process can involve research, clinical guidelines, medication reviews, patient-safety systems, ethics reviews and practical questions about whether the health system has the staff, space and equipment to deliver it.

“VA moves new treatments into practice through a step-by-step process,” Dr. Ilse Wiechers, a VA mental health official, told Military Times. “Only after a treatment is shown to be safe and effective does VA roll it out more broadly.”

It starts with evidence, but evidence is only the beginning.

A new treatment may start with research, move through increasingly larger clinical trials and, for drugs and certain medical devices, undergo FDA review. VA must then consider how the evidence applies to the veterans it serves and how a treatment fits into the health system.

The 2023 VA/DoD Clinical Practice Guideline for PTSD uses the GRADE methodology to evaluate the quality and strength of evidence and weigh the benefits and harms of treatment options. The guideline also considers patient perspectives and feasibility when developing recommendations.

The 2023 PTSD guideline applied GRADE more rigorously than the 2017 version, according to the guideline. That resulted in some recommendations being downgraded as the evidence was reevaluated.

Recommendations can change as research develops, and veteran-specific evidence can matter, too.

Wiechers said evidence involving veterans can be an important consideration when VA evaluates whether a treatment should become available, even when research in other populations is promising.

For PTSD, however, the 2023 VA/DoD guideline says a lack of data on veterans or service members alone did not alter its recommendations. That helps explain why FDA approval and VA availability are not necessarily the same thing.

How a treatment moves into VA care

Repetitive transcranial magnetic stimulation, or rTMS, offers a concrete example of how the VA adopts a new treatment.

The FDA approved rTMS for depression in 2008. According to VA, the department then conducted a large study involving veterans, tested the treatment in a pilot program at 35 VA sites and expanded access after the pilot.

VA says more than 60 of its facilities now offer rTMS, with some operating specialized clinics that combine it with other advanced depression treatments. Dr. Wiechers added that the success of the program’s original 35 clinics, as listed on the VA’s website, resulted in the program expanding to over 60 facilities.

The sequence illustrates the difference between FDA approval and VA implementation. VA says it studied rTMS in its own patient population, tested its delivery across multiple facilities, and then expanded access.

There is no single office that makes the decision.

Dr. Wiechers described a team-based process in which draft policies are shared with offices responsible for delivering or overseeing a treatment. That allows potential risks, downsides and ethical concerns to be identified before policies are finalized.

Among the offices involved, Dr. Wiechers identified the Office of Mental Health and its programs, including the National Center for PTSD; the Office of Suicide Prevention; Pharmacy Services; the National Center for Ethics in Health Care; Nursing Services; and Care Management & Social Work Services.

The considerations extend beyond whether a treatment works.

Wiechers said VA also considers whether it has enough trained clinicians, specialized equipment and space to deliver a treatment, as well as whether adding it could take resources away from other care.

For medications, another layer comes into play.

VA’s National Formulary establishes the department’s national preferred list of medications. Some medications also have Criteria for Use documents that establish evidence-based conditions or restrictions for prescribing.

VA says medication reviews can be prompted by new FDA approvals or research that could affect evidence-based prescribing, clinical practice or health outcomes for veterans.

The formulary process includes VA physicians, Pharmacy Benefits Management officials and Veterans Integrated Service Network pharmacist executives. Formulary documents are reviewed, and feedback is solicited from health care teams.

An FDA-approved medication, therefore, can be available in civilian medicine while having different prescribing conditions inside VA.

That distinction can be particularly important for treatments that carry significant risks or require specialized monitoring.

Emerging treatments test the boundaries

Emerging mental health treatments illustrate the difference between scientific promise and routine clinical care.

The VA/DoD PTSD guideline, for example, recommends against benzodiazepines for PTSD, citing a lack of evidence of benefit and known harms, such as drug dependence and addiction.

It also recommends against cannabis and cannabis-derived products for PTSD, citing a lack of well-designed randomized controlled trials and potentially serious side effects.

Veterans are questioning why their legal cannabis license can’t be considered by the VA.

“I have a medical cannabis license, and I have to pay for my medication out of pocket, but almost any other medication is covered by the VA,” explained George Canfield, a retired Army veteran.

“Why can’t VA offer some kind of subsidy to offset the cost of this naturally derived treatment? I don’t expect a VA-run dispensary, but I would like it to be more affordable since it’s what helps me more than any other medication I’ve tried,” he said. “And I’ve tried them all!”

Ketamine presents a different example. The VA/DoD guideline retained a weak recommendation against ketamine for PTSD, citing limitations in the evidence and a lack of demonstrated effectiveness for the condition.

Psychedelic-assisted therapies remain an area of active research, meaning promising findings do not by themselves establish a treatment as routine VA care.

VA has recently expanded its research into psychedelic therapies and is recruiting veteran participants for clinical trials in select regions.

For veterans, those distinctions can affect whether a treatment encountered outside VA is available or subject to different conditions within the federal health system.

What happens after a treatment works?

The process continues after a treatment enters clinical practice.

VA says it monitors treatments through individual reports of adverse events or other problems, ongoing quality monitoring and formal research.

If a patient experiences a bad reaction or other adverse outcome, local staff can report and investigate it. Dedicated safety programs can identify patterns that may warrant broader review or changes in guidance.

VA also evaluates how treatments perform in actual clinical practice, particularly when a new treatment is introduced or when policies governing its use change.

Once a treatment becomes standard care, researchers generally cannot create the same untreated comparison group used in many clinical trials.

Dr. Wiechers said the most rigorous safety and effectiveness checks tend to occur early, while a treatment is still being rolled out.

The process does not end there. VA and the Department of Defense periodically revisit clinical practice guidelines as evidence changes. The current 2023 VA/DoD PTSD guideline contains 34 evidence-based recommendations and is intended to assist, rather than replace, clinical judgment. The guideline is a tool for clinicians and does not define required care.

What veterans see at the end of the process

For a veteran sitting across from a VA clinician, much of this process is invisible.

The veteran sees a treatment that is available, restricted, unavailable or offered only through a clinical trial.

Behind that decision may be years of research, clinical practice guidelines, formulary reviews, safety monitoring and assessments of whether VA can deliver the treatment.

Dr. Wiechers said there are several reasons why a treatment may not be available to veterans.

“VA only offers treatments that have solid research behind them showing they help,” she said. When a treatment is not available, she said, it may be because “the evidence isn’t strong enough yet, or it hasn’t been proven to work well specifically for Veterans.”

There is no single moment when someone decides a treatment “works.”

Instead, VA describes a sequence of decisions involving evidence, safety, effectiveness for veterans, clinical guidance, feasibility and resources. Once a treatment reaches the clinic, monitoring and research continue.

The system is designed to answer a question bigger than whether a treatment works:

Is there enough evidence that it works for veterans, can VA deliver it safely and effectively, and should it become part of routine care?

Schiess will succeed Gen. Chance Saltzman, who has served as Chief of Space Operations since November 2022 and is expected to retire later this month. Upon assuming the position, Schiess will be promoted to four-star general, becoming the Space Force’s senior uniformed officer and serving as a member of the Joint Chiefs of Staff.

President Donald Trump nominated Schiess in May following Saltzman’s planned retirement.

Schiess currently serves as deputy Chief of Space Operations, a role in which he oversees the Space Force’s global operations, readiness, sustainment and training. Before joining the Space Force headquarters staff, he commanded U.S. Space Forces–Space, overseeing military space operations and integrating space capabilities in support of combatant commanders worldwide.

Earlier in his career, Schiess served as an Air Force missile officer and held assignments in military launch, GPS and satellite communications before commanding the 21st Space Wing and the 45th Space Wing. His 34-year military career also includes operational, staff and joint assignments supporting U.S. Central Command, U.S. Space Command and multinational operations.

During his confirmation hearing before the Senate Armed Services Committee in July, Schiess told lawmakers the Space Force must continue organizing, training and equipping Guardians to defend U.S. space capabilities, protect the joint force from space-enabled attack and deliver the capabilities needed to support military operations across the full range of missions.

“Our purpose is not confrontation, but deterrence, ensuring no adversary believes aggression against the United States will succeed,” Schiess told the committee.

He said he would work to ensure Guardians remain ready, the service’s capabilities remain resilient and its partnerships remain strong.

In written responses to the Senate Armed Services Committee, Schiess said he would prioritize strengthening the connection between force design, acquisition programs and combatant commanders’ operational requirements.

He also said he would focus on expanding launch infrastructure, improving the Space Force’s testing enterprise and continuing efforts to strengthen the acquisition workforce needed to field new capabilities more rapidly.

Gen. Francis L. Donovan, commander of U.S. Southern Command, directed the activation Tuesday, describing Joint Task Force Western Hemisphere, or JTF-WHEM, as a purpose-built joint task force that will provide unified command and control at the tactical and operational levels, while integrating military capabilities with the 18 partner nations of the Americas Counter Cartel Coalition, or A3C.

SOUTHCOM Media Relations Officer Steven McLoud told Military Times the activation of JTF-WHEM “represents an evolution from Operation Southern Spear,” reinforcing the command’s whole-of-government, multinational approach to defending the homeland while building on the successes of Operation Southern Spear.

McLoud said JTF-WHEM serves as SOUTHCOM’s “action arm,” focused on what he described as imposing “total systemic friction” against threats across the hemisphere.

He said the task force builds on Operation Southern Spear, which employed “precise kinetic strikes and maritime interdiction operations” to disrupt illicit trafficking and undermine entrenched criminal networks, by advancing efforts to disrupt, dismantle and defeat narcoterrorism networks.

According to McLoud, JTF-WHEM coordinates U.S. military actions targeting cartels and narcoterrorist networks while leveraging the commitment of Americas Counter Cartel Coalition member nations through expanded bilateral and multilateral cooperation in border security, countering threats and protecting critical infrastructure. He said enhanced cooperation and information sharing support the president’s national security strategy, the defense secretary’s national defense strategy and SOUTHCOM’s theater priorities.

According to SOUTHCOM, JTF-WHEM will serve as the command’s operational headquarters for executing missions across the region.

The command said the headquarters integrates intelligence, surveillance and reconnaissance, operational planning and multinational coordination while supporting intelligence sharing, combined training, interoperability, partner-capacity building and humanitarian assistance and disaster response.

SOUTHCOM said the task force is intended to increase operational effectiveness against transnational criminal organizations and other threats affecting the United States and partner nations.

“JTF-WHEM strengthens our ability to work alongside trusted allies and partners, synchronize military capabilities and apply sustained pressure against the networks that threaten our collective security,” Donovan said in a statement. “Together, we are increasing security across the hemisphere and protecting our homeland.”

Donovan also said, “Together with the 18 nations of A3C, we are changing the way we confront these threats.”

Gen. Donovan selected Marine Corps Maj. Gen. Kevin Jarrard to command the new task force. Jarrard most recently led U.S. military support to U.S. Department of State-led disaster relief operations following the June earthquakes in Venezuela.

In a letter shared exclusively with Military Times, the oversight committee’s ranking member, Robert Garcia, D-Calif., and Rep. Suhas Subramanyam, D-Va., ranking member of the Military and Foreign Affairs Subcommittee, asked Defense Secretary Pete Hegseth to provide a complete record of every change made to the Defense Casualty Analysis System, or DCAS, involving Operation Epic Fury, “Overseas Operations” or any other category used to track casualties from hostilities with Iran. The lawmakers requested a response by Aug. 18.

The investigation follows questions raised after three U.S. soldiers killed in Jordan and one killed in Iraq were initially included in the Pentagon’s Iran war casualty total before being removed. Days later, the deaths reappeared under a new “Overseas Operations” category.

The new category has a stated start date of July 7, the same date the Trump administration said renewed military operations against Iran started a new 60-day period under the War Powers Resolution.

The lawmakers are seeking records explaining why those changes were made, the rules governing casualty classifications and any legal analysis underlying those decisions.

Garcia and Subramanyam also requested records documenting every change made to DCAS, the policies governing how deaths and injuries are assigned to operational categories and legal analyses related to a proposed expansion of the Defense Department’s authority to withhold certain controlled unclassified information under the Freedom of Information Act.

Taken together, the requests seek to examine how official casualty records are created, revised and publicly disclosed.

“The Pentagon appears to be lying about the casualties of fallen soldiers to continue justifying Donald Trump’s war of choice with Iran,” Garcia said in a statement announcing the investigation. “The American people deserve the truth about every life lost and soldier wounded in this illegal war.”

Subramanyam said the lawmakers are seeking transparency because the four service members “were killed in action during Trump’s war of choice in Iran” and “the Department of Defense should not play games and try to hide the true cost of this war.”

Unlike a July 29 letter led by Sen. Elizabeth Warren, D-Mass., that primarily focused on force protection and medical care following the March 1 attack at Port Shuaiba, Kuwait, this inquiry seeks actual records related to the Pentagon’s casualty accounting process and public reporting.

The Defense Department declined to comment on either letter.

In a July 29 letter to Defense Secretary Pete Hegseth, Sen. Elizabeth Warren, D-Mass., joined by four other Senate Democrats and eight House Democrats, requested answers by Aug. 12 to 23 questions concerning medical care, casualty reporting, force protection and ongoing investigations related to the attack.

Lawmakers say the Pentagon has not fully responded to an April letter raising concerns about force protection before the attack and has not provided Congress with the Army’s investigative findings.

Recent reporting has raised new questions about the medical care provided to injured service members after the attack, which killed six U.S. service members and wounded more than 30 others.

A Pentagon official declined to comment about the letter to Military Times.

The letter cites CBS News reporting that soldiers requested additional medical personnel and supplies before the attack and that those requests were ignored. It also cites reports that, after the strike, some wounded troops drove themselves to a hospital in Kuwait City before later being evacuated and that about two dozen service members were not flown to Landstuhl Regional Medical Center in Germany until nine days after the attack.

Lawmakers also referred to reporting that some wounded service members arrived in Germany without being identified as medical evacuees or seriously injured patients in Defense Department Casualty Analysis System, which the lawmakers said resulted in only limited treatment at Landstuhl. Deeper reporting cited reveals that some troops waited weeks after returning to Fort Hood, Texas, before being evaluated by physicians qualified to diagnose and treat traumatic brain injuries.

Among other questions, the lawmakers asked why requests for additional medical support before the attack were reportedly denied, how the Defense Department classifies serious and very serious injuries and how many service members have sustained traumatic brain injuries since Operation Epic Fury began Feb. 28.

The request from lawmakers also asks the Pentagon to explain changes to publicly reported casualty figures during the conflict, provide updates on force protection measures at military installations across the Middle East, release the Army’s investigation into the Port Shuaiba attack and disclose whether additional Inspector General investigations are underway.

The March 1 attack at Port Shuaiba remains one of the deadliest attacks on U.S. forces during Operation Epic Fury. Reporting by The Washington Post, CBS News, The War Horse and Military Times have described concerns expressed by survivors and family members about force protection, casualty reporting and medical care following the attack.

The War Horse recently reported that medical records documented injuries including traumatic brain injuries, skull fractures, burns, broken bones, hearing loss and shrapnel wounds among those wounded in the strike.

Semaglutide is approved by the Food and Drug Administration to treat Type 2 diabetes and chronic weight management, but not alcohol use disorder.

VA researchers are studying whether the GLP-1 receptor agonist may affect parts of the brain involved in reward, potentially offering a new treatment option for veterans with moderate or severe alcohol use disorder if proven safe and effective.

The department cautioned veterans not to self-medicate or replace evidence-based alcohol use disorder treatments with GLP-1 medications without first consulting a health care provider.

The study, known as the Cessation or Reduction of Alcohol Consumption in Veterans (CRAVE) trial, will enroll more than 600 veterans ages 18 to 80 at 18 VA medical centers nationwide.

Participants with moderate or severe alcohol use disorder will receive weekly injections of either semaglutide or a placebo for 24 weeks, followed by a safety evaluation. Researchers will measure changes in alcohol consumption, overall health and quality of life.

Researchers at Washington University School of Medicine have increasingly studied whether GLP-1 medications, originally developed for diabetes and later approved for obesity, could also help treat substance use disorders.

VA cited an analysis published in March that found patients taking GLP-1 medications experienced lower rates of alcohol use disorder and other substance use disorders than similar patients taking other diabetes medications.

The department said larger, controlled clinical trials are needed to determine whether semaglutide is safe and effective for treating alcohol use disorder.

In an official statement, VA Secretary Doug Collins said, “By exploring emerging treatment options like the use of a GLP-1 for AUD, we aim to expand the tools available to help Veterans take control of their health and recovery.”

Recruitment began July 28. Veterans interested in participating can contact their local VA medical center or search for the trial on ClinicalTrials.gov.

Under Secretary of Defense for Policy Elbridge Colby announced on X Tuesday that the Defense Department had “kicked off” the review Hegseth unveiled during the NATO defense ministerial in Brussels on June 18. Hegseth described the effort at the time as “a real review” of America’s force posture and basing in Europe.

Neither Hegseth’s announcement nor Colby’s statement announced troop reductions, unit movements or installation changes as part of the review. The Pentagon also has not said when the review’s recommendations will be released.

The review follows repeated calls by Trump administration officials for European allies to assume greater responsibility for NATO’s conventional defense as the administration reassesses U.S. force posture worldwide.

Hegseth said the review is expected to take up to six months, but it “could be less.” He shared that the review will include input from U.S. European Command as well as consultations with Congress and U.S. allies.

Colby said the review is designed to ensure NATO is “moving fast and irreversibly toward Europe taking primary responsibility for its conventional defense.” He explained the outcome of the review is intended to accelerate NATO’s transition to what he described as “a stronger, more equitable, and sustainable alliance.”

The Pentagon review aims to ensure U.S. force posture in Europe reflects the 2025 National Security Strategy and the 2026 National Defense Strategy. Colby said the department will develop a range of options based on “strategic rigor, a strong empirical baseline, and a clear sense of the geopolitical and military realities.”

Colby also said he looks forward to working closely with Gen. Alexus Grynkewich, NATO’s Supreme Allied Commander Europe, on the review. He noted that the Defense Department plans to have “extensive consultations” with European allies, Congress and other parts of the U.S. government throughout the process.

The COMPACT Act allows eligible veterans and certain former service members to receive Veterans Affairs-funded emergency suicide crisis care at VA and community hospitals, even if they aren’t enrolled in VA healthcare. New data obtained by Military Times show 49,341 veterans have used the benefit since 2023, but veteran advocates and suicide prevention professionals say many eligible veterans still don’t realize it exists until they experience a crisis.

In 2025, retired Navy Master Chief David Hull’s life unraveled after he lost his job during the government shutdown.

The transition from military service had been difficult, but he had rebuilt his life. Then when his paycheck disappeared, so did his ability to provide for his three children.

“I didn’t always consider taking my own life,” Hull said. “It wasn’t until I felt like I had no one and nowhere to go.”

“It’s easy to sink into feeling nothingness when you can’t see your value anymore or you become disconnected from your purpose,” he said.

After putting his children to bed one night, Hull searched online for combinations of pills that promised an easier way to end his life. As he poured medication into a single bottle, he accidentally knocked the empty container onto the floor.

His 6-year-old daughter picked it up.

“She looked up at me with her big brown eyes,” Hull recalled, his voice breaking. “It cracked me wide open.”

Hull left his children with a neighbor and drove to Garrett Regional Medical Center, a community hospital in Oakland, Maryland.

He wasn’t enrolled in VA healthcare. He didn’t have health insurance. Until that night, he had never heard of the COMPACT Act or that eligible veterans could receive VA-funded emergency suicide crisis care at a community hospital.

“I just needed someone to help clear my head and get me straight again,” Hull said. “I was circling the drain. On the precipice of having no home, no food, no money and no job with a promise of a better tomorrow. Nothing.”

About 40 minutes after arriving, Hull was evaluated by an emergency physician, who assured him he would be taken care of. A hospital social worker then explained that the Department of Veterans Affairs would cover the cost of his emergency treatment and follow-up care.

“I was shocked to find out that I could be seen for free after they identified me as a veteran,” Hull said.

In 2020, Congress signed the COMPACT Act Emergent Suicide Crisis Benefit into law to remove financial and administrative barriers to emergency suicide crisis care. Three years later, it was implemented by the VA, but many eligible veterans remain unaware of the benefit until they need it, veteran advocates and suicide prevention professionals told Military Times.

A lifeline beyond VA’s doors

The Emergency Suicide Crisis Benefit was established under the Commander John Scott Hannon Veterans Mental Health Care Improvement Act, or COMPACT Act. Coverage includes emergency evaluation, treatment, inpatient or crisis residential care when clinically appropriate, and up to 90 days of outpatient follow-up care.

According to data provided by VA, nearly 50,000 veterans have received the Emergency Suicide Crisis Benefit since fiscal 2023, including just over 10,000 in fiscal 2023. 14,666 receieved the benefit in fiscal 2024; 15,218 in fiscal 2025; and 9,434 during the first half of fiscal 2026.

“The number of Veterans receiving the COMPACT Act’s Emergent Suicide Crisis Benefit has grown steadily since its inception in FY23,” VA Press Secretary Quinn Slaven said.

VA spent a record of nearly $110 million on acute suicide crisis care during fiscal 2025.

Slaven said VA reviews eligible cases to ensure veterans receive the benefit, educates veterans and community emergency department staff about its availability and works with providers so eligible veterans do not receive unexpected medical bills after crisis care.

According to VA, 72% of veterans who have used the benefit have since enrolled in VA healthcare.

Misconceptions persist

Despite growing use of the benefit, the Disabled American Veterans, or DAV, organization says many eligible veterans still misunderstand who qualifies for emergency suicide crisis care.

“DAV believes awareness of the safety net created by the COMPACT Act remains lower than it should be,” Jon Retzer, DAV’s national legislative director, said.

Retzer said DAV service officers routinely meet veterans who believe they must already be enrolled in VA healthcare, have a service-connected disability rating or seek treatment at a VA medical center before the benefit applies.

“Many veterans remain uncertain whether an emergency room visit will generate medical debt or whether VA will ultimately cover the care,” Retzer said. “That uncertainty can discourage veterans from seeking treatment during a crisis when immediate intervention is critical.”

Retzer urged veterans experiencing a suicidal crisis to seek emergency care first and allow VA to determine eligibility afterward.

Army Reserve Prevention Integrator David Arthur said those same misconceptions continue to surface in his work, particularly among older veterans.

He said distance from a VA medical center can create uncertainty because many rural veterans live an hour or more away, while nearby outpatient clinics do not provide emergency services.

“When they are in a crisis, in my experience with suicidal soldiers and vets, they are not even thinking about that,” Arthur said. “But those thoughts are huge barriers, especially the cost.”

“I want every vet to know they can go to any ER or hospital,” Arthur continued.

Returning to care

Hull completed the full 90 days of follow-up care available through the benefit before enrolling in VA healthcare.

“I don’t know if I could have afforded the treatment I received after that night without the VA,” Hull said. “And I don’t know that I’d be enrolled with the VA now without the care I experienced.”

“I wish so many of my brothers and sisters knew that this was an option,” Hull said. “It doesn’t matter if you have insurance. It doesn’t matter if you’re a patient in the VA system. None of that matters. There are no strings attached. No barriers to being seen. This is a gift that every veteran needs to know they’re eligible for.”

The legislation seeks to end a decades-old offset that forces many combat-injured medically retired veterans to forfeit a portion of their retirement pay for every dollar they receive in VA disability compensation. Supporters have long argued the policy amounts to penalizing service members for injuries sustained in combat, calling it a “Wounded Veteran Tax.”

Then Congress introduced a revised version of the legislation in March 2025.

When the Congressional Budget Office evaluated H.R. 2102, the current version of the Major Richard Star Act, its new cost estimate projected the bill would increase direct spending to $78.1 billion over 10 years, roughly $68 billion more than CBO’s estimate for the bill’s 2023 predecessor.

The revised estimate transformed the conversation surrounding one of Congress’ most broadly supported veterans bills and prompted a question that still remains unresolved:

What changed between the 2023 and 2025 versions of the Richard Star Act to increase the projected cost so dramatically?

The answer isn’t simply a larger number. It lies at the intersection of legislative drafting, statutory interpretation, DoD actuarial data and congressional budget scoring, where even subtle changes can reshape both the projected cost of legislation and its political future.

Two provisions with a $65 billion price tag

CBO’s explanation points to two provisions it concluded were added to H.R. 2102 that were not included in H.R. 1282.

The first would make Chapter 61 military retirees with fewer than 20 years of service eligible for Concurrent Retired and Disability Pay (CRDP), a benefit generally limited under current law to military retirees who completed at least 20 years of service. CBO estimated that provision alone would increase direct spending by approximately $63 billion over the 2026–2036 period.

The second provision would remove an existing cap on CRDP payments for Chapter 61 retirees with at least 20 years of service, adding another estimated $2 billion.

Together, CBO concluded those two provisions accounted for roughly $65 billion of the increase between the previous and current versions of the legislation.

For years, supporters understood the Richard Star Act as legislation intended to restore concurrent receipt for approximately 54,000 combat-injured Chapter 61 retirees whose military retired pay is reduced because they also receive VA disability compensation.

Its estimated cost, roughly $10 billion over a decade, was substantial but comparatively modest within the context of major veterans legislation. Then the revised estimate changed the conversation.

A different understanding of the revisions

Congressional staffers in Sen. Blumenthal’s office involved in developing both H.R. 1282 and H.R. 2102 understood the revisions differently than CBO ultimately interpreted them, explaining that the legislative revisions were intended to address a narrow gap affecting approximately 1,124 combat-injured Chapter 61 retirees who remained excluded under previous versions of the bill. Under that understanding, the intended affected population would increase from roughly 54,000 to about 56,000 veterans.

CBO reached a different conclusion.

Its estimate states that approximately 255,000 Chapter 61 retirees with fewer than 20 years of service would become eligible for concurrent receipt under H.R. 2102. That broader interpretation accounts for nearly the entire increase between the previous estimate and the March 2025 score.

CBO has reaffirmed its estimate, explaining that it evaluated the statutory changes contained in H.R. 2102 using population data provided by the Department of Defense’s Office of the Actuary, which identified the class of retirees CBO concluded would become newly eligible under the legislation.

The result is a striking disconnect between Congress’ stated intent and CBO’s interpretation of the revised bill. Military Times also asked the Department of Defense about its role in providing information used during CBO’s analysis. DoD did not respond by publication.

The stakes

For the combat-injured retirees who have spent years advocating for the Richard Star Act, the legislation has never been about budget estimates. It has been about restoring military retired pay they argue they earned through their service and sacrifice. But in Congress, budget scores influence legislative prospects.

CBO has explained how it arrived at its estimate. What remains unclear is why congressional offices involved in drafting the revisions believed the legislation would affect roughly 56,000 combat-injured retirees while CBO concluded the revised language would extend eligibility to a much broader population.

That difference transformed a bill long understood to carry a price tag of about $10 billion into legislation projected to cost $78.1 billion over a decade, fundamentally altering its prospects in Congress.

Before her death in 2024, in an interview with Wounded Warrior Project, Tonya Star, widow of Maj. Richard Star, reflected on what passage of the legislation would mean to the veterans and families it was designed to help:

“It’s not just a rubber stamp; this will affect their day-to-day life and help them provide for their families… This would be their win.”

The line at the Wendy’s drive-thru barely moved as Hailey Richards sat behind the wheel during her lunch break, staring into the rear-view mirror beneath a pair of dark sunglasses. The driver behind her had pulled close enough that she found herself wondering whether they could tell she was crying.

“I just broke down,” Richards said.

In a few minutes, she would wipe away the tears, drive back to the Department of Veterans Affairs hospital where she worked as a nurse and finish caring for veterans.

At the time, she couldn’t explain why an ordinary Tuesday afternoon had become the moment everything surfaced. Looking back, she doesn’t think it was about that day at all.

Richards became a nurse because she wanted to care for veterans. She loved listening to stories about their coffee mugs no one dared wash because years of coffee had seasoned them just right. Albert, a Vietnam War veteran, actually got her to drink from his mug one morning after repeatedly assuring her the taste was like no other.

She listened to their sea stories, anecdotes about deployments, friendships and losses that still lingered decades after the uniforms came off.

More recently, the moments that stick in her memory look different.

She thinks about the veteran who apologized for asking again for pain medication that hadn’t arrived long after it should have. The patient left staring at the ceiling while a call light continued to flash. The conversation that ended before she wanted it to because another veteran couldn’t wait any longer.

None of those moments would make a government report. Taken together, Richards says, they have changed what it feels like to care for veterans inside the VA.

For many of the 9 million veterans enrolled in VA health care, those moments are largely invisible. Patients may notice a delayed medication, a longer wait for help or a hurried bedside conversation. What they don’t see are the decisions nurses say happen behind the scenes when there isn’t enough time to do everything they believe their patients need.

Richards’ experience is unfolding against a backdrop of persistent staffing challenges across the Veterans Health Administration.

In its fiscal 2025 workforce assessment, the VA Office of Inspector General found that all 139 VA medical centers reported at least one severe occupational staffing shortage. Nearly four in five facilities identified nursing among those shortages, and facilities collectively reported 4,434 severe occupational staffing shortages across clinical and nonclinical occupations, a 50% increase from the previous year.

The report does not measure nurse vacancy rates. Instead, it identifies occupations that VA medical centers designated as severe shortages under federal recruitment and retention criteria. Unlike vacancy reports, which estimate open positions, the Inspector General’s review reflects occupations facilities identified as difficult to recruit or retain.

The Inspector General’s review measures where facilities say staffing shortages are severe enough to interfere with their mission.

VA Press Secretary Quinn Slaven said the Inspector General’s report is subjective, identifying occupations that facilities feel are difficult to recruit and retain, rather than measuring department-wide nurse vacancy rates.

The report “is not a reliable indicator of staffing shortages,” Slaven said, arguing that nursing shortages are in line with historical averages.

A series of tradeoffs

Richards says the hardest part of working inside the VA isn’t the pace; it’s knowing that no matter how quickly she moves, there are moments when she cannot be everywhere veterans need her to be.

A medication is due in one room while another veteran presses the call light for help getting to the bathroom. A family member has questions about a discharge plan. Another patient needs wound care.

The work itself isn’t unusual. What changes, Richards says, is the constant calculation of what can wait.

“You prioritize the sickest patient first,” she said. “But that doesn’t mean everyone else stops needing you.”

Those are the moments she carries home.

“You replay your day,” Richards said. “You think about the things you couldn’t do, not because you didn’t want to, but because there wasn’t enough time.”

Richards is careful to separate those experiences from the quality of care veterans ultimately receive. She says nurses continue to work together, adjust priorities and step in for one another to make sure patients remain safe. But safety and the kind of care nurses aspire to provide are not always the same thing.

Moral distress

For decades, nursing ethicists have studied the consequences of caring for patients when clinicians believe they know the appropriate course of action but lack the time, staffing or resources to carry it out.

In 1984, philosopher and nursing scholar Andrew Jameton introduced the term moral distress to describe that experience. Since then, researchers have expanded the concept beyond individual ethical dilemmas to include the organizational conditions that repeatedly force clinicians to compromise the care they believe patients deserve.

Ann Hamric, leading moral distress researcher, has argued that the problem is not simply exposure to difficult situations. It arises when institutional constraints prevent clinicians from acting in accordance with their professional judgment.

Repeated over time, she and other researchers have found, those experiences can leave a lasting psychological burden, sometimes referred to as “moral residue.”

More recently, nursing ethicist Cynda Rushton has described moral distress as a signal that something within the care environment is preventing clinicians from practicing in ways that align with their professional and ethical commitments.

Rather than viewing it as an individual failing, her work frames it as evidence of tension between the demands of the health care system and the standards clinicians strive to uphold.

Richards had never heard the term when she began questioning whether she was providing veterans the care they deserved. But she immediately recognized the experience it describes.

Richards still thinks about sobbing in that Wendy’s drive-thru. She recalls wishing someone would notice and offer her some kind of relief.

At the time, she couldn’t explain why she had broken down in the middle of an ordinary lunch break. Now she can.

Hailey says there was no single shift that convinced her something had changed. It happened gradually, one decision at a time.

She began replaying her days after she got home, wondering whether she had missed something, whether she could have spent another five minutes with a veteran who seemed anxious or answered one more question before leaving the room.

“I love taking care of veterans,” Richards said. “That’s what makes it so hard to deal with being short staffed, we know our veterans deserve better.”