As an Army infantryman, Ernest Barrington was very familiar with the thick smoke and fumes that came off the burn pit at Joint Base Balad in Iraq. The toxic dust that wafted from the huge, open-air ditches where the military burned everything from tires and ordnance to medical waste and plastic would coat his skin and settle on the inside of his nose and under his eyelids.

“You go to take a shower, it’s in the shower with you. So you’re cleaning your skin, and as you’re drying, the stuff is landing on your body. By the time you make it back to your room, you have the toxins right back on you,” he said. “Every day that you’re there, you’re breathing it in.”

Everyone on base breathed it in — Barrington’s fellow soldiers and the foreign military members from allied nations, the burly ex-Special Forces operators who took lucrative gigs working contracted security, the workers from Pakistan, the Philippines, and Nepal who ran the laundry and the chow hall and drove the fuel trucks.

The toxic ash was the same, but access to care for those battling cancers almost two decades later is not. Veterans are now guaranteed coverage; the estimated tens of thousands of contract workers debilitated by burn pits are not.

One group who served their country during the “forever wars” is now rightly protected, advocates say. But members of the other group are left to fight with insurance companies, one by one, claim by claim, beaten down by bureaucracy, exhausted by illness.

Barrington understands the predicament.

A historic commitment

When he retired from the Army in 2007, Barrington turned around at 40 and picked up a series of private contracting jobs, which took him from Kuwait to Saudi Arabia and eventually back to Iraq. In 2020, on a trip from Washington, D.C., to Erbil, the charter plane Barrington was in landed hard on the tarmac. He felt his back seize up.

Over the next few weeks, the pain got worse. An MRI revealed multiple shattered vertebrae, he told The War Horse. It was an unusual injury, doctors told him, so they ran some tests. Soon it made more sense. They diagnosed him with two separate types of cancer: prostate and multiple myeloma, a fairly uncommon blood cancer.

In the 13 years since Barrington had put his uniform away, veterans who served at bases with burn pits started getting sick with respiratory diseases and unusual cancers. Certain forms of multiple myeloma were among them. Years of advocacy around the issue led to the passage two years ago of the PACT Act, a historic commitment that for the first time removed veterans’ burden for proving their exposure to burn pit toxins was directly responsible for their sickness.

The law established a “presumptive service connection” for certain diseases — if a veteran was diagnosed with a condition on the list and had served at a base with a burn pit, VA would presume it was caused by their service, and the veteran would be entitled to care. After the law passed, Barrington said, he filed a claim with VA.

But Barrington, who now lives in Jacksonville, Florida, with his wife, says it’s unclear if his cancer stemmed from his time at Balad Air Base as a soldier, or if it’s connected to the toxins he was exposed to during his time working as a contractor—or both. So he’s also filing a claim under a World War II-era law called the Defense Base Act, which requires contracting companies to carry insurance for their workers’ war zone injuries or illnesses.

The hundreds of thousands of private contractors who served alongside uniformed service members in Iraq or Afghanistan—often doing similar work — have many of the hallmark injuries and illnesses of the post-9/11 wars: rare cancers, post-traumatic stress, traumatic brain injuries.

But those contracted workers injured on bases overseas aren’t protected by the PACT Act for cancers or lung diseases that follow their deployment. Instead, they must file a workers’ comp claim under the Defense Base Act, which can lead to medical coverage and monetary compensation for sick workers. Civilians who work directly for the government must file an entirely different type of claim.

But many workers are unaware that they are covered, and the arcane, bureaucratic process to see a claim through means civilian workers can wait years to get compensation for the harm they suffered. Many never get any at all.

The growing ‘camo economy’

Last month, President Biden announced that VA had granted more than a million PACT Act claims to veterans for cancers and lung diseases stemming from burn pit exposure. In the 23 years since 9/11, only about 150,000 Defense Base Act claims — for every type of illness or injury — have been filed by contractors who deployed to Iraq or Afghanistan.

The disparity is even more significant considering another trend: Civilians are playing a dramatically larger role in America’s wars.

For 200 years, the ratio of U.S. military members to contract workers remained fairly constant — about one contractor for every 100 soldiers.

But that changed after Vietnam. The American public had little stomach for the heavy toll the war had taken on its troops, and the end of the draft significantly decreased the size of the fighting force.

Privatizing government work was popular in Washington, and jobs previously done by soldiers, sailors, and airmen were increasingly contracted out to civilians. By the first Gulf War, there was one contractor for every 50 military personnel. By 2009, the ratio was 1-to-1 in Iraq and Afghanistan. And as troops began to withdraw, many contract workers stayed and soon exceeded the number of military members.

“When we talk about how many American troops are going overseas, we’re not also counting the number of contractors going overseas,” says Heidi Peltier, a Brown University economist who has studied what she calls the “camo economy” — the military contracting industry. “And when they talk about injuries and deaths, that’s usually the military injuries and deaths, not the contractor injuries and deaths. … The impact is much less visible.”

Brown University’s Costs of War project has estimated that more contractors than service members died in the post-9/11 wars — 8,189 to 7,053.

In Iraq and Afghanistan, civilian workers guarded bases, fuel convoys, and American diplomats. They maintained equipment and weaponry. They cooked and cleaned and did laundry.

Some of that work paid well. Private security contractors who worked for companies like Blackwater could make upwards of $1,000 a day. But much of the labor was subcontracted out to foreign workers from poorer countries, who were sometimes paid just $300 or $400 a month.

“This is one of the things my Afghan friends always used to joke about, they would sort of call the base an American base. But if you went onto the base, there were very few Americans there,” says Noah Coburn, a political anthropologist at Bennington College who has studied foreign labor on U.S. bases.

Coburn says that ostensibly, the military only uses contractors in support roles. But in reality, many civilian workers face the dangers of war: Macedonian janitors were taken hostage by the Taliban. Pakistani fuel tank drivers dodged enemy fire. Ugandan security guards were ambushed with rocket fire.

Under the Defense Base Act, anyone who works for a U.S. military contractor overseas is entitled to file compensation and health care reimbursement claims for injuries or illnesses that resulted from their work. In practice, though, filing can be nearly impossible for workers who return to their home countries with little idea how to navigate the process. It can be nearly impossible for workers to connect with American lawyers to file paperwork, Coburn said. Doctors abroad may not be aware of how to best document a medical condition to increase a claim’s chance of success.

Coburn has found that workers who file a claim from a non-U.S. address have a lower chance of getting claims approved than those from U.S. addresses. But even for Americans, getting compensation for their injuries can be difficult.

“There’s a whole bunch of these people that need help,” says Scott Dillard, a former Army officer who later worked as a contractor in Afghanistan and now helps fellow former contractors navigate the claims process. “They have no clue that there are resources available to them because they’re not educated on it.”

Military contractors are supposed to inform their employees about the Defense Base Act and post notices about workers’ rights to compensation. But Dillard says he never saw a notice.

When civilian contractors do file a claim, proving the condition stemmed from their work overseas can be difficult. The law’s statute of limitations begins when a worker becomes aware of his or her condition. That means that if an illness pops up years later, a worker can still potentially file for benefits — but it may be harder to prove what caused it.

That can be a problem. Collecting evidence can be difficult and expensive, and insurance companies say they need to scrutinize claims to make sure people aren’t abusing the system.

“When it comes to losses like this, you’re going to have people that are going to see what they can get for free, and you’re going to have legitimate claims,” says Brian Smith, who specializes in Defense Base Act coverage as a vice president at Insurance Office of America, an insurance broker firm. “The issue has to do with the validity of the claim when you go back that many years.”

‘Not going to deal with this’

Veronica Landry knows well the white-hot scrutiny of insurance companies.

In 2004, she took a contract job in Mosul, Iraq, staffing the base gym and the recreation center, then was quickly promoted to working as an operations specialist and historian. The work wasn’t as danger-free as it sounded. The air turned black when tires were in the burn pits. During her assignment, the dining facility was blown up by a suicide bomber. And when a soldier was hit with a mortar round in a separate incident, Landry tried to use CPR to keep her alive, she said.

She filed a claim for PTSD when she came home, but she says the insurance company denied it.

Lawyers who spoke with The War Horse said that’s not unusual. If an insurance company denies a claim, the person who files it can escalate it to a formal adjudication process through the Department of Labor. But Landry didn’t know that at the time.

“I thought when they said ‘denied,’ it’s just, that’s it. You’re done,” she said. And she didn’t feel up for a fight.

As the years passed, Landry began having trouble breathing. In 2015, her lungs collapsed. When she was diagnosed with obliterative bronchiolitis, an irreversible lung condition, she suspected her exposure to burn pits in Iraq might be the cause. This time, she said she did her research. She was prepared for the fight.

Landry’s new claim took two years to wind its way through the process. There are only 37 administrative law judges in the Department of Labor and more than 10,000 Defense Base Act claims pending adjudication as of March, according to data provided by the department.

For others, the wait can stretch past three years. And for those who aren’t able to work because of their injuries, it can feel interminable.

“You’re four years in,” says Howard Grossman, a lawyer who specializes in Defense Base Act claims, “and the client is living on ramen noodles and microwave popcorn.”

Landry says that investigators for the insurance company, AIG, combed through her social media accounts and used photos of her exercising to make the case that she wasn’t as sick as she said she was. AIG declined to comment.

Grossman said he has seen private investigators for insurance companies convince people to sign blank authorization forms that the firms can use to access personal medical and pharmaceutical information.

“The VA is not perfect, as we know, but its role in life is to help injured veterans,” says Gary Pitts, the attorney who represented Landry. “What happens with the contractors is they come home, and they have to deal with a worker’s comp insurance company whose role in life is to help the worker’s comp insurance companies.”

But Landry’s case was a victory: In 2018, a judge ruled that her condition was related to her toxic exposure in Iraq, citing Landry’s description of breathing in the thick, black burn pit smoke, and her doctor’s determination that she suffered from a “deployment-related lung disease.”

It was the first judicial decision in the country linking any burn pit exposure to a serious lung condition. Groups advocating for the PACT Act seized on the ruling as evidence that VA should do more to help veterans with lung diseases and cancers who were exposed to burn pits.

Obliterative bronchiolitis became one of the conditions that VA guarantees coverage for veterans under the PACT Act. But contractors like Landry, with the same condition, are still on their own and must find a lawyer to fight on their behalf for compensation.

“It’s one by one,” Pitts says. In 23 years of working on the Defense Base Act, his firm has filed around 11,000 claims.

In Landry’s case, the judge determined her insurance company should pay her medical bills. But Landry says that she had to fight AIG for every bill to be reimbursed. Eventually, she gave up and settled out of court.

Before settling, she was also awarded monetary compensation. The amount ended up being as small as the system made her feel.

Just $4 a week.

This War Horse feature was reported by Sonner Kehrt, edited by Mike Frankel, fact-checked by Jess Rohan, and copy-edited by Mitchell Hansen-Dewar. Abbie Bennett wrote the headlines.

The report asserts that the agency failed to appropriately assess whether claimants met the requirements for receiving compensation before issuing the payments. Investigators estimate that the Veterans Benefits Administration “prematurely” approved around a quarter of the 13,800 Gulf War Syndrome claims filed between Oct. 1, 2021, and Mar. 31, 2022. The report’s authors note, however, that the under-examined applicants may have been eligible for the benefits they received, even if their claims were mistakenly approved.

The errors could complicate treatment for an illness already clouded in ambiguity. Gulf War Syndrome encompasses a medley of unexplained chronic afflictions found in tens of thousands of veterans who served in the Persian Gulf during Operations Desert Storm and Desert Shield. Common symptoms include diarrhea, fatigue, rashes, joint pain and cognitive issues, though experts have struggled to pinpoint an exact cause for any of them. The VA announced in April that it would conduct a five-year study into the illness’ origins and impacts.

The VA first authorized disability checks for victims of Gulf War Syndrome in 1995. Gradual regulatory tweaks over the ensuing decades attempted to refine definitions for “unexplained illnesses” and the pathways to receive benefits for them. A 2003 rule change established the working definition of a “medically unexplained illness” as a diagnosed ailment lacking a clear cause and “characterized by overlapping symptoms and signs,” including fatigue, pain, and other disabilities.

The Promise to Address Comprehensive Toxics (PACT) Act, signed into law in 2022, expanded welfare provisions for maladies connected to toxin exposure in Iraq and Afghanistan, Vietnam, and nuclear testing sites.

Investigators say the questionnaires used by agency adjudicators to evaluate claims for Gulf War Syndrome and other mysterious ailments don’t collect enough information to reliably determine who deserves benefits.

“(Veterans Benefits Administration) lacked evidence needed to decide the claims because its examination requests and disability benefits questionnaires do not elicit the information needed by claims processors to determine whether a veteran is eligible for benefits under the regulation,” they wrote.

The inspector general report also faulted “confusing and inconsistent” guidelines on how and when claims processors should seek out more information to fill those gaps. These oversights, it warned, could result in around $25.6 million in undue payments between fiscal year 2022 and September 2024.

Simple fixes, such as updating questionnaires and instructions for examiners with the full, latest definitions for medically unexplained illnesses, could save millions, investigators stressed.

The VA accepted the inspector general’s recommendations and is expected to implement the suggested reforms by the end of September.

“We really didn’t see that it was dangerous at the time,” she said. “It was just part of the mission. So we had to get it done.”

But then her sinus problems began, only worsening after she returned home, where she sometimes found herself gasping for breath at night. She remembered thinking, “This wasn’t who I was before I got in.”

Although Leger already received disability benefits for post-traumatic stress, migraines and a hip fracture, it wasn’t until President Joe Biden signed legislation known as the PACT Act last year that her monthly payments expanded to take into account the impact of the burn pits. Now 34 years old, Leger and her fiancé have moved out of a cramped townhouse and into a larger home in a suburb of Tampa, Florida, where their four children can each have a bedroom.

“I still wake up pinching myself,” she said.

Leger is one beneficiary of the largest expansion of veterans assistance in decades, and the administration is racing to sign up as many people as possible as the first anniversary of the law approaches. Although there’s no deadline to apply, anyone who files a claim or simply signals the intent to do so by Wednesday could collect payments retroactive to last year if the claim is approved.

Under the law, certain cancers and ailments are presumed to be connected to the burn pits that were used to dispose of trash and potentially toxic materials. For veterans who served during the Vietnam War, hypertension and other conditions were added to the list of problems presumed to be caused by exposure to Agent Orange, which was used by the U.S. military to clear vegetation.

Biden will mark the law’s anniversary at a Veterans Affairs hospital in Salt Lake City on Thursday. According to administration statistics, the Department of Veterans Affairs has received nearly 786,000 disability claims under the PACT Act, processed almost 435,000 and approved more than 348,000.

About 111,000 veterans who are believed to have toxic exposure have enrolled in VA health care since the law was enacted. In addition, more than 4.1 million veterans have completed toxic screenings, which are questionnaires to analyze their potential exposure and determine whether additional tests are required.

Implementing the legislation has proved challenging for the VA despite hiring new staff to accommodate a historic influx of claims. The backlog is about 266,000, meaning waits of at least four months for claims to be processed, and the list is expected to grow to 450,000 in October and 730,000 in April. During a recent oversight hearing. Sen. Thom Tillis, R-N.C., expressed concern about “bad trends.”

Veterans Affairs Secretary Denis McDonough said his agency is doing better than expected based on internal projections and is using new technology to process claims faster.

“Am I satisfied? I’m not,” he said in an Associated Press interview. “Until every veteran in this country knows what is available to him or her, and has come in and filed a claim, and then we’ve awarded that claim for him or to her, I won’t be satisfied.”

Despite the growing backlog, the VA has kept up its outreach efforts. It has spent $7.5 million on advertising, including a billboard in New York’s Times Square, and hosted events around the country. Comedian Jon Stewart, who played a leading role in pushing for the PACT Act, has chipped in by posting videos on social media.

“The VA could have slow rolled it to make their job easier,” said Allison Jaslow, a former Army captain who leads the advocacy organization Iraq and Afghanistan Veterans of America. “But to their credit, they didn’t.”

Jaslow said the department is “doing a pretty incredible job given the influx of claims that came in.”

The outreach is paying off. Eli Feret, a 36-year-old former Army captain who lives outside of Denver, said he did not apply until a few days ago. After expecting a more archaic process, Feret said he was “pleasantly surprised” that he could complete his claim on his smartphone in a half-hour.

Cole Lyle, a 33-year-old former Marine corporal in Alexandria, Virginia, who leads the advocacy organization Mission Roll Call, made a similar decision. “I was getting barraged by Jon Stewart on Twitter and a couple other folks, and I thought, I really ought to file,” he said.

“I see the growing backlog not as a good thing,” he added, “but I think it’s a good thing that veterans are, in fact, applying.”

For a moment last year, it looked like the PACT Act might not get approved. The legislation unexpectedly stalled when Republicans balked, leading some advocates to start camping outside the Capitol. Biden had contracted the coronavirus and could not visit in person, so he sent McDonough with pizza and he talked to the veterans over FaceTime.

The pressure campaign worked, and Congress passed the measure. It was a bipartisan success but also a personal victory for Biden, who has long believed that his eldest son, Beau, developed fatal brain cancer from serving near burn pits in Iraq as a captain in the Delaware Army National Guard.

McDonough sees the PACT Act as a turning point for the VA, making the nation’s largest health care system more agile, robust and competitive.

“The president has been very clear to us that this new law can be the largest expansion of VA benefits and care in the history of the VA,” he said.

The legislation authorized the VA to expand its facilities through 31 leases, and it is pursuing them in 19 states. VA employees can now receive higher bonuses and more help with student loans than before. There are additional incentives for recruitment, retention and relocation.

In the past year, the VA has expanded by more than 21,000 health care workers and 4,300 employees for processing benefits.

But officials said the process remains too slow. Bringing on a new health care worker can take several months as the VA checks backgrounds and certifications, a delay that can lead candidates to find jobs elsewhere.

McDonough said the agency is not “where we need to be,” adding that “we’ll keep working on that.”

When former Army National Guard Sgt. Iona Bussiere turned 40 last year, she had her first mammogram and discovered breast cancer — stage 3 on one side, stage 2 on the other.

Since then it has been a blur of treatments, including months of grueling chemotherapy — “for the last three weeks I was like a zombie,” she said — and a recent mastectomy. Bussiere, who lives in Providence, Rhode Island, is starting radiation and expects to be taking pills for years to come.

Under the PACT Act, breast cancer is presumed to be caused by serving in proximity to burn pits. Bussiere said they were “everywhere” during her deployments in Iraq and Kuwait.

Although she wishes that the VA had started providing cancer screenings earlier, she said the benefits also provide “a lot of relief.”

“I’ve heard horror stories about people who get cancer and are unable to work and the bills are piling up,” Bussiere said.

Marcellus Beasley, 60, served in the Air Force during the first Gulf War, when he was based in Turkey and traveled to Iraq. He said there was always sand, dirt and smoke, sometimes from burn pits. When he blew his nose in the mornings, black stuff would come out.

“It’s almost like you worked in a chimney,” he said.

Beasley found the VA cumbersome and frustrating after he left military service.

“You always thought the VA was against you,” he said. “Like, they didn’t want you to get paid.”

But he said recent changes have made services more efficient, particularly at his location in Wilmington, Delaware, where a worker helped clue him in about the PACT Act. He applied for help with his psoriasis, a skin condition, and his disability benefits expanded.

“It’s been a huge impact for me,” he said.

It is not just veterans who receive benefits through the PACT Act. More than 16,000 surviving family members have submitted claims. One of those who have qualified for compensation is Ailyn Colby, 59, whose husband, Glenn, died of colon cancer six years ago.

He was 51 years old and a former major in the Rhode Island National Guard who served in Iraq.

“He never really talked to me about his experience because maybe I would worry too much about him,” said Colby, who lives near Hartford, Connecticut.

After his death, she filed for survivor benefits and was denied, describing it as “a horrible experience.”

But when she reapplied under the PACT Act in April, the claim was approved.

“I thought, they still remember the family,” she said.

VA physicians have screened more than 1 million patients since the start of November, a total they said surpassed their initial estimates for patient outreach.

The five-minute survey is conducted with all veterans seeking health care within the Veterans Health Administration, and is designed to both look for potential hidden health issues related to military toxic exposure incidents and highlight new benefits available to veterans with related injuries.

Of the group already surveyed, 40% have reported possible toxic exposures during their time in service, reflecting the massive scope of the problem.

The list of contaminants includes breathing in smoke from open-air burn pits used throughout Afghanistan and Iraq, working near Agent Orange residue in Vietnam, experiencing elevated radiation levels at various military sites throughout the 1970s and 1980s, and drinking contaminated water at military bases.

When Congress approved the Promise to Address Comprehensive Toxics Act — better known as the PACT Act — last summer, advocates had estimated the benefits included in the legislation could help as many as one in every five living veterans in America today.

But the recent survey results suggest that rate could be even higher.

“These screenings are paramount to improving the health outcomes for veterans and providing them with the health care and benefits they’ve earned as quickly as possible,” VA Under Secretary for Health Dr. Shereef Elnahal said in a release.

“Our health care teams reached an incredible breakthrough in a short length of time … This is among the first steps we have taken to deliver even more benefits and health care to veterans who have been exposed to toxins during their service.”

On Jan. 1, VA officials began processing PACT Act benefits claims for more than 212,000 veterans who had applied since last August. Payouts for those cases are expected to begin in coming weeks, although more complicated claims may take longer.

The legislation included presumptive benefit status for 12 types of cancer and 12 other respiratory illnesses linked to burn pit exposure in the Gulf War, the War in Afghanistan and the War in Iraq.

It also provides new benefit status for hypertension and monoclonal gammopathy of undetermined significance (MGUS) among veterans who served in Vietnam and radiation-related illnesses for veterans who served in several new locations in the 1960s and early 1970s.

The cost of providing the benefits is expected to top more than $278 billion over the next 10 years. In addition, VA will spend millions more on research related to the toxic exposures in the hopes of providing quicker and better medical care for long-term health conditions related to the exposures.

The surveys will play a key role in that research work, providing information about what veterans were exposed to and ways to track recurring medical complications that may be related to those contaminants.

More information on the PACT Act is available on the VA’s website or by calling 1-800-MYVA411 (1-800-698-2411).

“I’m urging all veterans of these decades of war to enroll in VA health care to get screened for toxic exposure and to promptly file your claims,” he told a crowd of veterans and dignitaries gathered at the Maj. Joseph R. “Beau” Biden III National Guard/Reserve Center. “The VA will move as quickly as possible to resolve your claim and to get you the benefits you’ve earned.”

The Department of Veterans Affairs hosted more than 100 events over the last seven days to raise public awareness of the Promise to Address Comprehensive Toxics Act, better known as the PACT Act.

They included public-service announcements from celebrities and in-person events in every U.S. state.

But Biden’s involvement in the effort lent even more emphasis to the message, and included a pledge from the commander in chief that his administration will continue to look for ways to help and thank veterans.

“We have a lot of obligations as Americans, but we all have one sacred obligation: to take care of those we send to war and care for them and their families when they come home,” he said. “I mean, and I know my colleagues mean, that from the bottom of our hearts.”

The PACT Act — passed last summer following a high-profile push for the legislation from Biden in his March State of the Union address — provides presumptive benefit status for 12 types of cancer and 12 other respiratory illnesses linked to burn pit exposure in the Gulf War, the War in Afghanistan and the War in Iraq.

The presumptive benefits status allows veterans to receive disability payouts even if they can’t prove a direct link to a chemical exposure during their time in service. Because of the widespread use of the trash fires in both Iraq and Afghanistan, anyone who served in the region is considered to have been breathing in the toxins.

The measure also provides presumptive benefits status for hypertension and monoclonal gammopathy of undetermined significance (MGUS) for veterans who served in Vietnam, and radiation-related illnesses for veterans who served in several new locations in the 1960s and early 1970s.

As many as one in five living veterans in America today could see new services or payouts because of the law.

But VA Secretary Denis McDonough told town hall attendees on Friday that those new benefits are only useful if veterans take advantage of them. Since the summer, more than 176,000 veterans have applied for disability benefits under the law. VA will begin processing most of those cases on Jan. 1.

“We will not rest until every single veteran and survivor knows about this new law, understands what it means for them, and gets the care and benefits they’ve earned,” he said. “That’s what our country owes you. And that’s what we will deliver to you.”

Veterans who believe they may be eligible for new health care services or benefits can visit VA.gov/PACT or call 1-800-MYVA411 (1-800-698-2411) for additional information.

Officials said the move will ensure that veterans facing life-threatening conditions will “receive their earned benefits and health care on the earliest possible date.” About 2,500 veterans are expected to be affected by the move.

“These veterans have stepped up to serve our country in the times when we needed them most, and now it’s our job to step up for them,” said VA Secretary Denis McDonough in a statement. “It’s the right thing to do to get these heroes the world-class healthcare and benefits they’ve earned as soon as possible, and that’s exactly what we’re going to do.”

Since the summer, more than 176,000 veterans have applied for VA benefits under the Promise to Address Comprehensive Toxics Act (better known as the PACT Act).

The legislation provides for presumptive benefit status for 12 types of cancer and 12 other respiratory illnesses linked to burn pit exposure in the Gulf War, the War in Afghanistan and the War in Iraq; hypertension and monoclonal gammopathy of undetermined significance (MGUS) for veterans who served in Vietnam; and radiation-related illnesses for veterans who served in several new locations in the 1960s and early 1970s.

Presumptive status for service-connected illnesses cuts down on the paperwork veterans are required to file to receive monthly disability benefits, which can total several thousand dollars a month.

Payout of those benefits originally was scheduled to be phased in over the next few years, but administration officials over the summer announced plans to start processing the PACT Act claims on Jan. 1, 2023, in an effort to get veterans care and financial support quicker.

The latest announcement moves that timeline up even further for some of the most vulnerable veterans. Individuals who reported facing life-threatening conditions will have their files worked immediately, and some could see disability payouts start within a few days.

Department officials said after Jan. 1, when all cases begin to be processed, staff will continue claims involving terminally ill veterans because of the time issues involved.

In addition, the department will prioritize “claims filed by veterans with cancer, veterans experiencing homelessness, veterans older than 85 years old, veterans experiencing financial hardship, and Medal of Honor and Purple Heart recipients.”

VA leaders have warned that sorting through the tens of thousands of new claims will take time, and some veterans may not see payouts for several months or more.

However, they have also promised in recent congressional testimony that they are hiring more staff to handle the flood of new claims, and are confident in their ability to handle the workload.

Saturday marked the start of a “week of action” on the PACT Act benefits throughout the VA medical system, with events in all 50 states designed to highlight potential benefits for veterans included in the new law.

Congressional staff estimated that as many as one in every five living veterans in America today could benefit from the PACT Act’s sweeping provisions.

Veterans who believe they may be eligible for new health care services or benefits can visit VA.gov/PACT or call 1-800-MYVA411 (1-800-698-2411) for additional information.

In a letter to the White House on the eve of Veterans Day, Sen. Kirsten Gillibrand, D-N.Y., asked President Joe Biden to consider granting the nation’s top civilian honor to Burn Pits 360 founders Le Roy Torres and Rosie Torres, as well as entertainer Jon Stewart and activist John Feal.

“Because of [their] tireless work, millions of American veterans and service members are eligible for life-saving care for injuries that occurred as a result of their service and sacrifice,” she said. “Because of them, millions of Americans may have more precious time on this Earth with their loved ones.

“They have shown how a small group of like-minded and passionate citizens can overcome any obstacle to transform millions of lives for the better, demonstrating the power of possibility that can only exist in the United States.”

The move follows passage of the Promise to Address Comprehensive Toxics Act (better known as the PACT Act) in August. The legislation directs nearly $300 billion in spending over the next 10 years in new disability benefits payouts, additional department facilities and staffing, and research into military illnesses related to toxic exposure incidents.

Both Le Roy and Rosie Torres have pushed for the legislation for years, saying the move was needed to help all veterans, but especially the millions of individuals exposed to poisonous smoke from waste pit fires used in the Iraq and Afghanistan wars.

Le Roy Torres, a former Army captain, began suffering health complications from that exposure when he returned home from a deployment to Iraq in 2008. Since then, the couple has used their struggles to help push for change in how the Department of Veterans Affairs handles such cases.

Stewart and Feal joined the advocacy work on the issue in recent years, using their celebrity status to increase public attention on the issue.

The pair were also involved in the week-long fire watch outside the Capitol in early August, urging Republican lawmakers to drop their opposition to the bill over concerns about its cost and scope.

Advocates and lawmakers at the time began to raise calls for the Presidential Medal of Freedom for the group, an idea that Stewart in particular deflected into praise for the thousands of activists involved in the effort.

The medal has been awarded to 673 individuals since it was established in 1963. Biden last awarded the medal to 17 individuals in July.

That group included prominent activist athletes like gymnast Simone Biles and Megan Rapinoe, Gold Star father Khizr Khan, former lawmaker Gabrielle Giffords and a posthumous award for Sen. John McCain.

White House officials have not yet responded to Gillibrand’s request.

The five-minute screening will involve a series of simple questions regarding veterans’ time in service, possible exposure to toxic chemicals and current health status.

Veterans will undergo the screening during their first visit after Nov. 8 (regardless of the reason for the visit) but will not repeat the questions on follow-up appointments. Officials plan to conduct the screening for every patient once every five years.

“These screenings are an important step toward making sure that all toxic exposed veterans get the care and benefits they deserve,” VA Secretary Denis McDonough said in a statement. “At the end of the day, these screenings will improve health outcomes for veterans, and there’s nothing more important than that.”

During a demonstration for the media last week, a VA physician started his regular patient check up with the new screening script, which includes information about the Promise to Address Comprehensive Toxics Act (better known as the PACT Act).

That legislation — signed into law by President Joe Biden in August — establishes presumptive benefit status for 12 types of cancer and 12 other respiratory illnesses linked to burn pit exposure in the Gulf War and the wars in Iraq and Afghanistan.

It also provides additional benefits for veterans with hypertension and monoclonal gammopathy of undetermined significance (MGUS) linked to service in Vietnam and similar help for radiation-related illnesses among veterans who served in various places in the 1960s and early 1970s.

Payouts for those benefits won’t begin until early next year. But VA officials have reported that 113,000 veterans have already applied for disability compensation under the law.

Veterans groups have estimated that as many as one in every five veterans in America may receive new benefits or medical care through the law. The screening is designed to help spread information about that, and ease the process of determining what veterans may qualify for.

Department officials conducted a pilot screening program in September, involving more than 19,000 veterans. Of the group, 37% expressed concern about toxic exposure injuries linked to their service.

In a recent press conference, McDonough said the information collected through the screenings will also help steer department research on toxic exposure illnesses.

The screenings will only be conducted by VA physicians at VA facilities, department officials said. Veterans using community care for medical appointments outside of the VA system will not participate in the new screening procedures.

Veterans who want more information on illnesses covered by the PACT Act or who want to apply for disability benefits can visit the VA web site or call 1-800-MY-VA-411 (1-800-698-2411).

Benefits officials began accepting claims for all presumptive illnesses included in the Promise to Address Comprehensive Toxics Act (better known as the PACT Act) after it was signed into law by President Joe Biden on Aug. 10.

They include 12 types of cancer and 12 other respiratory illnesses linked to burn pit exposure in the Gulf War and the wars in Iraq and Afghanistan; hypertension and monoclonal gammopathy of undetermined significance (MGUS) for veterans who served in Vietnam; and radiation-related illnesses for veterans who served in several new locations in the 1960s and early 1970s.

Coverage for those issues had been a point of contention for years. In particular, veterans advocates lamented that too many serious problems believed linked to burn pit exposure were being ignored by VA leaders because of incomplete science linking the health problems with the toxic smoke from the waste fires.

In the 75 days since the signing, the department has received 112,949 new applications for disability claims related to the new presumptive illnesses, an increase in the benefits workload of more than 21% from the same period last year.

“For too long, toxic-exposed veterans and their families have had to fight their government for the benefits and health care they’ve earned,” Acting Under Secretary for Benefits Josh Jacobs said in a statement. “Thanks to the PACT Act, generations of veterans will be able to get the care and benefits they deserve.”

Depending on the severity of a veteran’s injuries, he or she may be eligible for up to $4,000 in disability compensation. Presumptive status for service-connected illnesses cuts down on the paperwork veterans are required to file to receive the monthly checks.

VA officials have been urging veterans who believe they may be eligible to apply now, even though claims will not be processed until January 2023. Payouts should begin by early spring.

The delay between accepting claims and processing them was designed to give VA officials time to put personnel and processes in place to ensure the flood of new claims can be smoothly integrated into the current benefits workflow.

Even so, senior officials have warned that the backlog of overdue first-time claims (ones that take more than four months to complete) is likely to rise early next year because of the new PACT Act cases.

The backlog currently sits at more than 143,000 cases, roughly double what it was before the start of the coronavirus pandemic in America in March 2020.

Veterans who want more information on illnesses covered by the PACT Act or who want to apply for disability benefits can visit the VA web site or call 1-800-MY-VA-411 (1-800-698-2411).

“[Our findings] conclude that there are no refinements or improvements that will allow the registry to serve as a population health surveillance system,” said Kristen Olson, director of sociological research at the University of Nebraska-Lincoln and a member of the National Academies of Sciences, Engineering and Medicine committee analyzing the registry.

“Because there is no way for registry participants to update their health information, there is no way for the registry to accomplish this goal or even to monitor health patterns over time.”

Olson’s comments came during an event Friday unveiling the research, mandated by Congress after concerns arose about the effectiveness of the Airborne Hazards and Open Burn Pit Registry.

More than 317,000 veterans have enrolled in the registry since it was launched in 2014. VA officials say the goal of the effort is to “put data to work for veterans and help us better understand the potential health effects of exposure to airborne hazards during military service.”

But veterans advocates have complained for years that the registry is too restrictive and complicated, and offers little direct benefit to individuals who participate.

The Department of Defense estimates that nearly 3.5 million troops from the recent wars alone may have suffered enough exposure to toxic smoke from open-air burn pits to cause health problems.

Members of the committee researching the registry said more than 130,000 individuals started the enrollment process but never completed it, undermining the VA’s goal of getting a thorough accounting of illnesses among the veterans population.

It is also a voluntary endeavor, meaning the individuals who choose to participate may not be a good representation of the veterans population as a whole.

“The stated registry purpose of research about how the effects of airborne hazards and conducting population health surveillance are unattainable,” said David Savitz, a professor of epidemiology at Brown University in Rhode Island and chairman of the committee.

“The data collected to meet these purposes is not helpful. Efforts to address these important functions could be pursued in other more effective ways.”

The analysis comes just a few months after Congress approved a host of new benefits for veterans dealing with toxic exposure issues and research mandates for VA officials to better identify and care for those injuries.

Researchers said the time and resources spent on the registry could be better spent on new tools to improve outreach to victims of toxic exposure injuries and to link those individuals to their health care options.

“It has great value in certain areas, and those areas are well worth developing,” Savitz said. “So, even though it doesn’t meet some of the original goals, it has important goals that it is capable of attaining and that could be enhanced and streamlined going forward.”

The registry is available through the VA website. The report on its shortcomings is available on the academies website.