NPR — along with seven public radio stations around the country — is chronicling the lives of America's troops where they live. We're calling the project "Back at Base." This is the first of a three-part series about veteran benefits (Part 2 / Part 3).
If you're a veteran and rely on benefits from the U.S. Department of Veterans Affairs, where you live may have an effect on whether you receive the benefits you've earned.
NPR, together with member stations WBUR, Lakeshore Public Radio and KUOW, looked at data from 3,000 counties nationwide, and found there's a huge variation in coverage from state to state — and even within a state — on how much the VA spends per veteran.
We also found there's no obvious pattern. And there's no strong association between spending per veteran and the size or age of the veteran population, or the affluence of a particular area.
Veterans' benefits cover a wide range, including health care, monthly disability checks, home loans, life insurance, and education through the GI bill, among others.
Among the states, West Virginia and Arkansas had the highest per-veteran spending in 2013 — just over $7,600. Indiana, New Jersey, Delaware and Pennsylvania had the lowest — less than $5,000. Nationally, the average is just over $6,000. That's after filtering out things like costs to build and operate VA facilities.
When looking specifically at health benefit spending, calculating the amount of spending per "patient" — with a patient being a veteran who gets health benefits — there's a wide variation that doesn't fit discernible patterns.
For example, spending is nearly $30,000 per patient in San Francisco, and less than $7,000 per patient in Lubbock, Texas. Nationally, the average is just under $10,000. In places where more veterans are enrolled in VA health benefit plans, spending per veteran did tend to be higher.
There are lots of explanations for these disparities. Some are demographic and beyond the VA's control, while others the VA could maybe do something about. Some of the range is because benefits cost more in different places. Other discrepancies are because veterans aren't using all the services they're due.
Many of these issues play out in Massachusetts, where the VA spends four times as much on health care for veterans in Boston as it does on Cape Cod.
"This was my challenge coin when I was state commander," says George Murray, 69, the leader at Veterans of Foreign Wars Post 1018 in Boston. "We all come up with sayings when we're state commanders, and mine was to 'communicate, dedicate and educate.' "
Murray served in Vietnam, and he says his health problems — lung cancer, heart disease, heart attacks, strokes — started after exposure to Agent Orange. He gets almost all of his care at VA hospitals and clinics and has almost no complaints.
"The service at the VA has been outstanding," he says. "You get great care. The food isn't bad. The coffee stinks. If they improved their coffee, I'd go up there for coffee in the morning."
Places like Boston, with special VA services for elderly, homeless and low-income vets, tend to have sicker patients and higher VA health care spending. That may help explain why the VA spends $25,000 on medical services per veteran patient every year in Boston and just $6,500 per patient on Cape Cod.
Convenience is also a big factor. For 20 years, Murray went to one of two VA medical centers in Boston, both within 4 miles of his home.
But for Ron Percy, a Vietnam veteran on Cape Cod, access to VA services is a different story. When Percy woke at 3 a.m. one morning last July with chest pains, he was a long way from his assigned VA hospital.
"I couldn't breathe," he says. "There's no way I could go the 75 miles to Providence."
Cape Cod veterans have a clinic for checkups, but for almost everything else, they're sent to the VA in neighboring Rhode Island. After his heart attack, Percy had bills from a Cape Cod hospital that the VA has so far refused to pay. He appealed, and the VA says it is reviewing his case. For all of his planned care, Percy makes the three-and-a-half- to four-hour round trip.
"A couple of years ago, I was diagnosed with prostate cancer, so I had 44 treatments that I had to go to Providence for every single day," Percy says.
He got to Providence in a van run by volunteers. It would leave at 7:30 a.m. and return after all the passengers getting tests or treatment were finished.
"My appointment was like at 9:30, and I'm all done at quarter of 10," he says. "It's wasting the whole day. A lot of people just will say, 'Hey, I can't put up with it,' and they won't go."
That's one reason vets who live far from VA medical centers aren't getting all the benefits they have earned. That includes men and women suffering from PTSD.
"There's a lot of veterans, I get them set up for a doctor's appointment and everything else, and they don't get down there for transportation reasons, it's a long drive, their stress level," says Rob Harrington, a vet whose convoy was bombed in Baghdad. He now works at the Cape & Islands Veterans Outreach Center on Cape Cod. "To drive all the way down to Rhode Island, definitely, it's not fair."
Harrington says some vets on Cape Cod give up on the VA.
"They get on MassHealth, or they allow them to use their own personal insurance, even if it's combat related because of the inconvenience of it," he says.
It also costs more to treat veterans in cities where doctors and nurses are paid more. Still, part of the spending gap is hard to explain.
"Our best guess is that a lot of that probably has to do with management and stewarding the public dollar," says Ashish Jha, who studies VA health care at the Harvard School of Public Health. "Even when you look across VA hospitals, some organizations seem to be a little bit better at managing resources than others."
Tom Sullivan, who heads the Cape Cod chapter of Disabled American Veterans, says vets where he lives deserve better.
"We don't need a thousand-bed hospital, but a hospital where they can actually start caring for the vets here, and they don't have to go to Providence or Boston," Sullivan says.
There is no talk about building a new VA hospital in Massachusetts, and Rep.-elect Seth Moulton says a new hospital is not the answer. Moulton, a Democrat and a four-tour Iraq war vet, says the VA needs to make it much easier for veterans to use private doctors and health care facilities.
"The bottom line is that Americans who've put their lives on the line for our country ought to receive the best health care in the world," Moulton says. "We've got to make that happen."
A 2014 law requires that the VA cover private care if a veteran lives 40 miles or more from a VA facility, but this doesn't help most Cape Cod veterans because they live within 40 miles of their primary care clinic.
But even some vets with access to VA services don't receive all of their benefits. That's because each benefit has its own eligibility requirements, and they're complicated. Vets have a hard time figuring out the process. It's like doing your own taxes. In theory, it should be possible, but many people find they need help. To a veteran with brain injuries or other cognitive disabilities, the paperwork process can become maddening. Many give up before the process is finished.
That's where veterans service officers (VSOs) come in. VSOs are from veterans groups like the American Legion or VFW, and they help vets through the process. When veterans receive help from VSOs, they often end up getting double the compensation.
The VA has a hard time explaining why there are such huge disparities across the nation. And when the agency's data are published, a VA official says, they can count on angry calls from the congressional offices of whichever state ranks last in terms of dollars per veteran.
The VA says the data don't show the full picture because there are too many unknowns — only 9 million vets use the VA out of 22 million total veterans. They move around, sometimes disappearing off the VA's radar for decades, and then they walk back in the door. The numbers are also driven by where vets choose to retire, and by each state's efforts to educate veterans about the benefits and services available.
NPR's Robert Benincasa contributed to this story.
DAVID GREENE, HOST:
All this week, we're taking a close look at America's veterans and especially the benefits they receive. Now, over the past year, we've heard a lot about the long waits for care and also a persistent backlog for disability claims. It turns out there's something else. When you're a veteran, where you live matters, especially when it comes to getting all the benefits you might be eligible for. NPR's Quil Lawrence covers veterans' issues, and he joins us on the line. Hey, Quil.
QUIL LAWRENCE, BYLINE: Good morning.
GREENE: So Quil, I know we're going to dig into some data here in a moment. But just a broad question - I mean, if geography matters in terms of the benefits that you receive when you're a veteran, why is that important?
LAWRENCE: Well, really because the VA's mission says it shouldn't matter. The VA's mission is to care for those who've borne the battle and their widow and their orphan. And it doesn't say just if you live within 30 miles of a VA. So NPR, along with several of our member stations - we looked at data from 3,000 counties nationwide. And we're going to share some of what we found this week. The benefits they get - you know about a lot of them - health care is a big one - probably the biggest. There are monthly disability checks if you have a service-connected disability. There's also home loans. There's life insurance. There's education through the GI Bill. There's a lot that people don't know about.
GREENE: Yeah, a lot of these benefits, really - it runs the gamut. So tell us, in this research, what exactly you found.
LAWRENCE: So we found there's a huge variation from state-to-state and even within each state on how much the VA spends per veteran. It can sometimes be 50 percent more spent per vet per year. In the highest state, it's about $7,600 per year per veteran, and in the lowest one, it's less than $5,000. And we didn't find one big explanation, but we found a few things that might explain some of it. And we can start out with a story out of Massachusetts, where data from the VA shows that they spend nearly four times as much on health care for veterans in Boston as they do out in Cape Cod.
GREENE: That's a big discrepancy within one state.
LAWRENCE: And it can make a huge difference in a veteran's life. So we can hear now a piece from Martha Bebinger from member station WBUR. And she talked to vets in both places. She starts with a vet in Boston.
GEORGE MURRAY: This was my challenge coin when I was state commander.
MARTHA BEBINGER, BYLINE: At 69, George Murray is a shirt-popping, proud leader in the Veterans of Foreign Wars Home Post 1018, Boston. Murray served in Vietnam. He says his health problems started after exposure to Agent Orange.
MURRAY: I've had lung cancer, heart disease. I've had a heart attack. I had a triple bypass. I had a heart attack after that. Then I had a stroke.
BEBINGER: Murray gets almost all of his care at VA hospitals and clinics and has no complaints - well, one.
MURRAY: The service at the VA has been outstanding. You get great care. The food isn't bad. The coffee stinks. If they improved the coffee, I'd go up there for coffee in the morning.
BEBINGER: Places like Boston with special VA services for elderly, homeless and low-income veterans tend to have sicker patients. That may help explain why the VA spends $25,000 per veteran every year in Boston and just $6,500 per vet on Cape Cod. Convenience is also a big factor. For 20 years, Murray went to one of two VA medical centers in Boston, very close to home.
MURRAY: Tops - four miles - to the left, to the right. I mean, neither one of them are bad to get to.
BEBINGER: Now meet Ron Percy, a Vietnam vet on Cape Cod. When Percy woke at 3 a.m. one morning last July with chest pains, he was a long way from his assigned VA hospital.
RON PERCY: I couldn't breathe. So there's no way I could go the 75 miles to Providence.
BEBINGER: Cape Cod veterans have a clinic for check-ups, but for almost everything else, they're sent to the VA in neighboring Rhode Island. After his heart attack, Percy has bills from a Cape Cod hospital that the VA has so far refused to pay. He's appealed. And the VA says it is reviewing his case. For all his planned care, Percy makes the three-and-a-half to four hour round trip.
PERCY: Couple of years ago, I had - I was diagnosed with prostate cancer. So I had 44 treatments that I had to go to Providence for every single day.
BEBINGER: Percy got there in a van run by volunteers. It would leave at 7:30 a.m. and return after all the passengers getting tests or treatments were ready.
PERCY: My appointment was, like, at 9:30. I'm all done a quarter of 10. That's wasting the whole day. Lot of people just will say, hey, I can't put up with it. And they won't go.
BEBINGER: Won't go - that's one reason vets who live far from VA medical centers are not getting all the benefits they've earned. That includes men and women suffering from PTSD. Rob Harrington, a vet whose convoy was bombed in Baghdad, works at a Cape Cod outreach center.
ROB HARRINGTON: There's a lot of veterans. I try - I get them set up for a doctor's appointment and everything else. And they don't get down there for transportation reasons. It's a long drive. Their stress level - definitely it's not fair.
BEBINGER: Harrington says some vets on Cape Cod give up on the VA.
HARRINGTON: They get on MassHealth, or they allow them to use your own personal insurance, even if it's combat-related because of the inconvenience of it.
BEBINGER: Here's another factor. It costs more to treat veterans in cities where doctors and nurses are paid more. Still, part of the spending gap is hard to explain.
ASHISH JHA: Our best guess is that a lot of that probably has to do with management and stewarding the public dollar.
BEBINGER: Ashish Jha studies VA health care at the Harvard School of Public Health.
JHA: And even when you look across VA hospitals, some organizations seem to be a little bit better at managing resources than others.
BEBINGER: Whatever the explanation, veterans on Cape Cod are frustrated that the VA spends four times more per vet in Boston than it does on them. Tom Sullivan, who heads the Cape Cod chapter of Disabled American Veterans, says vets where he lives deserve better.
TOM SULLIVAN: We don't need, you know, a thousand-bed hospital but a hospital where they can actually caring for the vets here, and they don't have to go to Providence or Boston.
BEBINGER: There's no talk about building a new VA hospital in Massachusetts.
GREENE: OK, that reporting came to us from Martha Bebinger from member station WBUR. We still have NPR's Quil Lawrence with us. He covers veterans' issues. And Quil, one thing there that struck me in Massachusetts - convenience. I mean, there's some veterans who are literally leaving money on the table because they just can't get to a VA. Go through some of the other reasons that there are these discrepancies.
LAWRENCE: Right. There's that - that if they just don't go down there, they end up opting for private care. Some are totally beyond the VA's control. Where vets decide to retire - that ends up raising the number in that particular county. Some hospitals are more or less expensive depending on the location, the management. Another reason is outreach. If the vets in a state or county don't hear about these benefits, they're not going to use them. So that's down to the state VA on whether they're educating their veterans on the benefits they've earned. And each one of these has its own eligibility requirements, and they're very complicated.
GREENE: How complicated? I mean, can most people finally figure out how to - to sort of get through the bureaucracy?
LAWRENCE: They're set up so you're supposed to be able to do it yourself. But I don't know. Do you do your own taxes?
GREENE: I don't. I used to.
LAWRENCE: Yeah, yeah.
GREENE: It got too complicated.
LAWRENCE: It's a bit like that. And the VA sort of says, well, everyone should be able to do it. But at the same, time they've got a built-in system of advisors in each VA who are supposed to help you fill out your benefits. And we found that - you'll hear this in our story tomorrow - that if you get this semi-professional help to fill out your paperwork, you can end up getting double the compensation on your disability claim.
GREENE: Does the VA acknowledge these discrepancies and try to explain them?
LAWRENCE: Well, these stats cause the VA a huge headache every year when they come out because some state has to come in last in terms of VA dollars spent per veteran. And then the VA gets a dozen angry calls from that state's congressional offices. And they basically told us there are so many unknowns and so many factors in this data. And bear in mind only about nine million veterans use the VA, and that's out of about 22 million vets nationwide. So that's a huge unknown as well. But our look at the data sort of suggests that if VA services were all being given with equal efficiency, if all veterans were being educated equally well about the benefits that they've earned, then you wouldn't see these crazy variations in the numbers.
GREENE: And I know we'll be looking at a lot of these variations much more deeply as this week goes on. It's NPR's Quil Lawrence. Quil, thanks a lot.
LAWRENCE: Thank you, David.
GREENE: And we should say this project is a collaboration with NPR member stations. It's called Back at Base. Tomorrow, we'll hear about veterans in Indiana. And you can learn how much money the VA is spending on veterans in your county. Just go to our website, npr.org. Transcript provided by NPR, Copyright NPR.