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.
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