Jerral Hancock wakes up every night in Lancaster, Calif., around 1 a.m., dreaming he is trapped in a burning Army tank. He opens his eyes, but he can't move, he can't get out of bed and he can't get a drink of water.
Hancock, 27, joined the military in 2004 and went to Iraq, where he drove a tank. On Memorial Day 2007 -- one month after the birth of his second child -- Hancock drove over an IED, or improvised explosive device. Just 21, he lost his arm and the use of both legs, and now suffers from post-traumatic stress disorder.
The Department of Veterans Affairs pays him $10,000 every month for his disability, his caretakers, health care, medications and equipment for his new life.
No government agency has calculated fully the lifetime cost of health care for the large number of post-9/11 veterans of the wars in Iraq and Afghanistan with life-lasting wounds. But it is certain to be high, with the veterans' higher survival rates, longer tours of duty and multiple injuries, plus the anticipated cost to the VA of reducing the wait times for medical appointments and reaching veterans in rural areas.
"Medical costs peak decades later," said Linda Bilmes, a professor in the Kennedy School of Government at Harvard University and coauthor of "The Three Trillion Dollar War: The True Cost of the Iraq Conflict."
As veterans age, their injuries worsen over time, she said. The same long-term costs seen in previous wars are likely to be repeated to a much larger extent.
Post-9/11 veterans in 2012 cost the VA $2.8 billion of its $50.9 billion health budget for all of its annual costs, records show. And that number is expected to increase by $510 million in 2013, according to the VA budget.
Like Hancock, many veterans returning from Iraq and Afghanistan have survived multiple combat injuries because of military medicine's highly advanced care. Doctors at Brooke Army Medical Center in San Antonio repaired Hancock's body with skin grafts and sent him to spinal-cord doctors for the shrapnel that ultimately left him paralyzed. He still has his right arm, but he can only move the thumb.
Injuries like Hancock's likely will lead to other medical issues, ranging from heart disease to diabetes, for example, with age.
"So we have the same phenomenon but to a much greater extent," Bilmes said. "And that drives a lot of the long-term costs of the war, which we're not looking at the moment, but which will hit in 30, 40, 50 years from now."
Veterans like Hancock with polytraumatic injuries will require decades of costly rehabilitation, according to a 2012 Military Medicine report that analyzed the medical costs of war through 2035. More than half of Iraq and Afghanistan veterans are between the ages of 18 and 32, according to 2011 American Community Survey data. They are expected to live 50 more years, the Institute of Medicine reports.
About 25 percent of post-9/11 veterans suffer from post-traumatic stress disorder, and 7 percent have traumatic brain injury, or TBI, according to Congressional Budget Office analyses of VA data. The average cost to treat them is about four to six times greater than those without these injuries, CBO reported. And polytrauma patients cost an additional 10 times more than that.
Post-9/11 veterans use the VA more than other veterans and their numbers are growing at the fastest rate. Fifty-six percent of Iraq and Afghanistan veterans use the VA now and their numbers are expected to grow by 9.6 percent this year and another 7.2 percent next year, according to a VA report from March 2013.
In response to multiple injuries suffered by Iraq and Afghanistan veterans, the VA established its polytrauma care system in 2005, creating centers around the country where veterans are treated for multiple injuries, ranging from TBI and PTSD to amputations, hearing loss, visual impairments, spinal-cord injuries, fractures and burns. Post-9/11 veterans make up around 90 percent of polytrauma patients, said Susan Lucht, program manager of the polytrauma center at the Southern Arizona VA Health Care System in Tucson.
Each polytrauma patient costs the VA on average $136,000 a year, according to a CBO report, using VA data from 2004 through 2009. And many of their medical issues will never go away.
One TBI patient at the Tucson center, Erik Castillo, has received speech, physical, occupational, psychological and recreational therapies for all of the paralysis, cognition and memory issues associated with injuries he received in a bomb blast in Baghdad. But Castillo's treatment is exactly what medical professionals and economists say could potentially be cost-saving as well as life-saving.
If the VA treats primary injuries early on and creates a community and family support system, it might
be able to lower costs later, said Dr. James Geiling, Dr. Joseph Rosen and Ryan Edwards, an economist, in their 2012 Military Medicine report.
"And those are the costs that we're trying to reduce by giving the care that we do," said Dr. G. Alex Hishaw, a staff neurologist at the Tucson center.
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Castillo has been living with TBI for nine years, and he still goes to the VA three times a week for therapy. "I'll utilize the VA for the rest of my life," he said.
The shrapnel that entered Castillo's brain from a bomb in Baghdad in 2004 burned a portion of his frontal lobe, which had to be removed. Doctors told his parents that he wouldn't survive and that if he did, he would need care for the rest of his life.
Slowly, Castillo started to re-create himself. He learned to talk again, to eat again, to move his left arm and leg. Now, he is going to college.
"We want them to graduate," Lucht said. "But they always know that this is their foundation. This space is here. And their needs will change as they age."
As Hancock and other post-9/11 veterans age, they will need increased medical care and will become more expensive for the VA. The injuries they have now will likely lead to more complicated and expensive medical issues. TBI, for example, may lead to greater risk of Alzheimer's disease, psychological, physical and functional problems, and alcohol-abuse disorders.
Doctors and economists argue that today's conversation should not only be about the primary wounds of war, but about the medical issues that are often associated with them. PTSD, for example, is often associated with smoking, substance abuse, depression, anxiety, heart disease, obesity and diabetes. Amputations are associated with obesity, cardiovascular disease, osteoarthritis, back pain and phantom limb pain.
"We should help an amputee to reduce his cholesterol and maintain his weight at age 30 to 40, rather than treating his coronary artery disease or diabetes at age 50," Geiling, Rosen and Edwards wrote.
"Society is not yet considering the medical costs of caring for today's veterans in 2035 - a time when they will be middle-aged, with health issues like those now seen in aging Vietnam veterans, exacerbated by comorbidities of post-traumatic stress disorder, traumatic brain injury and polytrauma," they wrote.
Polytrauma centers have expanded across the country. But that doesn't mean that all veterans live close enough to access them. In many parts of country, health care is hampered by distance because veterans who use the VA live far away from their closest VA hospital.
For Army Spc. Terence "Bo" Jones, it is more important that he live near his family.
Jones lost both of his legs to an improvised explosive device blast in Afghanistan in 2012. Like Hancock, Jones woke up at Brooke Army Medical Center with his family by his side.
He was 21 when he stepped on the IED. It shot him 10 feet into the air and he landed in a nearby well. He doesn't remember it, but his friends told him he was conscious and trying to climb out.
Now an outpatient at the VA polytrauma center in San Antonio, Jones is learning to walk on prosthetic legs, provided to him by the VA. The VA also provides adaptive driving equipment for his car, and he is taking driver education to learn how to drive with only his hands. One day, he hopes to get a service dog, and the VA will pay for veterinary care and equipment for the dog to help its owner.
"We can get them anything that they need," Lucht said.
The VA provides other assistive accommodations for injured veterans - from grab bars and walk-in showers to wheelchairs and specialized seating. And a lot of veterans wear out their prosthetic limbs because they're active, Lucht said.
When Jones finishes rehab, he plans to move home to Idaho, go to college and open his own shop working on custom cars and motorcycles. But in Idaho, Jones won't be near a polytrauma center anymore.
One of the most rural veteran populations in the country is served by the Reno, Nev., VA hospital, said Darin Farr, the hospital's public affairs officer. "We're actually considered frontier," he said.
The hospital's patients come from as far away as 280 miles. More than 29,000 veterans are enrolled in the Reno hospital, staffed by 1,200 employees, only 40 to 50 percent of whom actually provide medical care.
Many VA hospitals fall behind in entering data from private health records or following up with patients, especially mental health patients for whom follow-up care is particularly important, according to VA Office of Inspector General reports.
The VA doesn't always provide timely mental health evaluations for first-time patients, and existing patients often wait more than the recommended 14 days for their appointments, the OIG reported last year.
Veterans have complained for many years about long wait times to schedule appointments. "Long wait times and inadequate scheduling processes at VA medical centers have been long-standing problems
that persist today," the U.S. Government Accountability Office reported in February. Inconsistent scheduling policies, staffing, phone access and an outdated scheduling system make the problem worse.
Meanwhile, both the GAO and OIG have reported that VA's data on wait times for medical appointments is unreliable, and some schedulers entered incorrect dates or changed them to meet performance standards.
Farr says the Reno hospital faces unique challenges that might contribute to wait times. The hospital competes with other hospitals for employees who might pay more than the government does.
"We don't have a lot of space," he added. The hospital schedules more than 373,000 outpatient visits and 4,200 inpatient visits every year. But it only has 64 hospital beds -- 14 psychiatric, 12 ICU and only 38 for general use.
When Terence Jones finishes rehab at the polytrauma center in San Antonio, he hopes adaptive equipment will help him return to a normal life. Jerral Hancock, on the other hand, knows that he never will.
Hancock misses the adrenaline rush of life before his injury. He longs for a wheelchair that will go faster than 5 mph. He described the time he fell out of his hospital bed as exhilarating. He busted his cheek open, but he loved it.
With the $100,000 the Defense Department gave Hancock for his injuries when he was discharged, he bought two mobile homes outside Los Angeles, one for him and his two children, ages 9 and 6, and one for his mother and stepfather, who take care of him full time. Hancock supports all of them with his monthly disability check from the VA.
The VA bought him a wheelchair and put a lift into his front porch. They widened the doors in his mobile home so his wheelchair could fit in and out. They will pay for his medications and all of his medical care for the rest of his life.
When Hancock arrived at his new mobile home, he couldn't fit his wheelchair in the front door. So he kept one wheelchair inside, and his stepdad carried him through the door and down the steps to a second wheelchair that he paid for himself. It took eight months for the VA to pay him $1,000 for the second wheelchair, and four months to put a lift into his front porch.
"I was stuck in the house for six months over this fight," Hancock said. "I had a wheelchair upstairs and I had a wheelchair downstairs. And my caretaker carried me up and down the stairs from wheelchair to wheelchair. It was ridiculous."
The VA also bought Hancock an $85,000 arm that he could attach to his shoulder to use. But he can't seem to get it to work.
The VA gave Hancock $11,000 toward a car, but his mother said that doesn't come close to the cost of a handicap-equipped vehicle. Instead, he bought a seven-passenger van with a lift for his wheelchair.
Even with all of the money that the VA spends on Hancock's medical and family care, he still lives in a mobile home, and his bedroom has little extra space with a hospital bed and a wheelchair in it. He can't fit into his kids' bedrooms. He can't drink a glass of water on his own. And his air conditioning hardly works, even though he can't be in the heat for too long because his burns prevent him from sweating.
Hancock's children also have had to adjust.
"My son watched me walk off -- he was going on 3 -- and I jumped on a bus with a couple hundred pounds of gear," he said. "The next time he saw me, I lost 100 pounds... I looked like a skeleton and I had tubes coming out everywhere... My daughter, this is all she knows."
(This report is part of a project on post-9/11 veterans in America produced by the Carnegie-Knight News21 program. For the complete project "Back Home: The Challenges Facing Post-9/11 Veterans Returning from the Wars in Iraq and Afghanistan," visit http://backhome.news21.com. Reach News21 at firstname.lastname@example.org .)
(Distributed by Scripps Howard News Service, www.shns.com .)