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OEF/OIF demographics compared to previous
cohorts: implications for medical issues
Hendricks, Ann
Hendricks, A., Amara, J. (2013). OEF/OIF demographics compared to previous
cohorts: implications for Medical issues. In J. Amara, & A. Hendricks (Eds.). Military
medical care: From pre-deployment to post- separation. Abingdon: Routledge
http://hdl.handle.net/10945/42150
Downloaded from NPS Archive: Calhoun
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OEF/OIF DEMOGRAPHICS COMPARED TO PREVIOUS COHORTS:
IMPLICATIONS FOR MEDICAL CARE
Ann Hendricks and Jomana Amara
INTRODUCTION
Since 2001, the United States (US) has deployed more than two million troops to Afghanistan
and Iraq for Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF), often for
more than one tour of duty (Tan, 2009). These major international conflicts were the first since
the Vietnam War that required a great number of troops on the ground. About 50 nations have
contributed troops to both conflict areas, but the majority of those deployed at any one time have
been from the US. For example, in 2009, 90,000 of the 130,000 troops deployed in Afghanistan
were from the US with the next largest contingents from the United Kingdom (9,500) and
Germany (4,818) (ISAF, 2012).
The nature of the OEF/OIF conflicts has translated into health care needs that have concerned
not only US service members and their families, but also the US Congress, the Department of
Defense (DoD) and the Department of Veterans Affairs (VA) (e.g., see S. HRG 112-95 or S.
HRG. 112-267). The signature conditions of the wars for US veterans are traumatic brain injury
(TBI) and post-traumatic stress disorder (PTSD), but the majority of health complaints for both
active duty military and veterans are relatively mundane, such as gastro-intestinal or musculoskeletal complaints. For example, Deyton (2008) reported that the largest proportion (46.6%) of
OEF/OIF veterans accessing VA health care had diagnoses for musculo-skeletal conditions.
Haskell et al., (2012) found that the odds for musculo-skeletal and joint problems were even
greater (both AORs > 1.3) for female OEF/OIF veterans compared to males.
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The concern about the nation’s ability to provide medical care for service members returning
from active war duty must be assessed in the context of the other demands on the system,
however. For example the Vietnam War cohort outnumbers the OEF/OIF cohort more than
threefold and is entering old age, the period of life with the greatest health burden from chronic
disease. In fact, demand for immediate post-deployment services by the OEF/OIF veterans is
overshadowed nationally by the demands of the Korean and Vietnam War cohorts in terms of the
number of patients and the average cost of care.
This chapter describes the US veteran population today and places the OEF/OIF cohort in the
context of all living US veterans. It relies on publicly available data and information. It does not
explore the ramifications for veterans’ education, insurance, loans, burial, compensation, or
pensions. Although the pressing needs of newly discharged veterans require immediate
attention, long-term care needs for aging veterans is a concern not only for the future of the
OEF/OIF cohort, but more immediately for the veterans of past conflicts.
We first present information about overall trends in the total numbers of US veterans and
compare demographic characteristics of OEF/OIF veterans and the overall veteran population.
The discussion then moves to some of the health care needs of veterans who separated from the
military in the past ten years.
THE US VETERAN POPULATION
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Over the past seventy years, the number of veterans grew following the nation’s involvement in
World War II, the Korean conflict, and the Vietnam War, all of which used drafts to enlist
military personnel (Figure 1). The total number of veterans peaked around 1980. Since then it
has generally declined as many older veterans died and the military downsized at the end of the
Cold War. However, the large cohorts from World War II, the Korean conflict and the Vietnam
War still make up the majority of today’s veterans. In 2012, most (55.5 %) of the 21.8 million
US veterans are age 60 or older; only 5.5 percent are age 30 or younger (VETPOP 2007).
Figure 1. Active Duty and Veteran Populations, 1940–2012
US Department of Defense, Personnel, Publications, Selected Manpower Statistics, Annual,
http://siadapp.dior.whs.mil/personnel/Pubs.htm.
Note: The increase in the veteran population is an artifact of the decennial census in 2000, which
identified more veterans than had been projected from the 1990 census. Some experts believe
that increased life expectancy was the reason for this difference
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Military conscription ended in 1973 and today’s members of the armed forces join voluntarily.
Across all services, there are over 1.4 million active military personnel today
(http://siadapp.dmdc.osd.mil/personnel/MILITARY/ms0.pdf). The relatively stable or perhaps
declining (Feickert & Henning, 2012) numbers of active military projected for the next few
decades imply that the total number of veterans will continue to decline through 2030 to about 14
million (Figure 2). By that time, the number of veterans over age 75 will be greater than the
number under the age of 40.
Figure 2: Forecast of Veteran Population by Age Group, 2000 through 2033
30,000,000
20,000,000
10,000,000
0
2000200520102015202020252030
Year 75-84 85+
<40 40-64 65-74
Page 5
Source: http://www1.va.gov/vetdata/docs/1l.xls, accessed April 23, 2012.
Women make up 8.7 percent of all living veterans, almost 1.9 million individuals (VETPOP,
2007). They are younger than male veterans; about half of women veterans are currently younger
than 50 while only about a quarter of the men are that young. This difference in age reflects
increased military opportunities for women after the Vietnam War, which in turn increased the
number of female recruits. Women have been a much larger proportion of active military from
the 1980s onward.
Projections through 2030 show the total number of women veterans increasing to over 2.1
million or one out of every seven veterans (VETPOP, 2007). In the 1990s, DoD changed the way
women are assigned and the positions they are assigned to. The combat exclusion was removed
and the number of positions to which women could be assigned increased. Given these changes
in the active military, OEF/OIF are the first military engagements to result in substantial
numbers of female service members in the theater of war.
The racial make-up of the US veteran population is also changing. In the early 1990s, nonHispanic white Americans were 85 percent of all veterans; in 2012, the proportion has fallen to
78 percent. Another 11.8 percent are non-Hispanic African Americans. Hispanic Americans
make up 6.1 percent and the remaining 3 to 4 percent are Native Americans, Asian Americans,
those of Pacific Island descent, or people who identify as having mixed racial heritage. Based on
current active military enrollments, the racial composition of veterans in 2033 is projected to
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become more diverse, but non-Hispanic white Americans will still be the majority (over 70
percent) with the other groups proportionately larger than they are today (US DVA, VETPOP,
2007).
The largest cohort of current veterans, almost 7 million, is from the Vietnam War
(http://www.va.gov/VETDATA/Demographics/Demographics.asp, Table 5L). Another 5.5
million or so are counted as “peacetime” veterans with service between major conflicts. There
are more than 3.4 million living veterans from World War II and the Korean War combined, but
in another twenty years, there will be virtually no veterans still alive from either of these wars.
About 2.5 million Vietnam veterans will still be alive, but the rest of the veteran population will
have served from 1980 onward.
THE IMPACT OF OEF/OIF ON VETERANS
What is the impact of the last decade’s actions in Iraq and Afghanistan on the number of US
veterans? The number of veterans who separated from the military since 2002 and served in
OEF/OIF is about 2 million, over half of whom were reservists or members of the National
Guard and may have already had veteran status from service in the regular Army, Navy, Marines
or Air Force. During those same years, the total number of veterans discharged is estimated at
about 2.7 million, approximately 12.4 percent of all living veterans. Thus, OEF/OIF did not
increase the numbers or change the characteristics of US veterans compared to expected
separations in the absence of these conflicts. However, these conflicts did affect the health
conditions of veterans.
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Physical casualties in recent wars are far more numerous than deaths. Table 1 details the US
military deaths and casualties from the Civil War to OEF/OIF. The table indicates the ratio of
casualties to deaths increased over time starting at about one casualty per death during the Civil
War and ending at about 7.5 casualties per death for OEF/OIF. This change can be attributed to
the improvement in medical services, particularly those located close to hostilities, over the
years. Battlefield medicine, evacuation procedures, and battlefield medical support services have
evolved tremendously, leading to greater survival rates for troops. In addition, the very high ratio
of casualties to deaths for OEF/OIF may be due in part to the use of body armor and helmets,
among other changes. This protective gear shields the user from bullets and shrapnel, improving
overall survival rates.
Table 1 US Military Deaths and Casualties from Principal Warsa
Conflict
Civil War (1861–1865)
Spanish-American War
World War I
World War II
Korea (1950–1953)
Number
Serving
Worldwide
2,213,363
306,760
4,734,991
16,112,566
Death
Casualty
Ratio
Casualty:Death
364,511
2,446
116,516
405,399
281,881
1,662
204,002
671,846
1:1
1:2
2:1
2:1
5,720,000
36,574
103,284
3:1
8,744,000
58,209
153,303
3:1
2,225,000
382
467
3:1
2,200,000
6,386
47,784
7.5:1
Vietnam (1964–1973)
Persian Gulf War
(1990–1991)
OEF/OIFb
(2001 to present)
a
Data as of April 2, 2012, Department of Defense,
http://siadapp.dmdc.osd.mil/personnel/CASUALTY/gwot_reason.pdf accessed May 1, 2012.
b
Number of deployed service members from Analysis of VA Health Care Utilization Among US Southwest Asian
War Veterans, VHA Office of Public Health and Environmental Hazards
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Despite the high ratios of casualties to deaths, the absolute number of physical casualties in
OEF/OIF is small compared to the number of disabled veterans from earlier actions. For
example, veterans from the Vietnam War era still comprise over 40 percent of today’s disabled
veterans, in large part because the largest number of veterans who are still alive served during
those years. In addition, several important conditions were recognized as service-connected only
after the Vietnam War adding to the ranks of the disabled. The primary one is PTSD, which the
American Psychiatric Association added as an official diagnosis only in 1980. Because this
condition may not be recognized as disabling until years after a service member has become a
veteran, the number of Vietnam veterans with disabling mental or emotional conditions far
exceeds the 153,000 recognized by the military at the end of the war.
Signature Conditions
The OEF/OIF wars are the most sustained combat operations since Vietnam. Two major veteran
health conditions stemming from these conflicts have received particular attention from
Congress and Veterans Health Affairs (VHA): TBI and PTSD. Neither of these is unique to
OEF/OIF, but the needs of these two groups of patients have garnered attention. In addition,
amputations have been prominent in the news, even though the absolute numbers are relatively
small: fewer than 1,500 as of September 1, 2010 (Fischer, 2010). Congress, recognizing the
special needs of OEF/OIF veterans, included funds for prosthetic research and increased funding
for the Defense and Veteran’s Brain Injury Center (DVBIC), the facility that coordinates
treatment and research for TBIs. Additional funding for programs for mental health care in
general and PTSD specifically has also been made available.
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TBI: According to DVBIC (2012), from 2000 through the fourth quarter of 2011, 233,425
soldiers had had a TBI, either combat- or non-combat-related. Non-combat-related brain injuries
can result from vehicle accidents, falls, and blows that could occur during training, recreational
activities or other pursuits. Symptoms of TBI may not be evident on first examination since
some cases of closed brain injury are not diagnosed properly at the time and may manifest later
(Okie 2005). DVBIC (2012) reports that 2.7 percent (over 6,000 cases), were penetrating or
severe injuries and 76.7 percent (almost 180,000) were “mild”.
The VHA has instituted a post-deployment TBI screening and evaluation process for veterans
accessing its services. The screening involves four sets of questions about events, immediate and
current symptoms. A positive screen (answering “yes” to at least one question in each of the
four sets of questions) leads to a referral for a comprehensive evaluation by a clinician (Figure
3). In fiscal 2008 and 2009, the rate of positive screens was 21.6%.
Insert Figure 3 about here
Not all patients who have had a TBI will screen positive, because they do not have current
symptoms. On the other hand, not all patients who screen positive have a history of TBI.
Positive screens may be due to the presence of other conditions, such as PTSD or inner ear injury
(Iverson, et al., 2009). Based on experience from past conflicts, VHA screening aims to be
inclusive, evaluating Veterans with lower probability of having TBI to ensure that all those
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potentially needing care receive appropriate assessment and treatment, especially those with mild
injury [US GAO, 2008; Hoge, et al., 2006).
On average, veterans with a diagnosis of combat-related TBI report a larger variety of symptoms
than those with TBI that is not combat-related. Vision impairment, sensitivity to light or noise,
sleep disturbance, and PTSD are among the symptoms experienced more by those veterans with
combat-related injury. Receiving timely treatment and rehabilitation may, at a minimum, help
veterans adapt to the physical outcomes caused by mild or moderate TBI. For example,
understanding the cause of physical symptoms like loss of hearing or feeling in the extremities
and learning coping strategies may forestall a variety of negative feelings. In this way, getting
treatment earlier is more cost effective than getting it at a later time. For a history of the
development of treatment, see Chapters 10 and 11 in this volume.
PTSD: The VHA has undertaken many efforts to improve PTSD care delivered to veterans. It
has developed a guide for clinicians and implemented a clinical reminder to prompt clinicians to
assess OEF/OIF veterans for PTSD, depression, and substance abuse. The VHA has
implemented a national system of 144 PTSD programs in all states and required all VHA
outpatient clinics to have either a psychiatrist or psychologist on staff full time. VHA has also
established Mental Illness Research, Education, and Clinical Centers (MIRECCs) to focus on
issues of post-deployment health of OEF/OIF veterans such as PTSD and suicide prevention.
In the case of OEF/OIF, 15.6 to 17.1 percent of veterans deployed to Iraq reportedly displayed
symptoms of PTSD and 11.2 percent of veterans deployed to Afghanistan reportedly did so
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(Hoge et al. 2004). Of the OEF/OIF veterans who have used VHA services, however, almost 37
percent had a diagnosis for any mental health condition (Deyton, 2008). Within this broad
category, PTSD was the most common diagnosis listed, with substance use disorders, major
depression, and neurotic disorders also reported for at least a quarter of the patients (VHA Office
of Public Health and Environmental Hazards 2007). Among women OEF/OIF veterans, PTSD is
potentially identified for at least as large a proportion of women as men (see Chapter 14).
Studies indicate that more frequent and more intense involvement in combat operations increases
the risk of developing mental health problems (Office of the Surgeon Multinational Force, 2006).
Due to the intensity of combat in OEF/OIF, returning veterans are at a high risk for mental health
problems—specifically those resulting from TBI or PTSD. These two injuries often coincide.
Because of its chronic nature, it is difficult to predict the pattern of utilization and therefore the
costs for treatment of PTSD (Hendricks, et al, 2011). Outpatient treatment for mental health
issues is the norm in VHA; some specialized residential treatment programs do exist, but these
programs are not located in every state.
VHA AND HEALTH CARE FOR OEF/OIF VETERANS
Both DoD and the VHA are responsible for the wellbeing and welfare of veterans, especially
those who were injured or disabled while on active military duty. Bass, et al. (Chapter 3, this
volume) show that veterans with disabilities connected to their military service (whether from
combat or non-hostile activities) are given the highest priority for care within the VHA. This
emphasis on service-related injuries and disabilities was also the case under precursors to the
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VHA, which were first established in 1930 when Congress authorized the President to
consolidate the activities of all government activities affecting war veterans. World War II
resulted in a massive increase in the number of veterans. Congress enacted a large number of
new benefits for veterans, most significantly the World War II GI bill of 1944. Further acts were
passed for the benefit of veterans of the Korean conflict, the Vietnam War, and the all-volunteer
force. In 1989, the Department of Veterans Affairs was established as a cabinet-level position. It
is second in size only to the DOD
The VHA health care benefit is funded by discretionary allocations that Congress reviews every
year. Thus, the level of VHA funding for veterans’ health care is not guaranteed and changes
year to year. Since 2001, it has expanded from $21 billion to about $53 billion requested for FY
2013, a 151 percent increase (Testimony, Secretary Shinseki, Feb 29, 2012). VHA’s national
health care delivery system is divided into twenty-one Veterans Integrated Service Networks
(VISNs). Each network includes between five and eleven hospitals as well as community based
outpatient clinics (CBOCs), nursing homes, and readjustment counseling centers (Vet Centers).
In 2012, VHA operated 157 hospitals, 134 nursing homes, 43 residential rehabilitation treatment
centers, and 711 CBOCs. In addition, the VHA provides grants for construction of state owned
nursing homes and domiciliary facilities.
VHA estimates that in 2013 it will treat over 600,000 OEF/OIF veterans, about 9 percent of all
veterans expected to receive VHA health care that year. OEF/OIF veterans receive care in all of
the VHA networks around the country, but are disproportionately affecting VHA medical centers
in California, Texas, Florida, and the southeastern states. These include states with some of the
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largest veteran populations, but the OEF/OIF patient loads represent larger percentages of this
veteran cohort than is true for other veterans. This pattern may be due to the existence in these
states of more military bases where military families reside and to which the veterans return. The
pattern has important implications for the future costs of care for OEF/OIF veterans because it
may indicate the need to expand VHA capacity more in these states than in other areas of the
country.
COSTS FOR CARE
It is currently difficult to quantify the costs and the amount of care that the OEF/OIF cohort
requires because of all the unknowns:
• Politically mandated changes in eligibility
• The nature, severity, and number of PTSD, TBI, and physical disabilities
• To which VHA centers the veterans will turn for care
• Medical discoveries and new treatments
• How much the veterans rely on VHA for care from one year to the next.
Because the range of estimates for OEF/OIF veterans with severe physical or mental conditions
is so large (e.g., 15 to 40 percent of OEF/OIF veterans possibly have PTSD, depending on the
sample and the measure of PTSD), translating those lower and upper bounds into amounts of
utilization or funding for more than a few years into the future is not policy relevant today.
Conventional wisdom holds that caring for returning veterans is placing a large burden on the
VHA system (Bilmes 2007). However, demand for immediate post-deployment VHA services
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by the OEF/OIF veterans will be overshadowed nationally by the demands of the aging Korean
and Vietnam Wars cohorts in terms of the number of patients and the average cost of their care.
The importance of the aging veteran cohort is apparent from Figures 2.1 and 2.2. In 2012, not
only were more than half of all veterans over age 60, almost two-thirds were 55 and older. The
healthcare needs of these older veterans are those of most elderly Americans with complex
chronic conditions such as diabetes or heart failure. Elderly veterans, however, often have
additional complications from disabilities sustained during military service, including mental
health disorders. These veterans will continue to comprise most of the demand on VHA funding
and services until the majority of World War II, Korean War, and Vietnam War cohort pass
through the system. By 2030, veterans from OEF/OIF will be middle-aged or older and will have
additional disabilities that are not service-connected, but that will require health services
nevertheless.
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