The PACT Act and the Long Fight for Veterans Exposed to Burn Pits

On August 2, 2022, the Senate voted 86 to 11 to pass a bill that most of its members had already voted for once. Outside, on the steps of the Capitol, a group of veterans and their families had been sleeping on the concrete for days, through the heat of a Washington summer, holding what they called a fire watch. Some had lung disease. Some had come in place of a husband or a father who had died. Their cause had a plain name, burn pits, and a long, bureaucratic history of denial. When the vote came in, they cheered, hugged and cried in front of the cameras. The bill, the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act, mercifully known as the PACT Act, became law eight days later. It was the largest expansion of veterans' health care and benefits in decades, and it passed only because people refused to leave.

In short: For years, veterans exposed to toxic smoke from open-air burn pits in Iraq and Afghanistan had to prove their illnesses were caused by their service, and most claims were denied. The PACT Act, passed with large bipartisan majorities in 2022, presumed that connection for a list of cancers and lung diseases. It nearly died in a last-minute procedural vote, and the pressure that revived it holds lessons for anyone fighting for people the system has decided to forget.

What burned

In the wars in Iraq and Afghanistan, the military disposed of much of its waste by burning it in open pits. Plastics, batteries, paint, medical waste, munitions packaging, human waste, tires and anything else that needed to go away went into the fire, often doused with jet fuel. Some pits were enormous; the one at Balad Air Base in Iraq burned for years and covered acres. Smoke drifted over living quarters, dining halls and work areas. Service members breathed it day and night.

Many came home with coughs that would not go away. Some developed asthma, bronchitis or constrictive bronchiolitis, a disease of the small airways that can be hard to diagnose without a lung biopsy. Some developed rare cancers at young ages. And when they went to the Department of Veterans Affairs to file claims for disability compensation, they ran into a wall.

The burden of proof

The way veterans' benefits work is worth understanding, because it explains why the fight lasted so long.

To get compensation for a disability, a veteran generally has to show three things: a current condition, an event or exposure in service, and a medical link between the two. For a gunshot wound, the link is obvious. For a cancer that appears ten years after a deployment, it is not. A veteran had to find evidence that the smoke caused the disease, often without records of what was burned, where, or in what concentration. The scientific studies were incomplete. Most burn pit claims were denied.

There is a precedent for fixing this, and it is called the presumption. When the evidence suggests that an exposure is linked to certain diseases, Congress or the VA can declare that veterans who served in a particular place and time are presumed to have been exposed, and that certain conditions are presumed connected to service. The veteran then does not have to prove causation one case at a time.

The model is the Agent Orange Act of 1991, which established presumptions for Vietnam veterans exposed to the herbicide. That law came only after years of activism, lawsuits and studies, and many Vietnam veterans died before it passed. Veterans of the post-9/11 wars and their advocates were determined not to wait that long. They waited long enough anyway.

A decade of incremental steps

Congress began moving in small ways. A 2013 law directed the VA to create a registry for veterans exposed to airborne hazards and burn pits, which opened in 2014. Hundreds of thousands of veterans eventually signed up. The registry gathered information but did not, by itself, grant benefits.

Advocacy groups organized. Burn Pits 360, founded by Rosie Torres, whose husband Le Roy had come home from Iraq with a lung disease, collected stories and lobbied relentlessly. Larger veterans service organizations joined. The comedian and television host Jon Stewart, who had spent years pushing Congress to fund health care for 9/11 first responders, turned his attention to burn pits and brought cameras with him.

The case gained a face in March 2022, when Danielle Robinson, the widow of Sergeant First Class Heath Robinson, sat with the first lady at the State of the Union address. Robinson had served in Kosovo and Iraq and died of lung cancer in 2020. President Biden, whose son Beau had served in Iraq and died of brain cancer, spoke about burn pits that night and asked Congress to act. He did not claim to know what caused his son's illness, but he made clear why the issue was personal.

Two votes that were supposed to be one

Here is where the story gets procedural, and where the procedure nearly killed it.

The House passed a version of the bill in March 2022. The Senate passed its own version in June, 84 to 14. Then a problem surfaced: the bill included a provision that counted as revenue, and the Constitution requires revenue bills to start in the House. The House fixed the problem by passing the bill again in July, by a wide margin, and sending it back to the Senate for what everyone expected would be a routine final vote.

On July 27, the Senate held a procedural vote to advance the bill. It failed. More than two dozen Republicans who had supported the bill in June switched to no. The stated reason was an accounting provision. Senator Pat Toomey of Pennsylvania argued that the bill would let hundreds of billions of dollars in existing veterans' spending be moved from the discretionary side of the budget to the mandatory side, freeing room for unrelated spending. He wanted an amendment to change it.

It is worth laying out Toomey's argument fairly, because it was a real budget objection, not invented from nothing. Budget hawks of both parties have long worried about accounting moves that loosen spending limits without anyone voting to do so. But the timing and the size of the reversal led veterans and many Democrats to believe something else was going on; the vote came on the same day that Senate Democrats announced a deal on the climate and health legislation that became the Inflation Reduction Act, and many observers concluded the burn pit bill had become collateral damage in an unrelated fight. Whatever the motives, the effect was the same: a bill that sick veterans had been told would pass had just been stopped.

The fire watch

The veterans and families who had come to Washington for what they thought would be a celebration did not go home. They set up on the Capitol steps and stayed. Stewart joined them and gave an angry speech that spread quickly online. Veterans sat through the nights in shifts, keeping a vigil in the language of military duty. Members of Congress from both parties came out to talk with them. News coverage was relentless.

The pressure worked. Within days, the Senate agreed to vote on Toomey's amendment, which failed, and then on the bill. On August 2, it passed 86 to 11. Many of the Republicans who had voted to block it the week before voted for it. President Biden signed it on August 10, 2022.

There is a lesson in that week for anyone who thinks public pressure is pointless. The senators who switched did not suddenly discover new budget information. They discovered that the political cost of being seen to block health care for sick veterans was higher than they had calculated. The people on the steps had changed that calculation, and they did it peacefully, with their own bodies and their own stories.

What the law does

The PACT Act established presumptions of service connection for more than twenty conditions, including a range of cancers and respiratory illnesses, for veterans who served in specified locations in the Middle East, Afghanistan and elsewhere after 1990. It added locations to the Agent Orange presumptions, including Thailand, Laos and Cambodia, and added high blood pressure to the list of conditions presumed linked to Agent Orange. It extended the window during which post-9/11 combat veterans could enroll in VA health care, required toxic exposure screenings for veterans in VA care, and funded new VA facilities and staff.

It also included the Camp Lejeune Justice Act, which allowed people exposed to contaminated water at the Marine Corps base in North Carolina over several decades to sue the federal government.

Since the law took effect, the VA has received a flood of claims and granted large numbers of them, and it ran outreach campaigns urging veterans to apply. Some veterans have found the claims process slow; others have been told their condition is not on the list. A law is not the end of a fight; it is a new set of terms on which to keep fighting.

The pattern, and the price

Step back and a pattern emerges. Agent Orange, Gulf War illness, the 9/11 first responders, burn pits: in each case, people who served the country were exposed to something toxic, came home sick, and spent years being told there was not enough proof. In each case, the fix came only after veterans and their families organized, testified and refused to go away, and often only after many of them had died.

There is something here worth saying plainly, and it is an argument rather than a neutral fact. A country that sends people to war takes on an obligation that does not end when the deployment does. The cost of caring for those who are injured, including by the smoke from their own bases, is part of the cost of war. Budgets that plan for weapons and operations but not for the decades of care afterward understate what wars really cost. Progressives who question military spending and conservatives who honor military service should be able to agree that this part of the bill must be paid.

And it was paid, in this case, by a broad coalition. The final votes were lopsided in both chambers. Veterans of every political stripe joined the fight. That should be remembered the next time someone says nothing can pass.

Why the science was never going to settle it alone

One reason the fight took so long is that the scientific evidence was genuinely hard to gather, and opponents of broad coverage could point to that difficulty in good faith.

In 2011, a committee of the Institute of Medicine, part of the National Academies, reviewed what was known about the long-term health effects of burn pit exposure and concluded that the evidence was insufficient to draw firm conclusions. That finding was cited for years as a reason for caution. But the committee's conclusion said more about the state of the data than about the safety of the smoke. The military had not systematically measured what was burned or what troops inhaled. Records of who was stationed near which pit, and for how long, were incomplete. Rare cancers are hard to study in any population, let alone a scattered one of young people who came home and dispersed across the country.

That is the honest trade-off at the heart of every presumption. If Congress waits for conclusive proof, it may wait until most of the affected people have died, and the proof may never arrive because no one collected the measurements that would supply it. If Congress acts on reasonable suspicion, it may pay benefits to some veterans whose illnesses had other causes. Both errors are real. The question is which one a country prefers to make with the people it sent to war.

The PACT Act chose the second. Its supporters argued, persuasively in our view, that the burden of uncertainty should fall on the institution that created the exposure and failed to record it, not on the individual soldier who breathed it. The law also built in a process for the VA to study and add conditions over time, which is a recognition that the science will keep moving.

What you can do

• If you are a veteran or family member, make sure you know what the law covers. The VA's own PACT Act pages list the presumptive conditions and locations, and accredited veterans service organizations can help with claims at no cost; our organizations directory lists nonprofits by cause in every state, including legal aid and veterans' help. This is general information, not advice about any individual claim.
• Ask your members of Congress about VA staffing and claims backlogs. Our representatives lookup shows your House member and senators, their phone numbers and their latest votes. Veterans' benefits depend on the people who process the claims.
• Watch the next exposure fights. Questions about other toxic exposures and about VA funding come up regularly; the Pentagon and militarism topic page follows military budgets and what they leave out.
• Remember the record. Our list of bills both parties passed together is a useful corrective when the story is that Washington cannot do anything for anyone.
• Show up. The fire watch worked because people were physically present and would not leave. If veterans in your community are organizing on health care, go and stand with them.