As with all government agencies, the Department of Veterans Affairs (VA) is facing an unknown number of tight – even declining – budgets, just as the number of veterans they serve is positioned to swell after 11 years of combat in Southwest Asia.

Current estimates place the number of U.S. veterans at more than 22 million, covering five generations of warfighters back to World War II, with some 68 percent age 55 or older. Vietnam veterans long ago replaced those from World War II as the largest single demographic in that population, but those who served in Iraq and Afghanistan will be growing the ranks of younger veterans throughout this decade and beyond.

“Changes in our national security environment [also] have direct impacts on VA strategic planning and operations,” according to the department’s Strategic Plan Refresh: FY 2011-2015. “Prolonged conflict – OEF [Operation Enduring Freedom] and OIF [Operation Iraqi Freedom] have already lasted longer than World War II – means that VA must be prepared to accommodate the influx of new veterans requiring our services. The new nature of warfare and the potential for future conflicts are likely to create significant demand for VA services and infrastructure.”

While the one-third of today’s veterans younger than 55 and the two-thirds older share a number of concerns, they also each have health issues specific to their ages and combat experiences, placing a growing strain on the Veterans Health Administration (VHA) to fully serve the entire population. That is further complicated by the growing number of female veterans, who also have unique health needs that have not been a top VA priority in the past.

“There continues to be a significant increase in the number of women veterans [who] comprise 7.5 percent of the total veteran population and nearly 5.5 percent of all veterans who use VA health care services,” the Strategic Plan Refresh reported. “By 2020, women veterans will constitute at least 10 percent of the veteran population and 9.5 percent of VA patients.”

In terms of the conflicts during which most veterans served, the VA reports the Vietnam era now leads with 7.4 million, the two Gulf wars stand at about 5.9 million, peacetime only at 5.7 million, Korea 2.3 million, and World War II now down to 1.7 million (some served across more than one of those periods).

In recent years, Congress has sought to maintain, even increase, the overall budget proposals submitted by the VA, much of which involve health care, including research and development (R&D), treatment, facilities, and staff. But that effort has not kept up with the increasing requirements of changing veteran demographics nor the VA’s ability to fully address previously hidden or under-reported health issues among veterans, many of whom have found it difficult to get into crowded and understaffed VA hospitals.

For example, according to an article in the American Military Retirees Association (AMRA) newsletter by VA clinical social worker Steve Barrett, up to 80 percent of new post-traumatic stress disorder (PTSD) patients referred to some VA hospitals are in the oldest age groups. In addition to meeting the normal added health needs of an aging population, coming from the largest veterans age group, that will put growing pressure on VA expenditures and budget priorities.

“All of the mental health care through the VA is stretched to the limits already, so an increase in PTSD among older veterans is just going to make it worse,” AMRA Executive Director Margaret Bergeron warned.

The VA’s report to Congress on “FY 2013 Funding and FY 2014 Advance Appropriations Request” for medical programs said it expected to provide treatment to more than 6.3 million unique patients – including civilian family members – in FY 13, up 1.1 percent from anticipated 2012 numbers. The 2013 estimate includes more than 610,000 new OEF/OIF veterans. The total number also is forecast to grow to 6.4 million unique patients in 2014.

The VA defines unique patients as uniquely identified individuals treated by the VA or whose treatment is paid for by the VA. That includes patients only receiving pharmacy benefits, CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs) patients, Readjustment Counseling patients, employees seen as patients, collateral patients, and other non-veterans treated by the VA. Non-veterans include spouses, reimbursable workload with affiliates, humanitarian care, and employees receiving preventive occupational immunizations, such as Hepatitis A and B and flu vaccinations.