(This article by Hope Hodge Seck originally appeared in the March 2025 issue of Military Officer, a magazine available to all MOAA Premium and Life members. Learn more about the magazine here; learn more about joining MOAA here.)

As an Army intelligence specialist in Mosul, Iraq, in 2004, Paul McMillin was monitoring the chaotic fall of nearby Fallujah and sensed his unit could be in the fight soon. So, he did what he thought would make him most ready: hit the gym at his forward operating base (FOB).

In addition to pumping iron for about three hours a day, he’d run around the FOB to build his endurance. He had no idea that, with every deep breath of the Iraqi air, he was pulling poisonous fumes from nearby garbage burn pits deeper into his lungs. Unlike some veterans who could see the burn pits from their living quarters, McMillin, pictured, couldn’t see or smell what he was breathing.

It wasn’t until 2005, when he’d left active duty and decided he wanted to try out for special operations, that his struggle to complete workouts without getting breathless and winded gave him a clue that his body was compromised.

“I just figured, ‘Hey, you know, it’s probably me; I’m not working out with other guys to keep motivated,’” McMillin, 44, recalled. “Most GIs are usually able to find a way to blame themselves before they even start to ask questions about if anything else is wrong.”

[TAKE ACTION: Ask Congress to Deliver Toxic-Exposed Veterans the Care They've Earned]

McMillin’s chronic asthma and lung irritation, which in 2015 would send him to the ICU for a three-week stay, wouldn’t be officially recognized by the VA as connected to his service until 2022 with the passage of what’s known as the PACT Act, nearly two decades after that Mosul deployment.

Along the way, he’d end up walking the halls of Congress to advocate for the Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act and participating in the all-night “fire watch” stakeouts on the steps of the U.S. Capitol organized by the advocacy group Burn Pits 360. After the bill was signed, the VA approved McMillin’s asthma disability claim within months, allowing him to start covering living needs like home upgrades to support his limited mobility.

“At least now it feels like they’re going to work toward letting us have care instead of just saying, ‘Oh, well, we’re not interested in treating you,’ which is the impression I had before,” he said. 

McMillin is one of more than 1.3 million veterans who have had toxic exposure disability claims approved under the PACT Act, which acknowledged 23 new categories of medical conditions presumed to be service-related, established free toxic exposure screenings, and sped up VA health care eligibility for veterans with a history of toxic exposure. The bill, which naysayers said would drag the VA into deep backlogs amid a surge of new claims, represents a historic achievement for veteran advocates that has worked much more effectively than critics predicted.

[FROM VA.GOV: The PACT Act and Your VA Benefits]

But as medicine evolves and more becomes known about the complex and long-term effects of exposure to burn pits and other environmental toxins that poisoned generations of veterans, those who fought for the bill say still more is needed to ensure the VA fulfills its promise of care to those who served.

‘They Failed on Health Care’

Rosie Torres, who co-founded Burn Pits 360 with her husband Le Roy Torres, a former Army reservist whose lungs were severely compromised and brain injured by burn pit exposure on a year-long deployment to Balad, Iraq, recalls how her “knees buckled” when she learned the PACT Act was going to pass after 13 years of her tireless advocacy.

[FROM 2022: Toxic Legacy: They Served With Honor ... Then Their Country Let Them Down]

But she doesn’t feel like her work is done: The VA has yet to approve a rule that would give a dedicated diagnostic code to constrictive bronchiolitis (CB), a disease of the small airways common among burn pit-exposed veterans, and a rule proposed by the VA in September has been criticized as lacking the diagnostic criteria needed to help the most veterans.

Torres is glad that toxic exposure screenings are proliferating and disability claims are being granted but worries too many veterans with undiagnosed conditions related to exposures are still not receiving the answers they need — answers that would also provide a nexus to care. As well as CB, she’s focused now on research concerning the effects on the brain of toxic inhalation, including the toxic encephalopathy that she believes was responsible for a suicide attempt her husband made in 2016.

To date, brain cancer is on the list of presumptive conditions under the PACT Act, but no other brain conditions have made the list. 

[RELATED: VA’s Latest Toxic Exposure Moves Show Progress, But Point to Need for Major Changes]

“They’ve done a great job on the benefit side,” Torres said of the VA, “but I feel like they failed on the health care side.”

Burn Pits 360 cofounder Rosie Torres, right, and husband Le Roy attend the signing of the Sergeant First Class Heath Robinson Honoring our Promises to Address Comprehensive Toxics (PACT) Act at the White House on Aug. 10, 2022. (Mike Morones/MOAA)  

McMillin, who also suffers from CB, said he gets his primary treatment for the disease from an outside provider. Even though the new rule has been proposed, he said he’s suspicious of the VA’s testing protocol for CB, which is hard to diagnose and not always well understood.

For this reason, advocates like Torres have also pushed the VA to establish a center of excellence focused on treatment of these challenging and nuanced conditions.

“I would like to see everyone going through the VA have access to this kind of care,” McMillin said, referring to the outside expert now treating him. “But we are moving the needle in the right direction. It’s just, unfortunately, it’s got to be by degree.”

A Way Forward

In September 2024, a joint report from MOAA and DAV (Disabled American Veterans) offered more PACT Act accountability and a way forward on more rapid acknowledgement of the nexus between toxic exposure and disease.

While the report, Ending the Wait for Toxic-Exposed Veterans, found it takes an average of 2.4 years for the VA to establish a presumptive condition after toxic exposures are established, it takes 34.1 years, on average, to provide presumptive care to the first veterans exposed to a new toxin.

[READ THE REPORT: Ending the Wait for Toxic-Exposed Veterans]

The Agent Orange veterans of the Vietnam War might still provide the best example of this process: The symptoms of chemical defoliants take years
to manifest after servicemembers return home; then, they’re forced to wait years or decades while scientists and clinicians prove that their ailments are indeed caused by exposure. The first Agent Orange veterans were exposed to the chemical in 1962; Congress passed the first exposure presumption for the group in 1991, 29 years later.

“We don’t want to be in a situation where we wait another three decades and need to write a check with American taxpayer dollars, which means that millions of veterans are not getting taken care of in the meantime,” said Cory Titus, MOAA’s director of Government Relations for currently serving affairs. “So the effort here, for the report, is to make sure that we’re fixing the process in a way that, as these exposures are happening, we’re acknowledging them right away.”

The report recommends Congress establish a new legal framework for the process, from acknowledgement of possible exposure to final presumption of service connection. It also calls for more funding for disease research, the creation of a classification system for toxic exposures that allows for concessions where there are gaps in evidence, and pathways for caring better for veterans and their families while they’re waiting for crucial answers regarding potential exposures.

Now, Titus said, the work to move forward involves aligning a coalition of veterans service organizations to build awareness about the report’s findings and “start the dialog” on Capitol Hill about needed changes.

“The good news is that there’s been a lot of momentum and interest, because the scar tissue of having to get the PACT Act across the finish line is real,” Titus said.

[RELATED: How MOAA Plans to Build Momentum in the 119th Congress]

In the 119th Congress, which began its work in January, advocates say they plan to work toward the introduction of model legislation that codifies some of the report recommendations.  

VA’s Surge and Outreach

For its part, the VA has stressed transparency in working to meet the requirements of the PACT Act. A regularly updated online dashboard, as of Feb. 24, shows that 1.53 million total PACT Act claims had been approved, with an approval rate of 74.4%. On average, according to the dashboard, it takes about 167 days for a PACT Act-related claim to be completed.

In addition to nearly 1.6 million veterans who’ve received claim decisions, nearly 28,000 surviving family members have also had PACT Act claims adjudicated. More than $8 billion in backdated benefits had been awarded by the VA as of Nov. 30, 2024, as claims continue to roll in.

In FY 2023, VA officials said, the department hired 60,000 more claims processors to meet the surge and prevent backlogs. As a result, said Dr. Shareef Elnahal, who until recently was the VA undersecretary for health, wait times across the department in certain categories, including mental health and primary care, had actually gone down.

[RELATED: VA Eases Benefits Rules for Cancers From Post-9/11 Service, K2 Tours]

As the VA has organized thousands of outreach events across the country to inform veterans of new PACT Act provisions and how they can receive screenings and apply for presumptive conditions, officials also have noticed health care enrollment increases among veterans who don’t have toxic exposures but might have been hearing about what the VA offers for the first time.

“What the PACT Act really did in principle for health care is, it allowed us to be there in a preventative posture for many veterans for the first time,” Elnahal said in an interview. “… Even if veterans don’t have service-connected conditions, if they were exposed to a toxin, or they were deployed to one of these conflicts, they can enroll in health care, and we can be there for them with our preventative health care before they get a condition that may end up being service-connected. And so prevention is obviously the best that you can possibly do in health care.”

While the number of veterans exposed to one of the identified sources of toxins, be it burn pits, contaminated water at Camp Lejeune, N.C., or petrochemicals and radiation at Karshi-Khanabad Air Base (K2) in Uzbekistan, is finite, claims continue to flood the VA at high rates as outreach continues. In FY 2024, the department received an average of 77,000 PACT Act-related claims each month, said Josh Jacobs, VA’s former undersecretary for benefits; in October 2024, the first month of the new fiscal year, the department received 83,000 claims.

The officials signaled an openness to the criticisms from veteran advocates on treatment of conditions like CB. Jacobs said the VA was working to update its approach for evaluating that condition and seeking out public comment in consultation with internal and external medical experts to determine the most effective diagnostic approach.

Elnahal added the VA was collaborating with the National Academies of Sciences, Engineering, and Medicine to explore the nexus between toxic exposures and brain conditions ranging from depression and PTSD to dementia and other neurocognitive disorders.

Veterans receive assistance at a VA PACT Act outreach event in Georgia in 2024. (VA photo)

“If any of these things have a signal,” he said while in that role, “we’ll be pursuing that further.”

David Shulkin, who served as VA secretary in 2017 and 2018 and recently joined the Burn Pits 360 advisory board, said, by and large, he was impressed with how the VA had risen to the challenge of meeting the PACT Act requirements but stressed that serious and comprehensive overhauls were still required to reform the department’s benefit-granting process and remove more of the burden from veterans of proving the harm they’d incurred.

‘We Are Still Learning’

Even with the new PACT Act provisions, a December report from the VA’s office of the Inspector General found that claims processors had at times requested unwarranted examinations from veterans with presumptive conditions, resulting in undue burden and delay.

“I think that the current administration has had the appropriate focus on this,” Shulkin said in a late November interview, shortly after the presidential election. “I don’t think that means that they have everything right; this is a process here where we are still learning about how to do this better. So there’s more work to do, and I would expect that the new administration is going to continue that with a fresh set of eyes.”

Despite ongoing challenges, the PACT Act has been life-changing for many, including Gina Cancelino, whose husband, Marine Corps Gunnery Sgt. Joseph Cancelino, died in 2019 at age 52 from aggressive testicular cancer caused by exposure to burn pits in Iraq. After years of financial difficulties and efforts to secure coverage in the wake of her husband’s death, Cancelino said the passage of the law created a path for her to receive a monthly survivor’s benefit as well as health insurance for herself and her children.

“If it wasn’t [for the PACT Act], I don’t know if I would still be fighting, because I got two denials, and there’s a good chance I would probably still be somewhere in the mix,” Cancelino said, “trying to figure out how to make them see or how to make them admit that it was service-connected.”

Hope Hodge Seck is a writer based in the Washington, D.C., area who focuses on military-related issues.