1. The Secret VA Waitlists

In 2014 the public learned that VA facilities had been making veterans' waits for care look shorter than they were. Some facilities kept veterans on unofficial lists outside the official Electronic Wait List (EWL); schedulers across the system entered dates that made delays disappear from the data. It started in Phoenix and the VA's own audit found it nationwide.

Phoenix

In February 2014 a whistleblower, Dr. Sam Foote, alleged that 40 veterans had died waiting for appointments at the Phoenix VA Health Care System. The VA Office of Inspector General (OIG) investigated.

  • Interim report (May 28, 2014): OIG found about 1,700 veterans waiting for primary care who were not on any official wait list, and recommended the Secretary act immediately to get them care. OIG wrote that the multiple lists it found outside the official EWL "may be the basis for allegations of creating 'secret' wait lists." Staff told investigators that printed request records were held for one to two months, and some were destroyed.
  • Real versus reported waits: The VA's internal review found Phoenix veterans waited an average of 115 days for a first primary care appointment, while the facility reported an average of 24 days.
  • Final report (August 26, 2014): Beyond the roughly 1,400 veterans properly on the EWL, OIG identified more than 3,500 additional veterans, many on unofficial lists, who "were at risk of never obtaining their requested or necessary appointments." OIG identified 40 patients who died while on the EWL between April 2013 and April 2014. Reviewing 3,409 patient records, it documented 28 cases of clinically significant delays in care (6 of those patients had died) and 17 other cases of deficient care (14 had died). OIG stated it could not conclusively assert that the lack of timely care caused the deaths.

In the same final report, OIG said it had received about 445 allegations of manipulated wait times at other VA facilities, had opened investigations at 93 sites of care, and that those investigations "have confirmed that wait time manipulations are prevalent throughout VHA."

Nationwide: the VA's own audit

On June 9, 2014, the VA released its Nationwide Access Audit of 731 hospitals and clinics.

57,436veterans waiting to be scheduled for care (VA fact sheet)
63,869enrolled over the past ten years but never seen for an appointment
13%of schedulers said they were instructed to enter a date other than the one the veteran requested
76%of VA facilities had at least one such instance

The audit also found that 8% of schedulers used alternatives to the official wait list or scheduling package, and that the 14-day wait-time performance target was "not attainable" given demand. VA removed the 14-day goal from employee performance contracts to eliminate the incentive to game the numbers.

Accountability

  • May 30, 2014: VA Secretary Eric Shinseki resigned. President Obama said he accepted the resignation "with considerable regret." The Associated Press reported that Shinseki took the blame for what he called a "lack of integrity" in the system.
  • August 7, 2014: The Veterans Access, Choice, and Accountability Act became Public Law 113-146. It created the Veterans Choice Program, funded with $10 billion, letting eligible veterans get care from community providers if VA could not schedule them within 30 days or they lived more than 40 miles from a VA facility.
  • August 2014: Secretary Robert McDonald: "We sincerely apologize to all Veterans who experienced unacceptable delays in receiving care."

What the follow-up investigations found

The OIG's criminal investigators completed 77 wait-time investigations and began publishing summaries in 2016. By the VA's own count, OIG substantiated intentional misuse of scheduling systems in 18 of those reports, and 29 employees were disciplined, with actions ranging from admonishment to removal. Examples from the published summaries:

  • Salisbury, North Carolina: OIG found "over half of the schedulers who were interviewed were routinely 'fixing' patient appointments at the request of their supervisors," so appointments would appear to fall within 14 days, a measure that appeared in staff and director performance plans.
  • White River Junction, Vermont: 152 of 293 schedulers entered the appointment date as the veteran's "desired date" 100% of the time, producing the appearance of zero-day waits.
  • Manchester, New Hampshire: OIG substantiated the same desired-date practice through at least 2011, described by staff as standard practice.

Sources

  1. VA OIG, Interim Report, Phoenix Health Care System, Rpt. 14-02603-178 (May 28, 2014): vaoig.gov · PDF
  2. VA OIG, Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System, Rpt. 14-02603-267 (Aug. 26, 2014): summary · PDF
  3. Statement of Acting VA Inspector General Richard Griffin, Senate VA Committee (Sept. 9, 2014): PDF
  4. VA Access Audit & Wait Times Fact Sheet (June 9, 2014): va.gov PDF; full findings report: PDF (KPBS mirror); VA press release: news.va.gov
  5. AP, "Audit: More than 57,000 await first VA appointment": apnews.com
  6. BBC, "Veterans Secretary Eric Shinseki resigns after report" (May 30, 2014): bbc.com; AP, "Shinseki resigns amid vets' health care problems": apnews.com; White House statement: archives.gov
  7. H.R. 3230, Veterans Access, Choice, and Accountability Act of 2014 (P.L. 113-146): congress.gov; House VA Committee summary: veterans.house.gov
  8. VA press release on the OIG final report (Aug. 2014): news.va.gov
  9. VA statement on OIG wait-time investigation summaries: news.va.gov
  10. VA OIG administrative summaries: Salisbury, NC, 14-02890-255: PDF; White River Junction, VT, 14-02890-248: PDF; Manchester, NH, 14-02890-243: PDF

2. Denial of Care and Benefits

A wait list is one way to keep a veteran from care. A discharge label, a missing record, or a burden of proof that cannot be met is another. In case after case below, recognition came years or decades late, usually after lawsuits, investigations, or an act of Congress.

"Personality disorder" discharges

A personality disorder is treated as a pre-existing condition, so a discharge on that basis can leave a servicemember without disability benefits. GAO reported about 26,000 enlisted personality-disorder separations from November 2001 through June 2007, about 2,800 of them after deployment to Iraq or Afghanistan, and found the services were not fully complying with DoD's own separation requirements. Using records obtained under the Freedom of Information Act, a 2012 Vietnam Veterans of America report counted more than 31,000 such discharges from fiscal 2001 through 2010, and argued many were improper and swept up troops whose real injuries were PTSD or TBI.

"Bad paper": misconduct discharges of troops with PTSD and TBI

GAO's 2017 review of DoD data found that of 91,764 servicemembers separated for misconduct from fiscal 2011 through 2015, 62% (57,141) had been diagnosed within the prior two years with PTSD, TBI, or certain other conditions that could be associated with misconduct. Of those 57,141, 13,283 received an "other than honorable" discharge, making them potentially ineligible for VA health care. GAO also found that Navy policy did not require the PTSD/TBI screening DoD policy called for in some cases, and that Army and Marine Corps separation packets were missing documentation of screening and of counseling about losing VA benefits.

The Pentagon has since directed review boards to give "liberal consideration" to upgrade requests tied to PTSD (Hagel memo, September 3, 2014) and expanded that to TBI, sexual assault, and sexual harassment (Kurta memo, August 25, 2017). See Where to get help for upgrade routes.

Agent Orange and the Blue Water Navy

Vietnam veterans fought for years for recognition of herbicide-related disease. The Agent Orange Act of 1991 (signed February 6, 1991) finally created a presumption of service connection for listed diseases. But VA limited the presumption to those who served on land or inland waterways, leaving out sailors offshore. It took a federal appeals court ruling, Procopio v. Wilkie (Federal Circuit, January 29, 2019), holding that the "Republic of Vietnam" includes its 12-nautical-mile territorial sea, and then the Blue Water Navy Vietnam Veterans Act of 2019 (signed June 25, 2019, effective January 1, 2020) to extend the presumption to those veterans.

Gulf War Illness

VA's Research Advisory Committee on Gulf War Veterans' Illnesses reported in 2008 that at least one in four of the 697,000 U.S. veterans of the 1990–91 Gulf War had Gulf War illness. In 1996, DoD publicly acknowledged that U.S. troops had destroyed chemical weapons at Khamisiyah, Iraq, in 1991. GAO found in 2017 that from fiscal 2010 through 2015, approval rates for Gulf War Illness claims were about three times lower than for all other claimed disabilities, that VA's training for examiners was elective (only 10% had taken it), and that denial letters did not always explain why claims were denied.

Burn pits before the PACT Act

Testifying before Congress in September 2020, a VA official said that between 2007 and 2020 VA approved burn-pit-related disability claims for 2,828 veterans out of 12,582, a denial rate of about 78%. Veterans had to prove a direct link between a specific exposure and their illness. The Sergeant First Class Heath Robinson Honoring our PACT Act, signed August 10, 2022, created presumptions for many toxic-exposure conditions so veterans no longer had to prove that link.

Camp Lejeune before the Justice Act

Drinking water at Camp Lejeune, North Carolina, was contaminated with TCE, PCE, benzene, vinyl chloride, and other chemicals from the 1950s until 1985, when the most contaminated wells were taken out of service. The federal health agency ATSDR says as many as one million military and civilian staff and their families might have been exposed. For decades, people harmed had no workable path to sue. The Camp Lejeune Justice Act of 2022, enacted as Section 804 of the PACT Act, opened one for those exposed for at least 30 days between August 1, 1953, and December 31, 1987.

Atomic veterans' oath of silence

Troops who took part in nuclear tests were bound by secrecy, which made it hard to even describe their exposure in a VA claim. VA's own guidance explains that only in 1996, with the repeal of the Nuclear Radiation and Secrecy Agreements laws, were atomic veterans free to describe their participation as needed to establish a claim.

Edgewood and Project 112/SHAD

Thousands of servicemembers who were test subjects for chemical and biological agents (see Exposures and Testing) spent decades without records or notice. DoD did not begin declassifying Project 112/SHAD records and sharing information about participants and exposures with VA until 2000, at VA's request. For the Edgewood chemical tests, it took a lawsuit: in Vietnam Veterans of America v. CIA, the Ninth Circuit held in 2015 that an Army regulation requires the Army to notify former test subjects of newly acquired information that may affect their health, and to provide medical care for injuries caused by the tests.

Sources

  1. GAO-10-1013T, Defense Health Care: Personality Disorder Separation Requirements (2010): gao.gov; GAO-09-31: gao.gov
  2. Vietnam Veterans of America / Yale Law School Veterans Legal Services Clinic, "Casting Troops Aside" (2012): vva.org PDF
  3. GAO-17-260, DOD Health: Actions Needed to Ensure PTSD and TBI Are Considered in Misconduct Separations (2017): gao.gov
  4. Hagel memo (Sept. 3, 2014): PDF (Yale Law School copy); Kurta memo (Aug. 25, 2017): army.mil PDF · alternate copy
  5. Agent Orange Act of 1991, P.L. 102-4: govinfo.gov PDF
  6. Procopio v. Wilkie, No. 17-1821 (Fed. Cir. Jan. 29, 2019): cafc.uscourts.gov PDF; Blue Water Navy Vietnam Veterans Act of 2019, P.L. 116-23: govinfo.gov; VA Blue Water Navy FAQ: va.gov PDF
  7. VA Research Advisory Committee on Gulf War Veterans' Illnesses, "Gulf War Illness and the Health of Gulf War Veterans" (2008): va.gov PDF
  8. DoD GulfLINK, Khamisiyah, "DoD Announced Possible Chemical Weapons at Khamisiyah: January–September 1996": gulflink.osd.mil
  9. GAO-17-511, Gulf War Illness: Improvements Needed for VA (2017): gao.gov
  10. Stars and Stripes, "VA has denied about 78% of disability claims from burn pits" (Sept. 23, 2020): stripes.com
  11. Honoring our PACT Act of 2022, P.L. 117-168 (incl. Sec. 804, Camp Lejeune Justice Act): congress.gov
  12. VA, Camp Lejeune water contamination: va.gov; ATSDR Camp Lejeune drinking water public health assessment fact sheet: stacks.cdc.gov
  13. VA, "Are you an atomic Veteran?" brochure: publichealth.va.gov PDF
  14. VA, About Project 112 and Project SHAD: publichealth.va.gov
  15. Vietnam Veterans of America v. CIA, No. 13-17430 (9th Cir. 2015; amended 2016): 2015 opinion · 2016 amended opinion

3. Exposures and Testing

Shorter summaries of the documented cases where servicemembers were used as test subjects or exposed to hazards the government knew about or was slow to acknowledge.

WWII mustard gas and Lewisite tests

About 60,000 U.S. servicemen took part in WWII chemical-defense testing with mustard gas and Lewisite; roughly 4,000 had full-body exposures in gas chambers or field tests, according to the Institute of Medicine's 1993 report Veterans at Risk. A 2015 NPR investigation found some tests grouped subjects by race, including Black, Japanese American, and Puerto Rican soldiers.

Sources: National Academies, Veterans at Risk · NPR (2015) · VA: Mustard gas

Atomic veterans

Roughly 400,000 U.S. servicemembers were present at atmospheric nuclear tests or post-test cleanup activities between 1946 and 1962. They were barred by secrecy agreements from describing that service until the 1996 repeal.

Sources: Atomic Heritage Foundation · VA atomic veteran brochure

Edgewood Arsenal / Aberdeen experiments

Between 1950 and 1975, about 6,720 servicemembers took part in experiments involving exposures to 254 different chemicals at U.S. Army laboratories at Edgewood Arsenal, Maryland, according to VA. A federal appeals court later held the Army owes those test subjects notice of new health information and medical care for test-related injuries.

Sources: VA War Related Illness and Injury Study Center · 9th Cir. (2015)

Project 112 / Project SHAD

From 1962 to 1973, DoD ran chemical and biological warfare tests on land and at sea. About 6,000 servicemembers took part, according to VA. DoD began declassifying the records and sharing information with VA only in 2000, at VA's request; GAO later reported DoD had identified 5,842 servicemembers as potentially exposed.

Sources: VA: Project 112/SHAD · GAO-08-366 · Health.mil

Agent Orange

Herbicide exposure in Vietnam and elsewhere. Presumptive coverage came with the Agent Orange Act of 1991; sailors offshore waited until the Blue Water Navy Act of 2019 (see Denial of Care).

Sources: P.L. 102-4 · P.L. 116-23

Camp Lejeune

Contaminated drinking water from the 1950s until 1985; as many as one million people might have been exposed, per ATSDR. Benefits and legal claims cover service or residence from August 1953 through 1987. Legal recourse came with the 2022 Camp Lejeune Justice Act.

Sources: VA · ATSDR fact sheet

Gulf War

At least one in four of 697,000 Gulf War veterans had Gulf War illness, per VA's 2008 advisory committee report. DoD acknowledged in 1996 that U.S. troops had destroyed chemical weapons at Khamisiyah in 1991.

Sources: RAC-GWVI (2008) · GulfLINK

Palomares (1966) and Enewetak (1977–1980)

Troops responded to the 1966 crash of a nuclear-armed B-52 near Palomares, Spain, and later cleaned up nuclear test contamination at Enewetak Atoll. The PACT Act added onsite Palomares response (January 17, 1966–March 31, 1967) and Enewetak cleanup (January 1, 1977–December 31, 1980) as radiation-risk activities, which VA implemented in a 2023 rule.

Sources: Federal Register (2023) · DTRA Enewetak dose assessment

Karshi-Khanabad (K2), Uzbekistan

U.S. forces occupied K2 from 2001 to 2005. VA lists exposures there including jet fuel, asbestos, depleted uranium, and chemical agents. Uzbekistan is a covered country under the 2022 PACT Act, and in 2024 VA began an expedited process toward additional K2-specific presumptions.

Sources: VA: K2 · VA K2 briefing · VA News

Burn pits

Open-air burning of waste on bases in Iraq, Afghanistan, and elsewhere. About 78% of related claims were denied from 2007 to 2020 before the PACT Act created presumptions in 2022.

Sources: Stars and Stripes · P.L. 117-168

PFAS ("forever chemicals")

As of June 30, 2026, DoD had determined that 727 installations and related sites required assessment for PFAS use or release, much of it tied to firefighting foam. DoD reports PFOS and PFOA above 70 parts per trillion in off-base drinking water from DoD activities at 55 installations.

Read the full PFAS page →

Sources: DoD PFAS cleanup data · GAO-25-107401

Anthrax vaccine mandate

A federal court issued a preliminary injunction on December 22, 2003, and on October 27, 2004, permanently enjoined the involuntary anthrax vaccination program, ruling it "illegal absent informed consent or a Presidential waiver" because the vaccine had not been properly approved for its intended use.

Sources: Doe v. Rumsfeld, 341 F. Supp. 2d 1 (D.D.C. 2004) · OpenJurist

Mefloquine (Lariam)

On July 29, 2013, FDA added a boxed warning, its most serious, to the antimalarial mefloquine, warning that neurologic side effects can persist for months to years or become permanent, and that psychiatric side effects can occur.

Sources: FDA Drug Safety Communication · National Academies (2020)

3M Combat Arms earplugs

Aearo and later 3M made Combat Arms Version 2 earplugs from 1999 to 2015. On August 29, 2023, 3M agreed to pay $6.01 billion between 2023 and 2029 to resolve servicemembers' claims, without admitting liability.

Sources: 3M announcement · 3M SEC 8-K · Master Settlement Agreement

4. Timeline

WWII
About 60,000 servicemen take part in WWII mustard gas and Lewisite testing.
1946–1962
Roughly 400,000 servicemembers present at atmospheric nuclear tests or cleanup, under secrecy.
1950s–1985
Contaminated drinking water at Camp Lejeune (claims window: Aug 1953–Dec 1987).
1950–1975
About 6,720 servicemembers in Edgewood chemical experiments (254 chemicals).
1962–1973
Project 112/SHAD chemical and biological tests; about 6,000 servicemembers.
1966
Palomares, Spain, nuclear weapons accident response.
1977–1980
Enewetak Atoll cleanup.
Feb 6, 1991
Agent Orange Act of 1991 signed.
1991 / 1996
Khamisiyah chemical weapons demolition; DoD acknowledges it in 1996.
1996
Repeal of the Nuclear Radiation and Secrecy Agreements laws frees atomic veterans to describe their service.
2000
DoD begins declassifying Project 112/SHAD records for VA.
2001–2005
U.S. forces at K2, Uzbekistan.
FY2001–FY2010
More than 31,000 "personality disorder" discharges (VVA count).
Dec 2003 / Oct 2004
Court enjoins the involuntary anthrax vaccine program.
2008
VA advisory committee: at least 1 in 4 Gulf War veterans has Gulf War illness.
Jul 29, 2013
FDA boxed warning on mefloquine.
Feb 2014
Phoenix whistleblower alleges veterans died waiting for care.
May 28, 2014
OIG interim report: about 1,700 Phoenix veterans on no official wait list.
May 30, 2014
Secretary Shinseki resigns.
Jun 9, 2014
VA Nationwide Access Audit: 57,436 waiting; 63,869 never seen; 13% of schedulers told to alter dates.
Aug 7, 2014
Veterans Access, Choice, and Accountability Act signed.
Aug 26, 2014
OIG final Phoenix report; investigations at 93 sites.
Sept 3, 2014
Hagel memo: liberal consideration for PTSD-related discharge upgrades.
2015
Ninth Circuit: Army owes Edgewood test subjects notice and care.
2016
OIG publishes wait-time investigation summaries (77 investigations).
2017
GAO: 13,283 troops with PTSD/TBI or related diagnoses got OTH discharges (FY2011–2015). Kurta memo expands liberal consideration.
Jan 29, 2019
Procopio v. Wilkie decided.
Jun 25, 2019
Blue Water Navy Vietnam Veterans Act signed.
Aug 10, 2022
PACT Act signed, including the Camp Lejeune Justice Act.
Aug 29, 2023
3M agrees to $6.01 billion Combat Arms earplug settlement.

5. Where to Get Help Today

In crisis right now

Veterans Crisis Line: dial 988, then press 1, text 838255, or chat online at veteranscrisisline.net. You don't have to be enrolled in VA benefits or health care.

Discharge upgrades

Step-by-step guidance on which board to apply to (Discharge Review Board or Board for Correction of Military/Naval Records): va.gov/discharge-upgrade-instructions. Liberal consideration applies to PTSD, TBI, sexual assault, and sexual harassment.

Report wait-time manipulation or wrongdoing

VA Office of Inspector General hotline: vaoig.gov/hotline

Related: Diego Garcia drinking water

A companion packet on missing water records at NSF Diego Garcia and other overseas installations: limitedenergy.net/diego-garcia

About this page

This is a record, not a theory. It includes only what government reports, laws, court rulings, the National Academies, and major news organizations have documented, and it notes where official investigators drew limits (for example, the OIG's statement that it could not conclusively tie the Phoenix deaths to delays). If you find an error, please report it so it can be corrected.

Last reviewed October 8, 2026.