Army veteran Rafael Rivera didn't always think much about his future or his health, especially while on patrol in southern Afghanistan, smoking cigarettes when he was deployed there for 13 months starting in May 2010.
"Having made your last will and testament three times by the time you're 20, you don't have thinking, long-term," Rivera said.
When he came home from Afghanistan, Rivera focused on his health, quit smoking and changed his diet. He also started teaching yoga. Despite these efforts, he said he never started to feel healthy.
"A year went by without having smoked a cigarette. And like, 'I'm still a coughing up this (expletive),'" said Rivera, who was a mechanic and driver while in Afghanistan. "Like, wait a minute, two years goes by and I'm still struggling?"
Like millions of troops, Rivera was exposed to open pits of trash burned with jet fuel, which is a known carcinogen. Now he gets winded from seemingly simple exercise; his doctors tell him he's got constrictive bronchiolitis.
The United States Department of Veterans Affairs routinely denies the vast majority of claims for a long list of cancers and other maladies linked to toxic exposure. It took 50 years for the VA to accept all the conditions caused by Agent Orange in Vietnam, and history is repeating itself, pulmonologist Dr. Anthony Szema said.
"That's putting all the soldiers who actually have constrictive bronchiolitis in a quagmire - that they're never going to get diagnosed and they're never going to get treated," Szema said.
Szema, who directs the International Center of Excellence in Deployment Health and Medical Geosciences, says he is glad the Biden administration has been adding new illnesses to the VA's list of diagnoses connected to burn pits. Biden added several more in his first State of the Union address this month but at this piecemeal rate, Szema said many vets will die of cancer before the VA accepts their claims.
"Soldiers have a ticking time bomb that it will get progressively worse over time," he said.
The House of Representatives passed a bill this month to change that; the Honoring our PACT Act would make the VA accept 23 illnesses as "presumptive," meaning any vet who was exposed to burn pits and other known toxins would automatically get benefits and treatment for those illnesses.
Thirty-four Republicans joined all the House Democrats to pass the bill, but Rep. Mike Bost, R-Ill., the ranking member of the House Committee on Veterans, opposed the bill, calling it too broad and too expensive.
"I'm a veteran from a military family. My son and grandson currently serve," Bost said. "I know what war costs. I also know that veterans pay taxes, too."
Bost has also pointed to strong Republican opposition in the closely divided Senate, where a much more limited bill has bipartisan support.
Speaking in Fort Worth, Texas, on Tuesday, President Biden endorsed the PACT act and the Senate measure, which veterans advocates fear would use up their momentum on the burn pits issue without fully addressing the 3.5 million veterans who were exposed to them since the first Gulf War.
A long wait
While the debate continues, young healthy veterans are coming down with rare cancers.
"I was diagnosed with stage four breast cancer in January of 2018," said Kate Hendricks Thomas. She was only 38, but after serving as a Marine in Iraq, she said her VA doctor urged her to get a mammogram.
"The cancer had spread all throughout my body, which means it had been developing for a very long time," Thomas said. "So I had skeletal metastases from my skull to my toes. My radiologist said it looked like I had been dipped in something."
Thomas began planning for a short future. She recently wound down her career as a professor of public health at Charleston Southern University.
"I loved what I did," she said. "I really grieved the loss of that career. I worked so hard to get there."
Thomas said she fought with the VA for three years to get them to recognize her cancer as service-related. That struggle took precious time away from enjoying life with her husband and young son, time said she'll never get back.
"I know I don't have that much longer," she said. "I accept that reality, but I'm just trying to preserve quality of life so that I can parent and that I can enjoy people as long as possible."
She said the VA's service connection decision means her family will get a small VA pension when she dies, but her hope is that the laws will change so other veterans might get VA care and benefits sooner than she did.