"The crisis is not going away," said Paul Sullivan, the executive director of Veterans for Common Sense, a nonpartisan advocacy group. "Everyone thinks that with bringing the troops back from the war, things (at the VA) are going to get better. They're not."
The VA has treated 400,000 Iraq and Afghanistan veterans since 2001, but it's often underestimated how many of those former troops would need its help.
What impact the pullout from Iraq will have is unclear. President Barack Obama wants to withdraw around 100,000 of the 142,000 U.S. troops there by August of next year.
"It is something we need to be watching," said Democratic Sen. Patty Murray of Washington state, a leading veterans' advocate in Congress. "We don't yet know the percentage of those who will be coming home, but we do know there will be some. There is a combination of factors that are sending a big, yellow, blinking caution light."
Since 2001, the twin wars have stretched the VA's capacity as it's been called on to provide long-term treatment for the kinds of devastating physical wounds that have become signatures of modern combat, as well as a host of unseen, but no less searing, mental health traumas.
Veterans' advocates said they were concerned about the agency's ability to handle more patients since its health system already was operating at full tilt.
"We are really getting slammed left and right," said Kathy Lee, a service officer for the Veterans of Foreign Wars at the Kansas City, Mo., VA Medical Center.
Lee is a former Army nurse in Vietnam who helps veterans access the VA system.
"Our parking lot is so full, we're doing overflow at the church across the street," she said. "It just makes me sick to think about what we're going to be doing this time next year. We're all behind as it is."
Dr. James Sanders, the hospital chief of staff, said, "I think we're all in the same situation of not knowing what to expect."
Sanders said that while 400,000 Iraq and Afghanistan veterans had gone to the VA, "the numbers are significantly less for any one facility than you might think."
Repeated attempts to seek a comment from VA officials about the impact of the troop pullout and other developments on the agency were unsuccessful.
According to interviews with veterans' advocates, as well as a little-publicized report earlier this year from Veterans for Common Sense, those developments include:
-A lack of jobs for returning veterans, which could leave many without health insurance and dependent on the VA. Even before the economy sank, a 2007 VA survey of troops mostly discharged in 2005 found that their unemployment rate was more than 18 percent.
-Free VA health care for five years for Iraq and Afghanistan veterans, courtesy of Congress.
-Repeat deployments, including the posting of more troops to Afghanistan, which will increase the chance of more combat injuries.
-Recognition that mental health problems such as post-traumatic stress disorder affect a lot of veterans, which could erase the stigma and make them seek VA help.
The VA has treated nearly 180,000 Iraq and Afghanistan veterans for at least one mental health condition, according to its most recent health analysis. That's 45 percent of all the veterans of those conflicts whom the VA has treated.
The department operates more than 1,000 hospitals, clinics and Vet Centers. It has 5.5 million patients, including an ever-increasing stream of men and women who have served in the Middle East and southwest Asia, as well as veterans of past conflicts going back to World War II.
"Right now we're being flooded with Vietnam vets and Iraqi vets," Lee said, "but I've got a 90-year-old World War II vet, the Battle of the Bulge. He wants a hearing aid. He just wants to hear them call out his number at bingo."
The veterans community has unanimously applauded Obama's plan to increase VA funding by $15 billion, but few doubt that meeting the growing demand will be hard.
"The VA is seeing a flood of new veterans who are entering the job market during the worst economic crisis since the Great Depression," said Vanessa Williamson, the policy director for Iraq and Afghanistan Veterans of America. "The American dream of buying a home is being put on hold. Unemployment rates are sky high, and for those who can find a job, many aren't getting health care coverage through work. All of these things combine to put real stresses on the VA."
In addition, with recent veterans comes a troubling array of problems that the VA tries to handle: rising levels of domestic violence, drug abuse and suicide.
About 1,000 veterans under VA care attempt suicide each month, according to internal e-mails. Several advocacy groups, including Veterans for Common Sense, obtained the e-mails as part of a 2007 lawsuit against the agency.
"It isn't just about getting somebody in for that first visit," said Joy Ilem, the assistant national legislative director of Disabled American Veterans. "What is needed is somebody willing to admit they have a problem. That takes a number of appointments, not just one. That, I think, will be the real challenge for VA. Are they going to be able to handle the volume in a timely manner?"
VA inspector general reports show that veterans can wait a month or more to see doctors. Meanwhile, the agency takes six months to process disability claims, and it has a backlog of more than 700,000. That's a third more than it was five years ago, according to VA records.
"They can barely handle the patient load and claim load now," Sullivan said. "The crisis may become catastrophic, especially for those veterans who can't get into the system."