House lawmakers on Thursday passed sweeping military toxic exposure legislation which could grant new disability benefits for 23 illnesses linked to burn pit smoke and benefit as many as one in every five veterans living in America today.

However, whether the bill can become law — either in its current form or massively scaled down — remains unclear. The measure faced significant opposition from Republican lawmakers worried about its cost and scope, and Senate lawmakers have thus far backed smaller measures on the issue.

Thursday’s 256-174 vote came just two days after President Joe Biden stood in the House chamber to deliver his State of the Union speech, where he called for Congress to “pass a law to make sure veterans devastated by toxic exposures in Iraq and Afghanistan finally get the benefits and comprehensive health care they deserve.”

The Promise to Address Comprehensive Toxics (PACT) Act would establish a presumption of service connection for 23 respiratory illnesses and cancers related to the smoke from burn pits, used extensively in those war zones to dispose of various types of waste, many of them toxic.

The bill also provides for new benefits for veterans who faced radiation exposure during deployments throughout the Cold War, adds hypertension and monoclonal gammopathy to the list of illnesses linked to Agent Orange exposure in the Vietnam War, and requires new medical exams for all veterans with toxic exposure claims.

All together, the provisions could affect more than 3.5 million veterans, a dramatic expansion of benefits that officials estimate could cost more than $207 billion over the next decade.

But bill sponsor Rep. Mark Takano, D-Calif. and chairman of the House Veterans’ Affairs Committee, said the price tag should not stop lawmakers from giving veterans the benefits they deserve.

“For far too long, Congress and the Department of Veterans Affairs have been slow to accept responsibility for [veterans’] care, citing high costs or lack of absolute scientific proof of connection to service,” he said in floor debate on the measure on Wednesday.

“The result is a disability claims process that is cumbersome and places the burden of proof of toxic exposure on veterans themselves … Our veterans are fighting their own government to grant them the care they deserve.”

The measure has been pending in the chamber for nearly a year. A day before the House vote, advocates held a rally outside the Capitol to urge swift passage of the legislation.

Some of these veteran service organizations, they’ve been out here working on this since Vietnam,” said comedian Jon Stewart, who has been lobbying on the burn pits issue for several years. “The learning curve of this country on how we treat our veterans when they come home from war is so painfully slow. The pace is unacceptable.

“But today you can feel a difference. Hope.”

Katie Purswell, an Army veteran and director of Veterans Affairs and Rehabilitation at The American Legion, said her deployments to Iraq and Afghanistan left her with permanent damage because of the burn pit smoke that was frequently present.

“I just can’t take a deep breath anymore,” she said. “I struggle to think of a single person that I deployed with that was not exposed to some form of toxin.

“While it was our decision to raise our hands and to fight our nation’s wars, what we didn’t know was that our long-lasting health issues might not even begin to show while we were in service. The extent of damage done to us will not be known for decades.”

Past estimates from the department have put the number of individuals exposed to toxic smoke from burn pits during the last 20 years at more than 3.5 million. But only a small fraction of that group has received disability benefits for long-term health issues, and typically only after years of paperwork and arguments with Department of Veteran Affairs claims staff.

Last August, VA for the first time granted presumptive benefit status to veterans of the Iraq and Afghanistan wars for a limited number of respiratory illnesses. Department officials said that since then, they have granted more than 16,500 new claims related to burn pit injuries, totaling $36 million in retroactive benefits.

But advocacy groups say that doesn’t go far enough, given the rising number of rare cancers and unusual respiratory illnesses being found in younger veterans.

Only 34 Republican lawmakers joined with Democrats in passing the measure. All of the 174 votes against the bill were Republicans, who pushed before the vote to substitute a slimmed-down plan which would extend health care coverage for veterans for 10 years after they leave military service.

“If the PACT Act is enacted, VA estimates the disability claims backlog could reach over 1.5 million claims by the end of fiscal year 2023,” said Rep. Mariannette Miller-Meeks, R-Iowa and an Air Force veteran. “That’s more than double the height of the backlog in 2013.

“If veterans were waiting years for their benefits nine years ago, imagine how long they would have to wait today for a backlog that is more than two times the size it was then. That is completely unreasonable.”

VA and White House officials have both backed congressional action on the issue but declined to support any specific measure.

Last month, Senate officials unanimously passed legislation extending veterans’ health care coverage to 10 years post-service in a move that Senate Veterans’ Affairs Committee Chairman Jon Tester, D-Mont., insisted was only the first step in addressing the issue.

Ahead of Thursday’s House vote, he said he supports the PACT Act but “the House has the ability to get this all done in one fell swoop, and I don’t.”

On Wednesday, House Speaker Nancy Pelosi said she will work with Senate leadership personally to find a compromise on the issue that delivers meaningful help to as many veterans as possible.

“I do think that when our colleagues on the other side of the building understand the differences between the two pieces of legislation, we will find common ground,” she said. “But if we’re not willing to pay the price of war, then we shouldn’t go to war in the first place.”

Leo covers Congress, Veterans Affairs and the White House for Military Times. He has covered Washington, D.C. since 2004, focusing on military personnel and veterans policies. His work has earned numerous honors, including a 2009 Polk award, a 2010 National Headliner Award, the IAVA Leadership in Journalism award and the VFW News Media award.

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