[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
VA CAREGIVER SUPPORT PROGRAM: CORRECTING COURSE FOR VETERAN CAREGIVERS
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
TUESDAY, FEBRUARY 6, 2018
__________
Serial No. 115-47
__________
Printed for the use of the Committee on Veterans' Affairs
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Available via the World Wide Web: http://www.govinfo.gov
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COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BRAD R. WENSTRUP, Ohio JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida KILILI SABLAN, Northern Mariana
JODEY ARRINGTON, Texas Islands
JOHN RUTHERFORD, Florida ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
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C O N T E N T S
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Tuesday, February 6, 2018
Page
VA Caregiver Support Program: Correcting Course For Veteran
Caregivers..................................................... 1
OPENING STATEMENTS
Honorable David P. Roe, Chairman................................. 1
Honorable Julia Brownley, Member................................. 2
WITNESSES
The Honorable David Shulkin M.D., Secretary, U.S. Department of
Veterans Affairs............................................... 4
Prepared Statement........................................... 39
Accompanied by:
Margaret (Meg) Kabat LCSW-C, CCM, Acting Chief Consultant,
Care Management, Chaplain and Social Work Service,
Veterans Health Administration, U.S. Department of
Veterans Affairs
Richard M. Allman M.D., Chief Consultant, Geriatrics and
Extended Care Service, Veterans Health Administration,
U.S. Department of Veterans Affairs
Adrian Atizado, Deputy National Legislative Director, Disabled
American Veterans.............................................. 26
Prepared Statement........................................... 41
Sarah Dean, Associate Legislative Director, Paralyzed Veterans of
America........................................................ 27
Prepared Statement........................................... 48
Steven Schwab, Executive Director, The Elizabeth Dole Foundation. 29
Prepared Statement........................................... 51
STATEMENTS FOR THE RECORD
The American Legion.............................................. 54
Veterans of Foreign Wars of the United States.................... 57
Wounded Warrior Project.......................................... 59
RAND Corporation................................................. 63
GPO Federal Register Insert...................................... 69
HVAC Letter to Office of Regulation Policy & Management.......... 70
QUESTIONS FOR THE RECORD
HVAC to Shulkin.................................................. 71
VA Response...................................................... 72
VA CAREGIVER SUPPORT PROGRAM: CORRECTING COURSE FOR VETERAN CAREGIVERS
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Tuesday, February 6, 2018
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Committee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. David P. Roe
[Chairman of the Committee] presiding.
Present: Representatives Roe, Bilirakis, Coffman, Wenstrup,
Poliquin, Rutherford, Higgins, Bergman, Takano, Brownley,
Kuster, O'Rourke, Rice, Sablan, Esty.
OPENING STATEMENT OF DAVID P. ROE, CHAIRMAN
The Chairman. Good morning. The Committee will come to
order.
Welcome and thank all of you all for joining us for today's
Full Committee hearing on the Department of Veterans Affairs
Family Caregiver Program.
The Family Caregiver Program was created by Congress in
2010 to support severely wounded post-9/11 veterans and their
caregivers. Approximately 4,000 caregivers were expected to be
approved for the program at the time. VA ended up with more
than 22,000 approved caregivers; that is a 550-percent increase
over what was expected.
Needless to say, significantly higher than expected demand
for the program has created setbacks. There has been
miscommunication, confusion, and frustration from veterans,
caregivers, and VA employees alike concerning practically every
aspect of this program, from eligible to determinations, to
clinical appeals, revocations, and more. To the Department's
credit, they are well aware of those issues and have taken
steps in the last year to address them.
I am particularly glad that, following a 6-year wait, a
formal directive was published last June containing guidance on
how the program should be administered. I applaud the Secretary
and Ms. Kabat at the National Caregiver Program lead for the
actions they have taken, and I am fully supportive of their
ongoing efforts to include the request for information that was
issued in early January to solicit public feedback on how to
modify the program to better serve veterans and their
caregivers.
That said, serious issues still remain to be resolved,
including, as seems to be in every VA program, long-standing,
critically important IT issues. I support expanding the Family
Caregiver Program to pre-9/11 veterans, but I believe that
before doing so we must ensure that the program is working as
intended.
I have had the opportunity over the years to get to know
caregivers who have provided life-saving care on a daily basis
to the veterans in their lives, and I have been a caregiver for
my elderly parent in the past and so I have some understanding
of what this involves. And my heart goes out to them for the
time, health, money, and personal aspirations that they have
sacrificed to be there for their loved ones. The selfless
devotion that it takes to be a caregiver knows no age or era,
and what caregivers of post-9/11 veterans have been
experiencing over the last 17 years is old hat to what the
caregivers of pre-9/11 veterans have been experiencing for, in
some cases, decades.
I am a Vietnam-era veteran myself and I am well aware that
I and my fellow brothers and sisters in arms are not getting
any younger, neither are our caregivers. However, I share this
Administration's concern that the significant expansion of the
Family Caregiver Program cannot be discussed or supported
without an honest conversation about finding the right balance
between clinical appropriateness and cost.
I also share the Obama Administration's concern that
expansion of the Family Caregiver Program under current budget
framework would compromise resources needed to meet VA's core
mission of providing high-quality care to our Nation's
veterans.
Those are the very high stakes and they should give us all
pause. Accordingly, I feel strongly that any legislation to
improve and expand the Family Caregiver Program should be
developed, proceed through regular order, and passed on its own
merits. Today's hearing is my commitment to Members and
stakeholders that we will have that debate. No veteran and no
caregiver from any generation is well served by having access
in name only to a program that has the deficits that this one
does and as ill-prepared as this one is to accept a sudden
influx of new beneficiaries with complex, widely differing
care-giving needs from those veterans that the program is
currently serving.
I hope that today's hearing will shed light on the way
ahead, and I hope that those in this room will be able to work
together to make sure that this program is working well and
then, finally, serving all.
The Chairman. I now yield to Ranking Member Brownley for
any opening statements that she may have.
OPENING STATEMENT OF JULIA BROWNLEY, MEMBER
Ms. Brownley. Thank you, Mr. Chairman, and thank you for
accepting I think many requests from our colleagues and our
veterans service organizations and veterans nationwide to hold
this hearing to discuss the improvement and the potential
expansion of the VA Caregiver Program.
In the early 2000s, our Nation saw a wave of young veterans
returning home from Iraq and Afghanistan, many who were
severely wounded. So, in 2010, Congress passed the Veterans
Omnibus Health Services Act and created the Caregiver Program.
We all know the Caregiver Program's mission is critical to
the care of our veterans, but the program has experienced its
share of issues. We have seen some veterans and caregivers be
mistakenly dismissed from the program, we have heard stories of
staff misconduct and veteran mistreatment. I think everyone in
this room can agree that the Caregiver Program has its flaws,
but it is not an excuse to abort the mission, to give up on
getting it right, or to abandon the veterans whose welfare
depends on the Caregiver Program.
When we take a step back, I think it is easy to see that
whether it is a lack of staff, lack of IT, or lack of
direction, each of these issues ties back either directly or
indirectly to a lack of resources. Yet instead of requesting
adequate funding in the Administration's budget request, the
Administration assures us that this year is the year that VA
will get it right. However, our veterans have yet to see the
Caregiver Program they need.
Late last year, President Trump said, ``We will not rest
until all of American's great veterans can receive the care
they so richly deserve.'' But in a memo sent to our Senate
colleagues by the White House, the Administration explicitly
states, ``The Administration cannot support a costly expansion
of the Caregiver Program without further engagement with
Congress on fiscal constraints.''
Mr. Secretary, I would like to give credit where credit is
due. When I learned of the VA's request for information
regarding potential improvements to the Caregiver Program, I
was pleased VA had engaged veterans and caregivers in this
process. I am concerned, however, that the VA may attempt to
justify cuts or changes to the program at the expense of our
most vulnerable veterans rather than working to improve and
expand the program. I ask you to review our concerns in full,
which have been submitted as a comment by the minority side of
the Committee.
And I would ask, Mr. Chairman, if we could add that to the
record.
The Chairman. Without objection.
Ms. Brownley. Thank you.
So, today I am looking forward to taking a close look at
this program, what is working, what is not, and having that
important discussion.
Ultimately, I am confident that the data will show us that
the VA and the taxpayers will save money in the long run by
expanding the Caregiver Program. We will do that by spending
the money VA already spends on long-term care more wisely. Most
importantly, expanding the Caregiver Program would allow
veterans of all eras to make the choice that works best for
their well-being and for their family's well-being.
As PVA says so eloquently in their testimony, ``What is a
more fundamental element of veterans' choice than the choice to
receive quality care at home from the people they trust the
most?''
One such veteran family I would like to recognize here
today is Kimberly Cole and her husband, Scott, who depend on
the Caregiver Program. After facing inconsistencies and
roadblocks with the program, and the difficulty of recognizing
mental health trauma, Ms. Cole has come here to offer her
perspective. She has submitted a statement for the record
outlining her suggestions for improving the Caregiver Program
that I encourage everyone to read, and I thank her for her
work.
I would also like to thank each of the almost 300 veterans
and caregivers that engaged in the VA's request for information
with the intent to improve the program.
I look forward to the Secretary's comments, as well as the
comments of the veterans service organizations, and I hopeful
today's discussion will lead to bipartisan support and to the
expansion of the program, so that it may better serve veterans
of all eras. This is the right and just thing to do, and we can
do better.
Before I close, Mr. Chairman, I just wanted to make a
statement that Mr. Walz can't be here today, that is why I am
sitting in this seat, but he intends to submit questions for
the record.
So, with that, I yield back, Mr. Chairman.
The Chairman. I thank the gentlelady for yielding.
And I am honored, we are honored today to be joined by our
first panel by the Honorable Dr. David Shulkin, Secretary of
the Department of Veterans Affairs.
Secretary, thank you for being here and thank you for the
incredible job you are doing for our Nation's heroes.
The Secretary is accompanied by Margaret Kabat, the Acting
Chief Consultant for Care Management, Chaplain and Social Work
Service; and Dr. Richard M. Allman, the Chief Consultant for
the Geriatrics and Extended Care Service.
Thank you all for being here and thank you for your service
to our veterans.
Mr. Secretary, you are now recognized for as much time as
you may consume.
STATEMENT OF THE HONORABLE DAVID SHULKIN M.D.
Secretary Shulkin. Okay. Thank you, Chairman Roe, and
Members of the Committee.
And I do want to recognize, Congresswoman Brownley, that
Congressman Walz is not able to be here, but he has been great
steward and champion on this issue.
I think that, you know, I also do want to recognize the
caregivers and the veterans who are with us here today. This is
a really important issue and it is one of the reasons why I
always say that we have the very best Committee in the House,
not only because of the leadership, but because we tend to
focus on the issues. And I think everybody here can agree, this
program is really important, it makes a difference in people's
lives, and we all agree that we want to get this right and that
is what we are discussing. And the way that you all work
together in a bipartisan way makes me proud and really honored
to work with all of you. So, thank you for that.
The Caregiver Program, as Congresswoman Brownley said, it
was passed in 2010. We began implementing it within 90 days in
2011. And what it provided was the ability for us to support
caregivers and eligible veterans with training, benefits, and
services, and that is really what I am going to be talking
about here today.
Last year alone, we had more than 400 VA staff dedicated to
this program; about 350 of them are Caregiver Support
Coordinators. They work in all of our VA Medical Centers and
they support about 26,000 family caregivers today. There are
about 30,000 who have been served in this program since we
began working it in 2011.
The program includes a monthly stipends; access to health
care coverage, which is so important; mental health services,
again, critical; counseling, caregiver training, and respite
care.
I think it is important, though, that VA leads the country
in an unprecedented way in providing a program like this. And
in every program where you are leading the way, where there is
really no roadmap, we have to periodically review it and see if
we can improve it, eliminate the inconsistencies on how we
might be able to improve it, but also potentially expand it
going forward, so that we can make this valuable service
accessible to other veterans and their caregivers.
Last April, it became very clear to me, as both the
Chairman and Congresswoman Brownley have mentioned, that we had
inconsistencies in this program; that it wasn't working the way
that we thought it should, that there were rates of revocations
that were in the very, very high levels than other programs
that didn't have that, and that was really unacceptable. So,
after I was made aware of that, I made a decision last April to
pause the program in revocations. I did not want caregivers
being taken away their benefits and their needed services until
we could make sure that this program was working right.
That pause took about 3 months and during that time we
conducted listening sessions with our veterans and their
caregivers, and a number of internal and external groups, some
of whom that you are going to get to hear from today. And as a
result of that strategic pause, we made a whole bunch of
decisions that we think improved the program: we looked at the
appeals process, we put up a new Web site, we changed our
procedures; most importantly, we trained all of our staff
across the country to have a consistent way of looking at this
program. And, as a result, our revocations dropped from 237 a
month before the pause to 192 a month after the pause, or a 20-
percent decrease.
Last month, as the Congresswoman said, in order for us to
even get more input into how we can make this program work
better, and these are really additional issues for VA to take a
look at, not for Congress, we published a notice in the Federal
Register where we had eight specific questions that we wanted
to get feedback from people that this program matters to, and
that comment period ended last night. So we are now going to
start reviewing all those comments and make sure that we really
understand the feedback that we are getting on how to improve
the program. So this is still a work in progress.
What we are trying to do is to still further improve the
consistency in the Caregiver Program and see how we can better
support family caregivers going forward.
When we launched the program 7 years ago now, it was the
first of its kind that it was incredibly innovative, and we
have to continue to make this an innovative program that works.
And, in that regard, I believe we must expand caregiver support
to all eligible veterans who need it. So, let me say that
again, I am in favor of expanding this benefit to those that
are pre-9/11. So, regardless of any age, regardless of when
they served, this is an important program, but we have to do it
in a way that is very thoughtful. We have to do it from what we
have learned is working in our current program and how we can
benefit those that need it most.
So this is really about our fulfilling our commitment to
those who have served and being good stewards to taxpayer
resources.
Last year, we spent about $500 million on the post-9/11
Caregiver Program. By expanding it to the pre-9/11 veterans, I
think we can have a much bigger impact. We can do this in a
cost-effective way and help those by focusing on those who need
the benefit the most. And I am not in favor of revoking this
from those who currently have the benefits, I think that would
be a mistake, this is about learning how we can do this better
going forward.
We know that, as veterans age, the cost of long-term care
and those with serious injuries are going to increase
dramatically. And so if you take a look at the screen, we have
prepared a chart. The blue line at the top is what we project
given our current spend, our current program, we are going to
be spending in future years on long-term care services. This is
mostly institutional care, think about it as nursing home care
and assisted care.
But if we do the Caregiver Program correctly and if we
figure out the best way to help those who want to remain in
their homes, we think that we can make a big difference in the
cost impact of this program on taxpayers, and we think that we
can improve the lives of veterans. So this is one of the
reasons why we think it is important to expand this program,
but do it in a thoughtful way.
We know that veterans who are able to stay in their homes
with caregiver support have better well-being, healing,
positive outcomes, both physical and mental. For example, if we
are able to change the eligibility requirement for veterans of
every generation who are at the highest risk, we think we can
expand caregiver support in a less costly and more cost-
effective way than simply expanding it using the exact same
criteria that we have now.
Let me just say that the caregivers that we have are
veterans' spouses, but they are also parents, brothers,
sisters, children of veterans, sometimes friends, neighbors,
and Members of the community, and they are people that know and
love their veterans. That is the primary reason why we think a
huge majority of veterans are better off in their homes with
caregivers than the alternative.
We have recently established a Caregiver Survivor Federal
Advisory Committee, which just had its first meeting last
October, and we are so fortunate that Senator Elizabeth Dole
has agreed to chair that. This is a really important advisory
committee. You all know how busy she is, so her agreeing to do
that was a big deal.
We have recruited lots of other distinguished Members who
are knowledgeable about this topic. Some of them are here with
us today.
We are also really excited that VA is going to be able to
share our expertise and what we have learned about caregivers
through the Caregiver RAISE Act, the Recognize, Assist,
Include, Support, and Engage Family Caregivers Act, that
President Trump just recently signed into law.
We know we have a lot more work to do and more decisions to
make about how we can support these selfless individuals, our
caregivers who devote their time and lives to caring for our
veterans. When compiled with all this Federal Register
information that we are just getting and input from our
caregiver advisory board, we hope we can work to provide advice
to make the Caregiver Program better and more efficient in the
future.
Mr. Chairman, that concludes my testimony today. We look
forward to any questions.
[The prepared statement of Secretary Shulkin appears in the
Appendix]
The Chairman. Thank you, Dr. Shulkin, for your testimony.
And I will now yield myself 5 minutes.
And we are going to stick real closely to the 5 minutes,
because we are going to have votes at 11:30 today. So we
certainly want to get through your testimony as quickly as we
can.
I want to begin by also stating what you said, that I
support the expansion of the program. What I would like to see
us do is not a Choice again, and we talked about this before we
came in. In the Choice program, we had six ways to get non-VA
care, and then we put the Choice program on top of it.
Right now, the VA has, the best I can understand this and I
spent a lot of time reading this in the last couple days, is
that VA does have support services, many services for pre-9/11
veterans, which include--and I am just looking at the request,
it is about almost--it is around $3 billion, and it is the
community nursing home, state home domiciliary, state home
nursing, VA community living centers, institutional
obligations, adult daycare, community residence care, home
hospice, home respite care, home telehealth, home-based primary
care, homemaker/home health aide, purchased skilled home care,
spinal cord injury and disability home care, state adult day
health care, VA adult day health care. Those are all programs
that now are available under you all's purview, am I correct,
for pre-9/11 veterans? And the thing that the Caregiver Program
would have it, correct me if I'm wrong, would be the stipend
and the health benefit, the CHAMPVA, am I correct? That is
really all we are talking about.
Secretary Shulkin. Yeah. Mr. Chairman, you have it exactly
right. VA provides an incredible array of services to help
support veterans, particularly the pre-9/11 veterans, it is
what makes VA unique. It is why when people talk about
privatization of VA, they don't understand, this isn't
available to outside, and so we are very proud of that.
What we are talking about now is adding that one piece that
has been missing for our pre-9/11 veterans and that is
caregiver support, because these caregivers are unbelievably
burdened and to provide them with what you are talking about,
both a small stipend, counseling support, if they need it,
training, education, a caregiver support telephone line, that
is what we are really talking about now.
The Chairman. Well, they have all of that except the
stipend and the CHAMPVA. Do you have any idea about what
numbers, because we missed it by 400 percent the last time that
we did this--
Secretary Shulkin. Yeah, yeah.
The Chairman [continued]. --in 2010, do you have any
numbers that might be relevant?
Secretary Shulkin. Yes. We think that, first of all, last
time, boy, did we miss it, but we were starting a program with
no experience, no one had ever done it before. Now we actually
have pretty good data and we have developed a model.
If we were to simply expand it and use the exact same
criteria that we do today for determining post-9/11 caregivers,
we think that in 10 years we would have about 188,000 pre-9/11
caregivers. Remember, today we have 26,000, so we would expand
that to 188,000 if we use the same criteria. If we used a
criteria that would be a little bit more discriminatory, in
other words, we used tiers, those that are in Tier 3 are our
most severely ill or injured veterans, we think that number
would be 40,000, 40,000 additional caregivers in the pre-9/11
group.
The Chairman. Well, it actually turned out that your
estimate on the Tier 3 was pretty close. It was about 5,000-
plus--
Secretary Shulkin. Yes.
The Chairman [continued]. --and you had estimated about
4,000.
A question on the slide that you had up there, and I think
I understand where you got your data now. You are assuming, the
assumption of the savings is that you will not have these folks
institutionalized. Could you explain to me--
Secretary Shulkin. Yes.
The Chairman [continued]. --how or why the VA's nursing
home is $400,000 per year? Where I live, it is about 75. Why is
it four times as much inside the VA as it is outside?
Secretary Shulkin. Well, the number that we used for that
model was about $104,000 a year and I think that that is on
average how much we are paying into our state nursing homes, I
think that is a better number. The 400,000 number--
The Chairman. Where did that come from?
Secretary Shulkin. I think this is the inability of VA to
separate out the overhead costs and all of the other costs
associated with the VA system. The number that we feel
comfortable using is 104,000.
And so what you see in the delta there is the cost of all
those wraparound services if we keep somebody in their home,
which is about $30,000 a year less expensive than putting them
into a nursing home.
The Chairman. And I am about done, so just to hang onto
this. But the question I have is, would we look at this whole
package, this plethora of programs that we have, is there a way
to consolidate those some, so that we can use those resources
in this Caregiver Program?
Secretary Shulkin. Yeah--
The Chairman. And, again, I am out of time. So I am going
to yield to Ms. Brownley.
Secretary Shulkin. Yes, if it is okay to answer,
absolutely. These are all a package of services. And we have
established this year what is called a moonshot and the
moonshot would be that we believe that no veteran should have
to ever leave their home because of one of these severe
illnesses or injuries if they don't want to, if they want to
remain in their home. And the way we would accomplish that by
setting that as our goal is through this whole wraparound
series of services to support somebody in their home, including
caregiver support, but not duplicating; there shouldn't be
duplication of those programs.
The Chairman. I yield now 5 minutes to Ms. Brownley.
Ms. Brownley. Thank you, Mr. Chairman. And I really do want
to associate myself with your comments that I believe, you
know, as we did in terms of community care, we had all these
different programs and then we laid Choice on top of it, we
shouldn't be doing the same thing, that there are resources.
The key, though, is that veterans pre or post have the choice.
And I think in most instances the veteran will choose in-home
care, because they are with the people that they trust and that
gives them the very best quality of life.
And, Mr. Secretary, I appreciate you making it very clear
in your statement that all veterans from every era, pre- and
post-9/11, should receive caregiver services, if they need it.
So I agree that it is inequitable the way we are approaching
this.
My concern is--and when you talk about the moonshot, my
concern is like when are we going to get there? Because I don't
want to study this to death. I think, you know, we are pretty
clear, despite some of the flaws in the program, that it is a
successful program, there is high veteran satisfaction with the
program. It is clear that there is a cost savings here.
And so I am interested in knowing when, and if you can give
us a timeline in terms of when we can rectify this inequity and
move forward with a program that we know serves our veterans--
Secretary Shulkin. Yes.
Ms. Brownley [continued]. --well and properly.
Secretary Shulkin. Yeah, I am going to try to do this very
short. As you know, when the Act passed in 2010, it required
the Secretary to come back in 2 years to give a recommendation
on when we could expand this to the pre-9/11. That was a
difficult challenge back then because of the cost of expanding
this program. I think we are seeing that same issue here.
And what we want to try to do, working with you and working
with the Senate, is to try to figure out, is there a way to
learn what we have experienced in the past to design this
program, so it really does what we want it to do and get on
with expanding it. The Senate has this included in their
version and I think that there is an opportunity for all of you
to have a discussion about that. We would like to participate
in that discussion to help design this program well.
I think the key point, if I had to boil it down to one
issue, Congresswoman, it is that every one of the programs the
Chairman mentioned, the home care, the respite, the aide and
attendance program, the homemaker program, all uses a clinical
criteria of three activities of daily living, the Caregiver
Program uses one activity of daily living.
So, if we could get some consistency on clinical criteria,
and reasonable people can discuss this. That is why we put it
in the Federal Register, we want to hear everybody's thoughts.
But if we could come up with consistency, we think we could
expand this program. It is the right thing to do, but let's do
it in a clinically appropriate way.
Ms. Brownley. So, consistency is the barrier in terms of
moving ahead on this, that is the only barrier--
Secretary Shulkin. I think it is--
Ms. Brownley [continued]. --from your perspective?
Secretary Shulkin [continued]. --yes.
Ms. Brownley. I would really like it if you could give us,
you know, a firmer timeline. So if that is what we need to do
to give that to you, fine, but if we give that to you, then
what do you see as the timeframe?
Secretary Shulkin. As soon as you guys pass a law on this,
giving us the authority to do it. We would like to see it with
clinically appropriate criteria to do it in the right way, but
this is really your decision; the Senate and the House have to
come to agreement on this.
Ms. Brownley. Okay. So in terms of, you know, moving
forward here in the short term, I think you have sort of laid
out in your testimony some of the areas that need to be fixed.
We have just talked about consistency, but there is also IT and
a number of other things, the number of Caregiver Support
Coordinators, properly trained, et cetera.
Can we expect to see a request for full funding for the
Caregiver Program to address these issues from the
Administration?
Secretary Shulkin. We currently have in the upcoming budget
a request for continuing the current Caregiver Program. Once we
were to have authority to expand--
Ms. Brownley. I am not talking about expansion right now--
Secretary Shulkin. Yeah.
Ms. Brownley [continued]. --I am talking about the issues
that need to be addressed, that that is going to cost some
money, whether it is IT, whether it is additional training--
Secretary Shulkin. Yeah.
Ms. Brownley [continued]. --whether it is more supervisors,
is that included in the budget request?
Secretary Shulkin. I think it is, but let's have Meg, who
runs the program, tell us.
Ms. Kabat. Yes, the current budget request does reflect all
that we need to do. There was some substantial growth early on,
the numbers were doubling in 2015-2016, and we have seen really
a steadying of the current need. We have been averaging about
24,000 for the past 2 years. So we don't have that huge
increase that we need, because about 80 percent of our budget
is the stipend payments that go to caregivers.
Ms. Brownley. Thank you. I need to yield back. I have more
follow-up questions, but I know we are on a strict timetable. I
apologize.
The Chairman. General Bergman, you are recognized.
Mr. Bergman. Thank you, Mr. Chairman, and thanks, Dr.
Shulkin and the rest of you, for being here.
I am a Marine, I am pretty simple. You know that, we have
talked before. Ready, aim, fire. Okay? Not ready, fire, aim.
You are asking us to fire before I have heard you aim.
You know, does the VA have the ability, because, Dr.
Shulkin, I heard you say that the inability of the VA to do
something, does the VA, as it is currently structured with the
people on board assigned to this task, do they have the ability
to assess what has worked and what has not worked already with
the population that we have, the post-9/11 veterans?
Secretary Shulkin. Yeah, I believe that we do. I believe,
at least it is my belief, that we do not right now have
consistency of the clinical criteria and it would be my
recommendation that we fix that, so that this program can be
targeted to those that would get the most benefit from it. But
Dr. Allman is our clinical chief, and so do you feel like we
know enough about how to fix this?
Dr. Allman. Yes, Secretary Shulkin, I think we do indeed
have--we have field expertise and expertise within--
Mr. Bergman. Can you put a cost? So the criteria you have
developed to fix this, because in your graph you are obviously
going to take the savings, you are counting on the savings from
expanding the program, okay? Can you take the criteria that you
have developed to fix the program, can you attach a dollar
figure to them now?
Dr. Allman. Well, the estimate that we had was by 2030, I
believe, we would be saving about--or cost avoiding $2.5
billion. Clearly, the cost is going up--
Mr. Bergman. But it is one thing to cost avoid, it is
another thing to cost--you are going to have to hire clinicians
if we change the clinical criteria, tighten up all these specs
and standards, are you able to tie a cost to that?
Dr. Allman. I think we have the staff, the people with the
ability to carry out this program, if Congress gives the
ability for--
Mr. Bergman. How long is it going to take to--the public
comment just closed at midnight--how long is it going to take
to assess the responses and the data that you have gotten from
that public comment? How long?
Ms. Kabat. So we have staff who have been collecting the
data as we go through. As with other Federal Register notices,
there are many comments that do not respond directly to the
questions. In fact, about a third of them are very short and
state that the program--
Mr. Bergman. How long is it going to take?
Ms. Kabat. For us to go through all those comments?
Mr. Bergman. Yes--
Ms. Kabat. Well, we already--
Mr. Bergman [continued]. --how long?
Ms. Kabat [continued]. --I expect it to take about 6 to 8
weeks to get to the point where we can identify some specific
recommendations. Now, those recommendations are about our
current program, they are not about--
Mr. Bergman. That's okay, that's okay. It is taking the
data that you have asked for and assessing the data, and then
applying it to what we are going to move forward to try to
accomplish. Because what you are asking us to do is to put more
money into an unproven program. I am a pilot, I have done
experimental aircraft flying and all of those kinds of things,
you don't put an aircraft into service until you know that it
is safe to fly, and I would suggest to you the same thing with
this program. Not only the number-one criteria is to make sure,
whether we expand the program or not--and, by the way, I
support expanding the program--is that we have to ensure that
it works for our veterans. And I get a little antsy at times
not seeing the data to support, whatever clinical criteria, is
the why of, you know, what we are doing.
And I guess I--because I know my time is going to run short
here--has over the last few years in our attempt to provide
this home care to the post-9/11 veterans, has that increased
the size of the VA bureaucracy?
Secretary Shulkin. We have about 400 staff working on this
program now.
Mr. Bergman. Did we hire new to do that?
Secretary Shulkin. Yes.
Mr. Bergman. So we created 400 more positions--
Secretary Shulkin. Yeah.
Mr. Bergman [continued]. --to do this? Okay.
I know my time is running short here. I am just going to
yield back the 30 seconds, because we are behind schedule.
The Chairman. I thank the gentleman for yielding.
Mr. Takano, you are recognized.
Mr. Takano. Thank you, Mr. Chairman.
Mr. Secretary, in your pre-hearing question responses you
suggested that to expand the Caregiver Program you would need
legislative authority, you reiterated that position in your
answer to Ms. Brownley, Ms. Brownley's question, but in the
past you have suggested that you could expand the Caregiver
Program under your own authority, you have made public
statements to that effect. Can you clarify your position?
Secretary Shulkin. Well, I think that we do need additional
legislative authority and appropriations to be able to expand
to the pre-9/11 population. I believe the 2010 Act was for
post-9/11 veterans.
Mr. Takano. But you have made prior public statements to
the effect that you believe that you could expand this program
under your current authority as Secretary.
Secretary Shulkin. Yeah, I think that, as I--
Mr. Takano. Were you in error? Were those erroneous
statements?
Secretary Shulkin. I think that what I was trying to say
was, was not on the legal legislative issue, but that if we
have the right consistency of clinical criteria, that that
would allow us to take current resources and expand them to
veterans who need them of any age.
Mr. Takano. So by adjusting these criteria, you do have the
authority to expand the Caregiver to pre-9/11 recipients?
Secretary Shulkin. Let's try to clarify this, because I
don't want to have a confusion.
Ms. Kabat. I think it is important to note that there are
all kinds of different programs that provide support to
caregivers. Dr. Roe mentioned many that provide home and
community-based services, we also within the caregiver--
Mr. Takano. Excuse me, I just want to cut in. I just want
to get a straight answer about your authority.
Ms. Kabat. We--
Mr. Takano. So I just heard the Secretary say that if he
were to adjust the criteria that he does have the authority to
expand the Caregiver Program to pre-9/11 individuals.
Ms. Kabat. We do not have the authority to provide stipends
directly to--
Mr. Takano. Wait a minute, you are now parsing the words
about stipends. Do you have the authority or do you not?
Ms. Kabat. It is the Program of Comprehensive Assistance
within the Caregiver Support Program. We do not have the
authority--
Mr. Takano. More comprehensive, but--
Ms. Kabat. Correct.
Mr. Takano [continued]. --if you were to adjust the
criteria, you could?
Ms. Kabat. Other services, but--
Mr. Takano. Well, I'm--
Ms. Kabat [continued]. --not the Program of Comprehensive
Assistance.
Mr. Takano [continued]. --taking your answers--I mean, you
have made previous public statements to the effect that you
could, Mr. Secretary. You have added that if you adjust the
criteria that you can. So you do have a certain amount of
discretion to expand under your own authority right at this
moment the program.
I just want to know whether the White House, the Budget
Director, or any other person in this Administration has put
undue pressure on you to change, you know, the tune here.
Secretary Shulkin. No, no. I apologize that there is
confusion, but I think that right now there shouldn't be
confusion. The Comprehensive Caregiver Program, we cannot
expand that to pre-9/11 veterans without legislation. We
provide a number of services to older veterans, but not this
particular program.
Mr. Takano. Okay. And the key word is comprehensive.
Secretary Shulkin. Yes.
Mr. Takano. You are able to offer less than comprehensive
services like--
Secretary Shulkin. Yes.
Mr. Takano. Okay. Well, in your response to pre-hearing
questions from this Committee, you discussed the cost of
expanding eligibility to pre-9/11 veterans. In the response,
you suggested it could be as much as $3 billion annually. In
the past, CBO has suggested that such expansion would cost $3.4
billion over 5 years. And just last year before this Committee,
you suggested the CBO score, quote, ``was not an accurate
reflection on the true cost, because I believe we are going to
save money, but not by institutionalizing people,'' end quote.
Can you please explain the discrepancy between your
estimate and that of past CBO scores?
Secretary Shulkin. Well, the CBO came up with the score on
the Senate bill. I think you are right, I think it was about
$3.4 billion over--was it a 10-year period or--
Ms. Kabat. It is 5 years--
Secretary Shulkin [continued]. --five-year period.
Ms. Kabat [continued]. --and that is because that
particular legislation rolls in eligibility.
Secretary Shulkin. All right. And what I have said in the
past, and that is what we showed the slide is, is that I do
believe that if you create the right criteria and consistency
of criteria with our other programs that there will be cost
savings that CBO did not consider.
Mr. Takano. All right. I appreciate that response. The
other questions I have to submit are going to make me run over
time and I will yield back the balance of my time.
Secretary Shulkin. Thank you.
The Chairman. Vice Chair, Mr. Bilirakis, you are
recognized.
Mr. Bilirakis. Thank you, Mr. Chairman.
And, Mr. Secretary, thank you for your outstanding work on
behalf of America's heroes, I really appreciate it, and I want
to thank the staff for being here as well.
I also want to thank you for your quick response with
regard to our veterans at Bay Pines, I appreciate that so very
much.
Mr. Secretary, I have a couple questions. Do you have a
legislative proposal to improve or expand the program?
Secretary Shulkin. The current law has the criteria of one
activity of daily living in the law, so it does not give us the
ability to change that criteria.
Mr. Bilirakis. Okay. Can we work with you on a legislative
proposal?
Secretary Shulkin. Absolutely.
Mr. Bilirakis. Okay. It is very important to us. Again, we
want to make sure we get that as soon as possible to Congress
and we want to work together--
Secretary Shulkin. Thank you.
Mr. Bilirakis [continued]. --to get this done, because I am
also a supporter of the pre-9/11 veterans, that they need the
care.
And also I have a proposal, a concept, the Hero's Ranch
concept that I would like to discuss with you as well.
Secretary Shulkin. Okay.
Mr. Bilirakis. You know, again, the veterans should have a
choice, but if they don't have the caregiver available, a
qualified caregiver, I don't want to see them in a nursing
home, you know. So, again, it is a quality-of-care issue.
All right, a couple questions here. Again, in your
testimony you mentioned that VA heard concerns about the
inconsistent implementation of the program, which led to the
strategic review in April 2017. What were the immediate actions
that were taken in response to those concerns?
Secretary Shulkin. We looked at the policies and procedures
and refined them, we then went out and did training for all 350
Caregiver Support Coordinators throughout the country. We met
with caregiver groups and their families and veterans and
talked to them about the program. We published a new Web site
which had clarity on it and, when we rolled it out, there was
greater consistency in decision-making, as evidenced by a 20
percent reduction in revocations around the country.
Mr. Bilirakis. Okay. I have heard from stakeholders in my
district that there are still inconsistencies in communication
and process with regard to the clear eligibility requirements.
Why has effective communication between VA and caregivers about
eligibility been such a challenge for this program? Again, I
hear it from constituents on a regular basis.
Secretary Shulkin. Well, I think what we are learning is
you can never communicate enough and we just have to constantly
be working at doing this better. One of the reasons why I
established a Family Caregiver Advisory Committee was exactly
for this. How do you find better ways to communicate? How do we
find better ways to hear the feedback?
And that Committee, as I mentioned, met for the first time
in October, Senator Dole chairs it. And I think we are learning
a lot from that exactly how to do a better job with
communication.
Mr. Bilirakis. Yeah. And we want to assist in getting the
word out as well--
Secretary Shulkin. Yes.
Mr. Bilirakis [continued]. --so please include us.
Secretary Shulkin. Thank you.
Mr. Bilirakis. Again, how many enrolled caregivers have
been disqualified or removed from the program and, again, for
what reasons?
Secretary Shulkin. Yeah. It is currently now at about 192 a
month, so we are probably on a run rate of 1500 a year. I am
just trying to do the math quickly. And the reasons why are--
the good reasons why would be because the veteran has gotten
better and doesn't need the services, doesn't meet the
criteria, that would be the good reason. The bad reason would
be because the initial decision wasn't the appropriate one.
And so in these evaluations, which are done in multi-
disciplinary teams, they are coming up with these decisions.
And we give the family and the veteran or the caregiver the
right to appeal it, because we don't always get the revocations
right, that is why I paused it. And I agree with what you are
hearing, we still have a ways to go to make this program work
better.
Mr. Bilirakis. Okay. How long does it take, maybe the--on
the average, maybe somebody else can--
Secretary Shulkin. Yes.
Mr. Bilirakis [continued]. --answer this question--Ms.
Kabat, on the average, how long does it take, the application
process? And the appeals process, because that is very
important as well.
Ms. Kabat. So about 85 percent of our applications are
approved or denied within 120 days. And really we have just a
handful of sites who are not in that group, so we have targeted
a lot of intervention and support and assistance to those
particular sites who are struggling with that timeliness beyond
the average for the other sites.
Mr. Bilirakis. Yeah, we have got to do better. Again, you
know, time is of the essence.
So thank you very much, again, for thinking outside the
box, Mr. Secretary, and again putting our veterans first. I
appreciate it very much.
I yield back.
The Chairman. I thank the gentleman for yielding.
Ms. Esty, you are recognized.
Ms. Esty. Thank you, Chairman Roe, and to the Ranking
Member for holding today's hearing.
I am one of the sponsors of and authors of an expansion
bill, and I appreciate your coming here today. And I really
want to thank the VSOs, who have been very strongly in favor of
this, advocating for veterans and their families for equity and
parity and recognizing.
And I will tell you, mine is one of those districts with a
lot of Korea and World War II veterans, with aging caregivers
who have been doing this for decades, and, frankly, I think it
is unfair and unwise not to give them the support and
assistance that they deserve to have, particularly at this
time. So I appreciate with your focus, but I want to drill down
on what that really looks like.
Dr. Shulkin, you have talked about Tier 3, so I want you to
do two things. Can you discuss what Tier 3 is? And I want you
to answer this question: are you suggesting or do you think we
should be restricting the post-9/11 to Tier 3? If you had your
druthers, if you were talking about the best way to serve,
would you recommend, is that what you are suggesting, that we
focus on those most in need? And the expansion should not be by
era, but the expansion should be by severity? Because that is a
really important thing for us to discuss with limited
resources.
And I think, in fairness to veterans and their families,
they should understand what exactly you would be calling on us
to do, because if we are going to look to expand to those most
severely, that is a really important distinction. We would have
to authorize that here in Congress.
Secretary Shulkin. Absolutely.
Ms. Esty. And I want to get my handle around that and it is
not clear to me that that--if that is only for one era--
Secretary Shulkin. Right.
Ms. Esty [continued]. --why would you not be actually
asking us for all eras? Thank you.
Secretary Shulkin. Well, thank you. And what I am doing is
just giving you my best advice, because this is your decision.
I do believe that, first of all, we should not be removing
caregiver support from people who have already been granted
that benefit. So I am not suggesting revocations. But moving
forward, if we were to expand, I believe that my recommendation
would be to move towards criteria that would be Tier 3, which
is three activities of daily living or cognitive dysfunction.
Cognitive dysfunction would be a separate category.
And the reason why I say that--and Dr. Allman is here as
the expert--is that every other one of our programs using three
activities of daily living as the criteria; the state Medicaid
programs in your states that offer caregiver services uses
three ADLs as their criteria, Medicare uses for nursing home
determinations three ADLs. So if we want consistency, I
believe, and the best use and impact in the area of not
unlimited resources, I believe that would be my best
recommendation, but I do not support withdrawing services from
those who have already been granted them.
Ms. Esty. And could you repeat again for us your best
estimate if we were to do expansion to all eras--
Secretary Shulkin. Well, we have--
Ms. Esty [continued]. --of how many would be Tier 3? I know
you have talked a little bit about what those numbers are.
Secretary Shulkin. Right. We have about 26,000 now that are
post-9/11 and we would have approximately 40,000 pre-9/11.
Ms. Esty. And the savings on the chart that you showed us,
those savings are predicated on the assumption that those Tier
3 veterans would otherwise be in a much more expensive
institutionalized setting that would in fact be paid for by
taxpayers, is that correct?
Secretary Shulkin. That is correct.
Ms. Esty. And is that assuming some of those are in VA
facilities and some are in other facilities?
Secretary Shulkin. Yes, yes. Yeah, community nursing homes,
state nursing homes, and VA facilities, yes.
Ms. Esty. Okay. And are those assumptions over the chart
you are looking at, is that based on inflation rates that we
have seen in nursing homes?
Secretary Shulkin. Yes, that is a good question.
Ms. Esty. I mean, it is a very important question because--
Secretary Shulkin. No, that is a good question.
Ms. Esty. Dr. Allman?
Secretary Shulkin. Yes, best we can. But you are right,
they have been climbing pretty high, yeah.
Ms. Esty. Is that correct, Dr. Allman? Do you know if that
is projecting out what we have seen over the last few years?
Dr. Allman. Yeah, the numbers were adjusted for inflation,
so they are in 2030 dollars.
Ms. Esty. But based on the inflation rate for nursing homes
or on the general inflation rate? Because those are two very
different rates.
Dr. Allman. It was just the general inflation rate, as I
recall.
Ms. Esty. So that could well be much higher than that, is
that correct?
Dr. Allman. Correct.
Ms. Esty. Okay. Thank you.
I yield back.
The Chairman. I thank the gentlelady for yielding.
Mr. Rutherford, you are recognized for 5 minutes.
Mr. Rutherford. Thank you, Mr. Chairman.
And, Mr. Secretary, thank you for everything that you have
been working very hard to do to improve medical care for our
veterans. I know how much they appreciate that.
I would like to first begin with a request. Could I get
some of the backup data for the chart that we have up here?
Because one of the things that I am a little confused about, I
did a little math here and Tier 1 with these stipends, just the
stipend amount, is $4.5 million, Tier 2 is $11.8 million, and
Tier 3 is $12.9 million, for a total of $29.2 million. And
there is a delta on the chart of 2 million, but I don't know
what that represents. Can we get the backup data--
Secretary Shulkin. Sure.
Mr. Rutherford [continued]. --for that, to make sense of
that?
Secretary Shulkin. The very easy math, but we absolutely
will get you the model, is we are using a nursing home costs
104,000 a year, and these wraparound services that the Chairman
talked about, including caregivers, about $30,000 a year less
than that.
Mr. Rutherford. So a $74,000 delta?
Secretary Shulkin. Yes.
Mr. Rutherford. Oh, okay. Yeah, I would like to see that.
Secretary Shulkin. Yeah, we will get you that.
Mr. Rutherford. Thank you. And so my next question is, is
it true that, as the testimony from the Elizabeth Dole
Foundation claims, that individual VISNs have the autonomy to
run the Family Caregiver Program as they see fit? Has anybody
addressed that comment?
Ms. Kabat. No, that is not accurate. As Dr. Roe said, we
published a directive, which is the national policy that all
VISNs are required--all medical centers are required to follow.
We have a lot of different ways that we provide oversight from
the national office, including site visits, as well as some
data analytics. So, certainly I will follow up with the
Elizabeth Dole Foundation about that specific comment.
Mr. Rutherford. Good. Thank you.
Also the--when we established the graduated-tier system,
did that complicate the execution of this program by actually
bringing more people in than we originally anticipated or
Congress anticipated?
Ms. Kabat. I think that having the three different tiers is
very difficult and confusing, it is confusing for caregivers
and veterans. We did our best in establishing a tool that is
used by VA clinicians and now we are, by the end of this year
we will have actually 90 percent of our sites using a multi-
disciplinary approach, because it is so very complicated, not
just the eligibility, but also establishing that tier level.
Mr. Rutherford. Right. And I think the eligibility issues,
Mr. Secretary, that you talked about is, you know, when you
look at Tier 3, that is pretty much what everybody had
projected, and then it turned out to be something completely
different.
Let me ask this: should the determination of eligibility
for stipend payments be restricted only to those caregivers
giving the 40 hours of treatment in Tier 3, understanding that
all of these other programs are available for caregivers who
may only be spending 10 hours a week? That doesn't seem like a
lot of time, and yet they have a lot of opportunity to get
assistance through these other programs. What is your opinion
on that, I guess?
Secretary Shulkin. Do you have a thought on that?
Ms. Kabat. Sure. I think it is certainly care-giving occurs
on a continuum. At one end, you have a family member that you
may start calling twice a day because you are concerned about
them, way up to the high levels of care in which a caregiver is
providing a lot more than 40 hours of support a week, and
including special diets, tube feeding, all of those kinds of
things. And we really want to be able to provide support to
every caregiver along that entire continuum and I think the key
is where we target the comprehensive assistance.
We need to make sure that we continue to provide all the
other kinds of supports that we have, the wraparound services,
training, and education, all of those things, but to determine
where that line is where we move to that comprehensive group.
Mr. Rutherford. Well, my time is up, but I would like to go
on record, I support expansion of the program, but I think, as
General Bergman said, you know, we really need to do this in a
smart way.
Secretary Shulkin. Absolutely. Thank you.
Mr. Rutherford. Mr. Chairman, I yield back.
The Chairman. I thank the gentleman for yielding.
And, Ms. Rice, you are recognized. They have called votes.
So we will get through yours and then we will have to come
back, I apologize.
Miss Rice. Thank you, Mr. Chairman.
Secretary Shulkin. No problem.
Miss Rice. Secretary Shulkin, very quickly. Caregiver
assistance is one of the biggest issues that comes up in my
district, as I am sure everyone on this panel will say, and so
I would just like to reiterate what my colleague Mr. Bilirakis
was saying in terms of doing the outreach to have them
understand exactly what they need to do in order to avail
themselves of these services. So, I appreciate your focus on
that.
Forgive me if I missed this. Were you able to figure out a
dollar figure in terms of the savings that you--because the
VSOs have well documented the savings, obviously, and you have
testified here today about keeping people out of facilities and
in their home--over the next 5 years, if you were to expand the
program to pre-9/11, have you been able to come up with a
number of what the savings, the long-term savings would be to
the taxpayer, basically?
Secretary Shulkin. Yeah. If we expand the program with the
exact same criteria that we are using right now, I do not
believe that there will be significant cost savings. And the
reason is, we have studied this in the current caregivers that
we have and costs actually went up, because I believe that our
criteria right now is not focused on those who need it the
most.
If we go, as Congressman Esty was asking my opinion, to the
consistent criteria used in the industry, it will save upwards
of 2 and a half billion dollars by 10 years, probably about
half of that by 5 years.
Miss Rice. And that has got to be done legislatively?
Secretary Shulkin. That would have to be done--
Miss Rice. Yes.
Secretary Shulkin [continued]. --legislatively.
Miss Rice. So just one last question. The Elizabeth Dole
Foundation pointed out that the VA has taken several steps to
address the persistent inconsistencies with implementing and
operating the Caregiver Program at the regional, local level,
but that the program still lacks a level of centralization. I
am just curious, Mr. Secretary, what steps you are taking to
kind of centralize that as requested?
Secretary Shulkin. Well, I shared that same concern, which
is why I paused the program in April this year. I said no more
revocations until we are sure we have program oversight. Meg
Kabat, that leads it, was responsible for telling me when she
was ready to start the program up again with the appropriate
program oversight. And we believe we have good program
oversight now, a consistent directive. Is it perfect? No, but
it is a lot better than it was.
Miss Rice. So, I lied. One quick question. I totally
support your position that there shouldn't be any revocations
to people who currently have qualified for this service.
Secretary Shulkin. Right.
Miss Rice. Going forward, though, if we were to make this
legislative fix, they would not suffer, the people who already
have it would not suffer and--
Secretary Shulkin. We would continue to support those that
are eligible under the current criteria. I don't think you can
just pull the wool out of people that you have already made a
commitment to.
Miss Rice. Right.
Secretary Shulkin. But we also have a commitment to the
pre-9/11 veterans. I think everybody in this room so far has
been in agreement with that. And so the issue is whether we
would just continue our current criteria or whether we would
accept industry standards for criteria and adopt new ones going
forward, and, you know, that would be my recommendation.
Miss Rice. Thank you very much, Mr. Secretary. I yield
back.
The Chairman. I thank the gentlelady for yielding.
Dr. Wenstrup, you are recognized.
Mr. Wenstrup. Thank you, Mr. Chairman.
Just a quick, multi-faceted question, I guess, but if you
could explain the purpose of the Family Caregiver monthly
stipend, the purpose of the aid and attendance benefits, sort
of the difference between the two, and should one offset the
other.
Secretary Shulkin. Yeah, yeah, yeah, that is a great
question. I am going to--Meg is more familiar.
Ms. Kabat. Sure. So the stipend is paid directly to the
family caregiver, so that is one significant difference,
because aid and attendance is additional money that is in the
veteran's compensation or pension check, because that veteran
requires the, quote, ``aid and attendance'' of another person.
In neither circumstance is there any requirement to use the
funds in any specific way, there is no oversight of how those
funds are being used. Historically, the aid and attendance
benefit, I think there is language around that that talks about
getting assistance in order to remain at home, but there is no
tracking of that that goes on.
So the difference is really who receives the money.
Mr. Wenstrup. So might they be compensating for the same
care?
Ms. Kabat. Well, the stipend, as the Comprehensive
Assistance Program, was really money that was paid directly to
caregivers and in recognition of the sacrifices that they had
made, it was not meant to be income replacement or anything
like that.
Mr. Wenstrup. Okay. Thank you.
I yield back.
The Chairman. We will adjourn until after votes and, again,
I apologize.
[Recess.]
The Chairman. I will gavel the meeting back to order. And
just a couple of things as Members make their way back to the
dais, that, first of all, I thought our first, before the
interruption, was extremely helpful to me to focus where this
program is going, could and should become. And I think one of
the things you pointed out, Mr. Secretary, is that if we would
apply the Tier 3 eligibility criteria, the same as other
different agencies do, you narrow it down to those most in
need, I think we need to work on the IT part, a phase-in for
people who might be going to nursing home care would be first
in the queue. I think if we do those things and we get a better
estimate of what they cost, I think that is something that we
could carry to the Congress and get passed; I really believe it
is.
So, have I pretty well summarized what you have--what your
thoughts are on this?
Secretary Shulkin. You have, Mr. Chairman.
The Chairman. Well, Mr. O'Rourke, you are recognized for 5
minutes.
Mr. O'Rourke. I appreciate it, Mr. Chairman.
Mr. Secretary, good to see you. Thanks for being here. And
Mr. Chairman, thanks for convening this hearing. I know that
every time we have a joint, House-Senate listening session with
the veteran service organizations, this is at the top of the
agenda, and so I love the fact that we are
trying to make some progress on it and I appreciate the
Secretary's effort and focus and attention on this.
And I wanted to ask a couple of questions about eligibility
going forward for pre-9-1-1 veterans and caregivers. You
mentioned that under one scope of the program, you could up to
eight--188,000 pre-9-1-1 caregivers and under a more restricted
scope, you could have just 40,000. I wanted to get your
thoughts about what happens to those other 148,000 caregivers
if they are not eligible for this program, and then you may
want to, in your answer, talk about--you are trying to
harmonize with other eligibility criteria for Medicaid, for
example.
You may also want to think about Department of Defense,
which I think has a more expansive set of eligibility
requirements and talk about how we take care of those other
148,000 families.
Secretary Shulkin. Yeah. No--thank you, Congressman.
First of all, it is very confusing when all these different
departments, all that work for the same employer, the Federal
government, have different eligibility criteria. So, it would
be--I think we would be doing a service to move towards what is
a reasonably, clinically appropriate criteria across the board.
The difference between the 40,000--let's talk about the
Tier 3 and the 188,000, which was the projection, if we
current--if we use the current criteria of one ADL. The 148,000
that you talk about, they are eligible for all of the other
services that the Chairman had mentioned. They are eligible for
home care visits, primary care-directed visits. Assistance with
respite care. General caregiver support services, just not the
comprehensive program.
Mr. O'Rourke. So, just to--sorry to interrupt--
Secretary Shulkin. Yeah, no problem.
Mr. O'Rourke [continued]. --I just want to make sure I
understand. Apples-to-apples would not be eligible for a
caregiver stipend, caregiver counseling and mental health
services, caregiver medical care, additional respite care, and
reimbursement of travel expenses?
Secretary Shulkin. I think that is right. That is the
comprehensive program that you are talking about.
But today we support 250,000 older veterans with these
wraparound services. So, we are really doing a lot today, but
you have it correct, Congressman.
Mr. O'Rourke. Yeah, but it excludes those.
Secretary Shulkin. Right.
Mr. O'Rourke. In reading some of the DoD eligibility
criteria, while I don't think it explicitly describes post-
traumatic stress disorder, it describes difficulty with sleep
regulation, requires assistance or supervision, as a result of
delusions or hallucinations, difficulty with recent memory,
self-regulation issues. And I am concerned, and I am sure you
are as well, that if we too narrowly constrain eligibility, we
will be missing the opportunity to help pre- 9-1-1 veterans and
their caregivers deal with very serious issues.
You are the first Secretary that I know of, who has made
reducing veteran suicide a priority. We know 20 a day will take
their lives today every day until we get a handle on this. And
I believe the largest cohort are not post-9/11 veterans; it is
pre-9/11, I think it is the Vietnam-era of service. So, if we
are going to exclude them from eligibility and the caregivers
in their lives from this kind of help, what will happen to
them?
Secretary Shulkin. Well, first of all, one of the criteria
that we would propose, besides the three ADLs, is any type of
cognitive type of dysfunction. So--
Mr. O'Rourke. Okay.
Secretary Shulkin [continued]. --that would absolutely need
to be in there.
Secondly, today, our Caregiver Program has a very high
incidence of mental health issues and post-traumatic stress; 89
percent of our current 26,000 caregivers in the comprehensive
program have a co-morbidity in a high percentage of the mental
health. So, we are very sensitive to that, and I do think this
fits in with providing as much support as possible to help
reduce, not only suicide, but also the burden of mental illness
and mental health issues.
Mr. O'Rourke. Thank you. I appreciate that.
Mr. Chairman?
Mr. Roe. I thank the gentleman for yielding.
Mr. Poliquin, you are recognized for 5 minutes.
Mr. Poliquin. Thank you, Mr. Chairman, very much.
Mr. Shulkin, it is always good to see you. Thank you very
much for being here, and please continue--I know you will--your
great work for our veterans.
My questions, sir, relate to the post-9/11 veterans that
are currently eligible for the program. Mr. Shulkin, my parents
are 89 and 87 and they live in a little apartment in an
assisted-living place and we need additional home care help for
my mom, who is a retired nurse. My father is a little bit
stubborn, but he gets it and she gets it.
We all know how vitally important it is to keep our
seniors, our veterans at home as long as we can, such that they
can recover fully and keep them out of hospitals and other
medical facilities. So, this is a great program that I
completely support. Especially in the rural parts of Maine,
where you don't have access--and I know you were up in Brewer
County--
Secretary Shulkin. Right.
Mr. Poliquin [continued]. --not long ago, and we don't have
a lot of options up there. You know, if you are one of our
great heroes and you are missing a limb, it is very different
from helping take care of mom and dad, but they need to learn
how to dress and walk and shower and cook and all these other
things, so, I am very, very supportive of this program.
However, I am also mindful, Mr. Shulkin, that you might
have not have been here for this hearing, it was last October.
There was a terrific veteran, one of our great heroes named
Brendan O'Byrne, and I quote, ``Being an active member of
society is the ultimate sign of healing from combat and we
should all be striving for it.''
So, my question to you, and where I want to go down this
path, if I may, Mr. Secretary, is I know this program is
designed to be temporary, to help our veterans adjust to their
new situation, showing them compassion to help them adapt and
get back into a regular routine and also for their caregivers,
to then move on with their normal lives. So I want to make
sure--I rather want to ask you the question, sir: Is this goal,
as Mr. O'Byrne testified, to get back to an independent living
and what have you, is that the goal of this program?
Secretary Shulkin. Well, I think that should be the goal of
all of our programs at VA, our benefits program and our health
programs, to restore independence. That is what people want.
Sometimes, of course, that is not going to be possible and I
think that is the reason why you should separate out high-need
people from those that can get on a program towards
independence and then reevaluate whether the people need the
continued support.
Mr. Poliquin. Do you--can you list, rather, any specific
reforms to the program right now that may help to that end?
Secretary Shulkin. Yeah. Yeah. Some of the things we did in
our Strategic Pause, I am sure.
Ms. Kabat. Sure. One thing we did was we instituted
something that we call our roles and responsibilities document.
It is on our Web site. We wanted to make sure that we were
being transparent about it, and it really describes what the
requirements of the program are and also helps our caregiver
support coordinator start the conversation that you are
describing about, for some of our veterans, this is an
intervention that may be short-lived, while the caregiver is
receiving additional supports that comprehensive assistance,
the veteran is also going to be receiving mental health
treatment or occupational physical therapy, so that as that
veteran increases their level of independence, the amount of
that comprehensive assistance that the caregiver receives will
decrease. So, that has been a significant change in our
program.
We actually required that all of our caregivers and support
coordinators go back and review that same document with all of
our current participating, as well as any new participating.
Mr. Poliquin. Can you, Dr. Shulkin, comment on any
potential obstacles that you are facing at the VA, with respect
to achieving this goal that we can help you with?
Secretary Shulkin. Well, I want to get the clinical
criteria correct. I mean, I think that having different
clinical criteria between these multiple programs is confusing
and doesn't allow us to focus on those that need it the most.
Mr. Poliquin. Thank you, Mr. Chairman. I yield back my
time. Thank you.
The Chairman. I thank the gentleman for yielding.
Mr. Higgins, you are recognized.
Mr. Higgins. Thank you, Mr. Chairman.
Secretary Shulkin, God bless you, sir. Thank you for your
leadership. You continue to provide encouraging testimony. Many
of us on this Committee have been advocates for expanding the
Caregiver Program to pre-9-1-1 veterans for quite some time.
For me, that is a year, since day one on this Committee.
Secretary Shulkin. Uh-huh.
Mr. Higgins. And I am sensing a path forward, sensing a
path forward, here, so let us forge forward and promise to
arrive at a bipartisan conclusion that we can make this thing
happen.
But let me just state that even in a world of unlimited
resources and funding, would we not want to eliminate waste
fraud and abuse?
Secretary Shulkin. Absolutely.
Mr. Higgins. Thank you, sir. So, given that additional
dynamic, where we certainly do not live in a world of unlimited
funding and resources, should we not seriously investigate
waste fraud and abuse where it does exist in the stipend
program, the Caregiver Program for post-9/11 veterans, whereby
that funding may be made available for deserving veterans, pre-
9/11. Would you concur with that general assessment?
Secretary Shulkin. Absolutely.
Mr. Higgins. Okay. Given that, how often are receivers of
stipends supposed to be visited by, in some sort of supervisory
role--
Secretary Shulkin. Yeah.
Mr. Higgins [continued]. --a VA employee, to go to their
home and observe their home and interview that subject; is that
supposed to be quarterly?
Secretary Shulkin. Yeah.
Ms. Kabat. Yes, it is quarterly.
Mr. Higgins. What is the reality, though?
Ms. Kabat. I don't have exact numbers. I can get back to
you on the reality of that. That is something that we have
really focused on.
And many caregivers are concerned that that is too frequent
and so we have allowed, in certain circumstances--and I can
provide you with those criteria--where that wouldn't be an in-
person visit, but it would be telehealth or over the telephone.
There is a requirement for an annual in-home, in-person visit,
however.
Mr. Higgins. But, there are caseworkers assigned to
individual veterans?
Ms. Kabat. Correct.
Mr. Higgins. This 46,000-number, they have corresponding?
Secretary Shulkin. Yeah, we have 350 caregiver coordinators
for 26,000.
Mr. Higgins. I'm sorry, for 26,000, yes, sir.
Well, there is--this particular program is just generally
known to be rife with abuse. I mean, can you imagine, viewed
from the prism of a soldier, can you imagine a soldier having,
you know, a full vest, 10 magazines for his M4 and his fellow
soldier having one magazine. Can you imagine any soldier that
would not give his fellow soldier a few magazines from his--
Secretary Shulkin. No, sir.
Mr. Higgins [continued]. --from his vest? Sure, of course
we would.
So, it is troubling that waste fraud and abuse even exists
and it is disheartening that it exists within a veteran
population, but it does.
Secretary Shulkin. Uh-huh.
Mr. Higgins. And in order for us to move forward as a body,
can we seek your commitment, sir, that there will be a genuine
effort to seek out unrighteous abuse of this program whereby
that funding can be made available to the righteous, deserving
veterans pre-9-1-1?
And may I ask, Madam, is social media used? If you have a
veteran posting pictures of him hitting in a gym, deep-sea
fishing, snow skiing, et cetera, he can probably feed himself
and bathe himself.
Ms. Kabat. So, is your question, do we review social media?
Mr. Higgins. Yes.
Ms. Kabat. We do not currently review social media. We rely
on an interdisciplinary approach made up of physicians, nurses,
social workers, occupational physical therapy, mental health
professionals to make a determination.
Mr. Higgins. As it should be, because the veteran's privacy
should be completely preserved and respected; however, we do
live in an era of social media, and this is available data. So,
if you have a staffing issue that is causing us not to be able
to investigate waste fraud and abuse, might I suggest that
social media, perhaps, could be an avenue.
With that, Mr. Chairman, I yield back.
The Chairman. I thank the gentleman for yielding.
And I would like to thank this first panel for your
instruction. It has been very helpful. I will add, as a matter
of fact, it cleared up a lot of things about how I think we can
see a way forward.
I thank all three of you for being here and I apologize for
the votes that came up in the middle; we couldn't help that,
and with that, you all are dismissed.
I know you have a busy day in front of you, Mr. Secretary,
and thank you so much.
Secretary Shulkin. Thank you, Mr. Chairman.
The Chairman. Thank you.
There--joining us will be our second panel, as soon as the
Secretary is able to leave.
Joining us on--excuse me--on our second panel this morning
is Adrian Atizado, the Deputy National Legislative Director of
Disabled American Veterans--welcome; Sarah Dean, the Associate
Legislative Director for Paralyzed Veterans of America--also,
welcome; and Steven Schwab, the Executive Director of The
Elizabeth Dole Foundation.
Thank you all for being here, and Mr. Atizado, you are
recognized for 5 minutes.
STATEMENT OF ADRIAN ATIZADO.
Mr. Atizado. Thank you, Mr. Chairman, Members of the
Committee. I want to thank you for inviting DAV to testify on
the VA Caregiver Program.
Since its inception several years ago, VA's Comprehensive
Caregiver Support Program has been annually serving over 20,000
caregivers of severely injured veterans. And there is mounting
evidence that the program is measurably supporting and
improving the lives of family caregivers and their veterans.
According to an online caregiver survey DAV conducted last
year, more than three-quarters of disabled veterans who
currently rely on family caregivers would require institutional
care now or in the near future if their loved one could no
longer be their family caregiver.
Here's what one of the caregivers we surveyed, a 38-year
old mother, with teenage children, who is caring for her
severely disabled husband said, ``We depend on the Caregiver
Program more than you can imagine. I miss doing what I love--my
career--but I love my husband and my children. My husband
depends on me in so many ways that there are days that I am
just so exhausted, but I continue on because I know he needs
me.''
Mr. Chairman, we are grateful that the Committee is holding
today's hearing to examine how to improve and expand VA's
Comprehensive Caregiver Support Program, and we offer a few
recommendations on how to improve the program in our written
testimony; however, there is no issue more important today than
finally be correcting the gross unfairness and inequity that
discriminates against veterans ill and injured prior to
September 11, 2001, and their family caregivers.
In the audience today are DAV past national commander,
Dennis Joyner, and his wife and caregiver, Donna, and DAV past
national commander, Dave Reilly, and his wife and family
caregiver, Yvonne. I would please ask that they raise their
hands to be recognized.
Now, Mr. Chairman, the last time Dennis walked was on
principal in Vietnam's Mekong Delta on June 26th, 1969. And he
has been confined to a one-arm drive wheelchair ever since.
While he led a successful rewarding career, it was greatly
aided by the love, work, and sacrifice of his wife, Donna. When
his good shoulder, his one good shoulder, finally gave out a
decade ago, Donna was forced to retire from her full-time job
to be his full time caregiver, but because Dennis was injured
in Vietnam, Donna isn't eligible for VA's Comprehensive
Caregiver Program.
Now, for Dave, after losing his arms and legs two decades
ago, during his service in the Coast Guard as a rescue swimmer,
each and every day begins and ends with the help and love of
his wife and full-time caregiver, Yvonne. Despite the
considerable progress Dave has made functioning with his
prosthetic limbs, as a quadruple amputee, he will always rely
on Yvonne for the many, many of his basic needs. Like Dennis
and Donna, Dave and Yvonne are not eligible, because, he, too,
is a pre-9-1-1 veteran.
But even if the date were changed, Mr. Chairman, Dave and
Yvonne would likely not be allowed access to VA's Comprehensive
Caregiver Program because he lost his limbs to a water-borne
flesh-eating bacteria. It would be an illness and not an
injury, and the law doesn't count illnesses.
Mr. Chairman, the most critical reform for Caregiver
Program is extending eligibility to severely disabled veterans
from all war eras. Research has shown that family caregivers
delay, avoid, and in certain situations, can actually help
transition veterans out of nursing homes at great cost savings
to taxpayers. The Congressional Budget Office estimated to
extend access to pre-9-1-1 veterans is about $30,000 a year.
Compare this to an average annual cost of over $400,000 for a
VA nursing home or $110,000 for a community nursing home for
disabled veterans.
Respecting a severely disabled veteran's choice to remain
in their homes longer is not only economically smart, making
more efficient use of VA and taxpayer funds, but it also allows
the veteran to lead high-quality lives with respect and dignity
and be an active member of society.
After a lifetime of caregiving, Gulf, Vietnam, Korea, and
World War II veterans, many family caregivers are aging and
their ability to continue in their role is declining.
With bipartisan support in the Senate, a growing support in
the House, we believe now is the time to act. Mr. Chairman,
DAV, along with virtually all the VSOs call on this Committee
to take bold action, similar to what the Senate Veterans'
Affairs Committee did last fall, pass legislation to expand
eligibility for VA's program to veterans severely ill and
injured, from all eras and their family caregivers. This
concludes my testimony.
Thank you so much, and I would be happy to answer any
questions you may have.
[The prepared statement of Adrian Atizado appears in the
Appendix]
The Chairman. Thank you very much.
Ms. Dean, you are recognized for 5 minutes.
STATEMENT OF SARAH DEAN
Ms. Dean. Chairman Roe, Congresswoman Brownley, and Members
of the Committee, Paralyzed Veterans of America thanks you for
the opportunity to present our views before you today.
We are grateful for your interest in the improvements and
potential expansion of the Caregiver Program. No group better
understands the value of caregivers, more than PVA's members,
veterans with spinal cord injuries or diseases, and most of
PVA's members currently do or will rely on a caregiver.
Seven years ago, the VA set up a program that was the first
of its kind in the United States. Recognizing the degree of
injury endured by servicemembers returning home and the burden
shouldered by their caregivers, Congress took bold action to
enable VA to meet their needs. Based on the clinical
determination of activities of daily living or need for
supervision, the caregivers of certain veterans receive
comprehensive critical supports to provide quality care at
home.
For PVA members who are eligible, this program has enabled
them and their families to better manage the new normal of
their lives. The feedback we receive of the program has been
crucial. It has given the caregivers the tools to manage the
emotional, physical, and financial stresses of caring for
someone with a severe disability.
As with any unique program, especially one of this scale
and this integrated reach, challenges were encountered, but
overall, and especially after the corrective actions of last
summer, it is our belief that VA has done a commendable job
addressing these issues and we see no reason why Congress
should not take bold action again and enable the VA to meet the
majority--the needs of the majority of veterans who rely on
caregiver services, those catastrophically injured on or before
September 10th, 2001.
PVA understands the costs associated with any expansion are
significant and there likely will never be a projection that
isn't, but as has been stated, not expanding will have
considerable costs. We know that veterans who remain home
receive a quality of life that they can't get in an institution
and we know that support of caregivers reduce hospital
admissions and medical complications.
In recent years, this room has seen a lot of discussion
about veterans choice and care in the community. This
Committee, for nearly four years, has shepherded reform
efforts, so veterans are able to receive care that best meets
their needs, in and outside of VA. So, I ask again, what could
be more fundamental to that question or to that question than
seeing that veterans are able to choose to stay home while
receiving the care that best meets their needs.
According CVO, roughly 70,000 veterans who were
catastrophically injured as a result of their service, are in
need of critical supports right now, but for 7 years, Congress
has said it costs too much. That is unacceptable. This is a
clinically determined program. If the cost is significant, if
it is the $3.4 billion over 5 years, the Senate projection
says, then that is what we owe, because that is the deal we
made when they signed up.
I know of no other clinically determined support service
for service-disabled veterans that cuts off access because of
date and then is justified by Members of Congress because of
costs. It is unconscionable to tell those injured that only
some of you will be helped. We are the beneficiaries of their
sacrifice. They served. They were injured. We do what we have
to do make them as whole as possible.
This program is an imperfect solution to the perfect one of
wholly healing these people, but for PVA members in the
program, it has made all the difference in their lives. For our
older veterans, who have been relying on their--the sacrifices
of their spouses, and now their grandchildren, some for half a
century, they need a difference made in their lives, too.
We stand ready and willing to help the efforts of this
Committee on this issue and thank you for the opportunity to
speak here today. I am happy to answer any questions.
[The prepared statement of Sarah Dean appears in the
Appendix]
The Chairman. Thank you, Ms. Dean. Thank you for your
testimony.
Mr. Schwab, you are recognized for 5 minutes.
STATEMENT OF STEVEN SCHWAB.
Mr. Schwab. Thank you. Chairman Roe, Congresswoman
Brownley, and Members of the Committee, I am pleased to be here
today to offer the views of The Elizabeth Dole Foundation and
the Department of Veterans Affairs' program of Comprehensive
Assistance for Family Caregivers.
I will simply refer to such program as ``the program'' in
my testimony. The Elizabeth Dole Foundation's mission makes us
uniquely qualified to share our views on this subject. We are
the only national organization exclusively focused on the
military and veteran caregiver population, the 5 and a half
million spouses, family members, and other loved ones, caring
for wounded, ill, or injured veterans at home.
We call these caregivers ``America's hidden heroes,'' since
much of their work is being done behind the scenes, in the wee
hours of the morning or late at night, with little support or
fanfare. Senator Elizabeth Dole, herself, a caregiver to her
husband, Bob, started the foundation six years ago to shine a
light on the work caregivers do each day and to advocate for
their support.
Mr. Chairman, our philosophy has always been to work hand-
in-hand with the VA and other support organizations to
determine what works for caregiver support and to provide host
feedback on what doesn't, ensuring that caregivers' needs are
heard, programs are truly responsive, and that they are built
to serve them as they serve their loved ones. With the passage
of the Caregivers and Veterans Health Services Act of 2010 and
the establishment of the program of Comprehensive Assistance
for Family Caregivers, the VA recognized caregivers for the
invaluable work they do to assist in the rehabilitation and
recovery of our Nation's veterans.
However, the implementation of the program has not been
without its challenged, as has been discussed. Congress
initially intended the program to serve a small number of
caregivers, those supporting only the most catastrophically
wounded post-9/11 veterans. Upon executing the program, the VA
realized that many more caregivers needed this support than
initially anticipated.
As we have discussed, the program now serves more than
26,000 caregivers; that is nearly three times the number of
caregivers for which the VA initially planned. Because of this,
the program has faced significant challenges as it accommodates
the growing number of veterans' caregivers that qualify for the
stipend program. Chief among these issues are unclear
eligibility requirements, lack of accountability, and
inconsistent implementation, which I expand upon in my written
testimony.
Despite these challenges, we know that this is an important
program for caregivers and we believe it should be available to
all who need it, regardless of which era they served. We cannot
let the pursuit of perfection delay us from doing what is right
and that is ensuring that vets of every era have access to this
program.
Mr. Chairman, Congress should act simultaneously to pass an
expansion of the program to include service-connected illnesses
and pre-9-1-1 caregivers, while also addressing the issues of
standardization and clarity. These efforts should not be a
zero-sum game.
I would like to leave you with a story that illustrates why
programs like this are so important. Jenny Beller is from
Indianapolis. Her husband, Chuck, was exposed to Agent Orange
while serving in Vietnam in his 20s, and as a result, he had a
stroke when he was in his late 50s. The stroke rendered Chuck
paralyzed and unable to speak.
As she grappled with her new reality as a caregiver, Jenny
struggled with the demands of her job as a public attorney,
while also slipping into debt. Jenny performs a juggling act
that almost every caregiver around the country knows too well
and many of them are watching us today. She balances career,
finances, Chuck's medical appointments, bathing, dressing,
cooking, and cleaning, all while trying to fit in time for her
own health and well-being.
Jenny made the difficult decision to quit her job last year
to care for Chuck full time, because, frankly, there is no one
else out there better suited to do it. So, I ask you to
consider Jenny. She cares for a pre-9-1-1 veteran with a
service-connected illness who was left paralyzed and without
the ability to speak after a sudden and traumatic event. For 7
years, she has devoted all of her time to Chuck's care at the
expense of her income and career as a civil servant, ensuring
that she can receive the help in the dignity of his own home,
rather than in an institution, yet, as of today, Jenny is not
eligible for the VA's program of comprehensive assistance.
Isn't it our duty, as stewards of those who have borne the
battle, to offer her the same support as those who care for
veterans just returning from war? The answer is a resounding
yes. As RAND's research points out, the number one factor in a
wounded warrior's recovery is a well-supported caregiver and it
is programs like this that are the lifeline for people like
Jenny and Chuck. The program needs to be expanded.
On behalf of Senator Elizabeth Dole and the caregivers we
speak, I thank you, again, for the opportunity to be here today
and to share our insights. I am happy to take questions.
[The prepared statement of Steven Schwab appears in the
Appendix]
The Chairman. I thank you for your testimony.
I will start now by asking a few questions. And just one,
Mr. Schwab, on Jenny, you just referenced, did she use any of
the other VA programs that I have referenced to begin with? Has
she sought those out.
Mr. Schwab. I don't know in her particular case, but I know
that there is an issue among many caregivers around clarity of
eligibility for programs. The Secretary mentioned in his
remarks that we have done a great deal of work across
organizations and within VA to put information out there in a
more proactive way. So, my hope is that folks like Jenny are
aware of benefits.
But the issue is that Jenny still doesn't qualify, herself,
for a program that post-9/11 veteran caregivers--
The Chairman. Well, I understand that; that is what this
hearing is about. But my question is, did she--is she aware--
and I think one of the things when I hold veteran town halls
around the country, is getting access to information that
programs that are there right now functioning for people. I
just wonder if this--I mean, there is at least a dozen programs
here that maybe help her right now. If she's not using them, I
would certainly ask her to reach out to VA and see if she can't
do that.
Mr. Schwab. I would just like to say that it may very well
be that Jenny is availing herself to certain programs, but I
think the bottom line is still the unjust fact that Jenny
doesn't qualify support--for support that post-9/11 caregivers
do.
The Chairman. A couple more questions that I had. Should
the veterans and family caregivers live in the same residence?
Should they be--should that be a criteria?
Mr. Schwab. Is that a question for me?
The Chairman. Anybody. It doesn't matter.
Ms. Dean. I believe under the comprehensive program, it is;
that they have to live with the veteran or--
The Chairman. Have to live in the same residence.
Ms. Dean [continued]. --if they are not a family member.
The Chairman. Okay. Cannot if they are not a family member.
A family member could live outside and come in and help--a
daughter or a son or someone?
Mr. Schwab. Mr. Chairman, if I could just add one--about a
third of the Nation's 5 and a half million military caregivers
are friends that live outside the home. So, there is a
significant portion of the population that, in fact, provide
care who aren't in the residence.
The Chairman. One of the things--and this the other support
programs that I was bringing out that are currently available,
what are your all--and anyone can grab this--what are your
views on the other programs, such as adult daycare or veteran-
directed home health care and how should they fit in or
compliment the current program? And that is--this is one of the
things that I was mentioning earlier, the way we provide non-VA
health care was we had six ways and then we had a choice on top
of that, now we are trying to get one way to do that.
Is that possible, to consolidate some of these and make the
services better?
Mr. Atizado. Well, Mr. Chairman, that is actually a very
good answer, and this is one thing that Secretary Shulkin had
mentioned, is that the VA is doing very well at--actually,
better than is seen in other health care systems, because VA
tends to take care of the caregiver--I'm sorry-- the veteran
for their lifetime. They seen the longitudinal need of that
veteran and so they provide a comprehensive array of services
from primary care all the way to nursing home care and in
between all of that are these home and community-based services
that you were just referencing.
I do want to talk very briefly before we get into this
about your question about caregivers knowing or not knowing
about these services that you are referencing. The other thing
that VA should be commended about is their desire to use
literature research to inform their policy and, in fact, the
research that they are doing on the Caregiver Program, which we
fully support, they found when they compared caregivers who
were in the comprehensive program versus a caregiver who is
not, is that those caregivers in the comprehensive program are
far more aware of the benefits and services that VA has to
offer.
The Chairman. Uh-huh.
Mr. Atizado. That is a key difference in the nuance between
the two programs.
Now, having said that, the availability of these services,
as we all know from the Choice Program, is a variable, because
they are predominantly paid for, or I should say, bought by VA.
They use community providers for homemaker home health aid, for
respite, for adult day health care. And because of the
variability of availability across the Nation, so is the
caregiver and the veterans's ability to access those services.
It depends on where they live.
It is no fault, necessarily, of VA or the private health
care system; this is the nature of the market. So, whether or
not a caregiver is able to avail themselves of those services
to support their veteran in their home depends on whether they
are able to access that and where they live.
The Chairman. I would say a lot of that has--and you have
just mentioned a problem in the health care system, where it
depends on where you live and access. As, if you live in rural
America, you are a lot less likely to have access to certain
things than if you lived in urban America.
My time is expired. Ms. Brownley, you are recognized.
Ms. Brownley. Thank you, Mr. Chairman.
My first question is to Mr. Atizado. So, we have--in these
ongoing discussions around the current caregivers program, we
have frequently heard concerns about the possibility of
duplication of services and I wanted to know, if you could
share with us if you agree with that or what are--what is your
opinion?
Mr. Atizado. Well, thank you so much for that question,
Congresswoman Brownley. I have to disagree with the perception
that there is a duplication of services. It may appear on paper
that some of these services are doing the same thing, but when
it is actually applied to a specific veteran, the patient, and
the family caregiver, they are quite distinct.
One of the key parts about the Caregiver Program, the
Comprehensive Caregiver Program, is that it integrates all of
these services. They have a support coordinator whose
responsibility is to make sure that these needs, the caregiver
and veteran's needs, are met in an integrated fashion.
When you are in the general Caregiver Program, it is not.
So, I want to make a distinction about that.
And there was another comment earlier, I want to--I would
like to speak to on this particular topic--there was a
discussion about a benefit called Aid and Attendance. That is a
benefit that was referenced that is paid to the veteran, which
is wholly distinct from the modest stipend a caregiver gets in
the Caregiver Program that is paid to the caregiver.
The reason why on paper this looks like a duplication of
services is because it appears to be serving the same need and
the difference is this, Congresswoman, Aid and Attendance
benefit is a compensation to the veteran that is able to, as
best as possible, distinguish a higher level of disability.
When a veteran is a 100-percent service-connected, like, I
am sure the past national commanders behind me are versus
somebody that is spinal-cord injured at the neck level and they
are bound to a bed, they, too, are 100 percent, but their
severity of need and disability is quite difference. And what
Aid and Attendance does is recognizes that greater severity of
disability above and beyond 100 percent.
And so I think what is most important here is that these
services that Chairman Roe had mentioned, the home and
community-based services, the Veteran-Directed Care, which is
in our testimony and may have been discussed earlier, that
these services be integrated in a sensible manner, rather than
fragmented, which does lend to waste and abuse.
And so a Comprehensive Caregiver Support Program really
fights against these fragmented services, integrate them in a
smart way in supporting the caregiver and the veteran at home.
Ms. Brownley. Thank you. And Ms. Dean, do you have anything
to add?
Ms. Dean. Only that, to recognize the function of a
caregiver in this program is within the directive, it says that
they are supposed to be providing supports that exceed what
would generally be expected from a spouse, et cetera. So, they
have agreed, under the physicians plan, that they will do X, Y,
and Z, that is required to keep this veteran at home. They are
there to serve a function. They aren't being paid to be a
family member; they are doing work.
The other thing is that the stipend is capped at the
understanding that they are only working a maximum of 40 hours
a week and we all know that they probably are working a great
deal more than that, but if they can manage, perhaps, only 40
hours a week, then they likely need to have a second job, and
then that second job means that they are unable to do other
things that maybe veteran-directed can then assist them with,
like coming in and offering them respite care or coming in and
shoveling the sidewalks or mowing the lawn or cleaning the
gutters, doing things that they need that they can't possibly
get to if they have a critical veteran who needs all their
attention or if they are trying to juggle jobs and care.
Ms. Brownley. Thank you. And I have limited time left, but
I wanted to ask the question to the panel, so in your opinion
in dealing with current challenges that we have talked about
today, to the Caregiver Program, prevent it from being expanded
to include all ages, all eras, I have a feeling I know the
answer, but, you know, if, for the record, you could just state
your opinion.
Mr. Atizado?
Mr. Atizado. So, clearly, we believe that VA can improve
this program and expand at the same time.
Ms. Brownley. The same time, very good.
And could you also comment about whether or not you believe
that veterans with severe post-traumatic stress benefit from
the Caregiver Program.
Mr. Atizado. Absolutely.
Ms. Brownley. But you don't see any barriers to that,
right, in terms of that not being a qualifier for being a part
of the program?
Mr. Atizado. Well, it shouldn't be; it is now for post-9/11
veterans--
Ms. Brownley. Correct.
Mr. Atizado [continued]. --so, we hope to carry that on, as
the Secretary of Veterans Affairs had said earlier, the current
eligibility criteria is--it should be carried forward. I
believe he wants to tighten up a little bit. The way we would
like to reform the eligibility criteria is to include illness.
Ms. Brownley. Thank you. That message was loud and clear. I
yield back.
The Chairman. I thank the chairlady for yielding.
Mr. Rutherford, you are recognized for 5 minutes.
Mr. Rutherford. Thank you, Mr. Chairman.
Mr. Swab, the--on the eligibility issue, could you talk to
whether you believe, for example, work outside the home by the
veteran or the caregiver, whether that should impact on that
eligibility?
Mr. Schwab. I think that each situation for every caregiver
is different and as Meg Kabat mentioned earlier, there is a
continuum of care and there are caregivers all along that
continuum.
Some of the folks that I know that are in the program who
spend 30 to 40 hours a week caring for their veteran have to
work because they are the sole breadwinner for the family and
many of them are doing that through work-at-home programs.
Hilton has a terrific work-at-home program that hires a lot of
caregivers to be reservation agents, and so they are putting in
double duty. So, yeah, there is a significant percentage of
caregivers who needed to both.
Mr. Rutherford. Okay. That is kind of a good segue into my
next question. Are you aware of any other government programs
that could--that the veterans could access to assist in this
caregiver need that they have?
Mr. Schwab. Well, Congressman, I think that is a great
question, and the Secretary mentioned a new piece of
legislation that the president just signed, the (RAISE) Family
Caregivers Act, which empowers the secretary of HHS--it
actually requires the secretary of HHS to bring an interagency
strategy group together to begin to better organizing across
the Federal government, benefits for family caregivers--
Mr. Rutherford. Uh-huh.
Mr. Schwab [continued]. --and to enact and develop a
national strategy for family caregivers.
So, I think we are going to see over the next year, a great
deal of attention across the Federal government and among
agencies to better organizing those services and support and
coordinate them for veterans and family caregivers.
Mr. Rutherford. Yeah, and that is kind of what, Atizado--
Mr. Atizado. Yes, sir.
Mr. Rutherford [continued]. --I think that is kind of the
point that you were making about the coordination of effort.
And do you believe--and this is for all three Members--do you
believe that there are offsets that we could find within VA
through, you know, better coordination and integration of some
of these programs?
Mr. Atizado. Mr. Rutherford, I would like--that is a great
question, and I want to rephrase that question just a little
bit. I think the discussion here today is about how to spend
the resources that VA has smarter so that you could use
whatever is not used on other needs.
Mr. Rutherford. Right.
Mr. Atizado. And so, to that point, I think the Caregiver
Program speaks to that. All of these home and community-based
services speak to that.
But one thing that I want to make sure doesn't get past
this Committee, is that because VA buys a lot of these home and
community-based services, they require an authority to do that,
which, as many of you know, is a temporary authority. There
is--the VA is now at risk of losing the ability to buy these
services in the community because their provider agreement
authority will cease to exist when the Choice Program
terminates.
Now, having said that, I want to point out that these
integration of services is working already today, Mr.
Rutherford. I believe we have somebody in our audience from
another federal agency that VA has collaborated with to
establish what is called the Veteran-Directed Care Program.
That is a very strong partnership between CMS and VA, and what
they do is they utilize expertise at both, VA and CMS, to
deliver services in the veteran's home.
And that is a great partnership and it has shown to save
money; in fact, there was a facility--I want to say it is in
Cleveland--that shows that they saved about $100,000 just on
one patient alone, just for that one program.
Mr. Rutherford. Uh-huh.
Mr. Atizado. So, I think the smarter use of resources is
what we are--we need to reframe our thinking about the costs of
this program. It is a smarter use of resources.
Mr. Rutherford. Thank you. Any other comments? Thank you.
And I see that Mr. Secretary is still here, so I want you
all to know that I look forward to working with you on those
provider agreements so that we don't have that lapse. And with
that, my time is expired.
Thank you, Mr. Chairman. I yield back.
The Chairman. I thank the gentleman for yielding.
Ms. Esty, you are recognized.
Ms. Esty. Thank you, Mr. Chairman. And to the three of you
and to the veterans and caregivers you represent so ably, thank
you. Thank you for your service and your passion and your
tireless persistence so that we do better on this issue. I know
several of the organizations have been working with me on the
expansion legislation.
And I do want to note that both of the stories that you
spoke of involved illness and the bill that we have introduced
would cover illness. And I think it is really important, Mr.
Secretary--and I want to thank you for staying, and I think
that is really important that you stayed, and I want to thank
you. Not everybody on the Committee could, but it is important
that you hear from the VSOs as well, so thank you.
But I think, absolutely, we have to figure out a way to
include illness. It is simply unjust and unfair not to include
illness, so I think we do need to do that.
We are looking at--you heard the discussion about a better
use of resources and that is critically important to meet those
needs. There was discussion about the expansion, which I am
fully in favor of to pre-9-1-1, where, frankly, many of those
are hitting greater needs, escalating needs, not declining
needs, and I do think we need to figure out some way to grapple
with those, too, as we have seen suicide rates going up of
Vietnam-era veterans.
People are experiencing now, later in life, different kinds
of disabilities than, perhaps, they did earlier. So I think it
is vitally important that we support families and help these
wounded warriors.
I would like you, each, the three of you, to comment on the
Secretary's proposal that we try to concentrate that focus
through some mechanism of, as he described, Tier 3, which
certainly the folks who talked about it, would be Tier 3, and a
cognitive component. Now, ideally, I think we would want
everyone to be fully covered in every respect, but trying to
get your feedback, as we try to find a way forward with the
limited resources that we have, what would you want to see a
cognitive component to cover?
I am assuming yes on illness would have to be a part of
that. Any part of that--any Tier 3 would need illness and not
just injury. I would be fighting--will be fighting for
inclusion of illness.
But can you talk about, given this population pool, what
you would advise us, as we try to find a way forward.
Mr. Schwab. Thanks for that question, Congresswoman, and
for all your support. You have been a terrific supporter of
caregivers.
And I want to commend the Secretary, who has been on the
record now, several times, that he has committed to expansion
and we work with him on a regular basis at The Dole Foundation;
he has just a terrific partner.
Specifically, on your question, and the notion of starting
with Tier 3, I think it is encouraging that we are beginning to
talk about pursuing expansion and I think it is really worth a
thoughtful conversation and to explore a timeline on how we
move beyond Tier 3 and make sure that all pre-9-1-1 caregivers
who need and deserve support and this benefit, receive it.
So, we would want to have a thoughtful conversation around
cognitive issues and we think illnesses should be included, and
I have said that on the record, so, yeah, I think we are open
to that thoughtful conversation.
Ms. Dean. We certainly won't oppose any efforts to expand
in any way, but--and if starting with Tier 3 is what we have to
do to start, then we will absolutely support that.
I just think that--I just don't want to lose sight of the
fact that if there is a clinical need for a caregiver, whether
it is 10 hours a week or not, that that clinical need is still
met, because it is a service-connected need and it is
clinically determined, it still has to be met at some point.
So, if we start at Tier 3, it just won't be the end of the
conversation, but we will support that.
Mr. Atizado. Congresswoman, first of all, I want to thank
you for your bill and for championing the need to include
illness and all pre-9-1-1 veterans into the Caregiver Program.
And I would agree with my colleagues, for several years now,
the DAV has been advocating for full expansion and as we know,
as when we--when we have such a lofty goal, incremental
improvements is generally how things happen, so we are not
averse to the Secretary's proposal.
Because I want to make sure that this Committee is
sensitive to this urgency of having to do this. Every day we
have members who are passing away and every day we have family
caregivers who are impoverishing themselves and need help now.
And so we are not lost on that, and so we want to move forward
with this Committee, not only with whatever proposal it is able
to provide--but to move that forward until everybody is
equitably treated.
Ms. Esty. Thank you very much.
The Chairman. I thank the gentlelady for yielding.
I think no further questions and the panel is dismissed. I
thank you very much for being here; it has been very helpful.
And I ask unanimous consent that all Members have 5
legislative days to revise and extend their remarks and include
extraneous material.
Ms. Brownley, do you have any closing comments?
Ms. Brownley. Thank you, Mr. Chairman.
I just want to thank everybody for being here. I think this
has been a very, very productive hearing and I hope that we can
follow up with another hearing or something so that we can kind
of roll-up our sleeves and start working on some of the issues
that are pretty clear that we need to work on.
I just wanted to highlight and get on the record, while the
Secretary is here, as well, is so these coordinators, social
workers, you know, I got some data to find out what the current
ratios are to coordinator to veterans and I just wanted to
point out in VISN 22 and several of their locations, that ratio
is very, very high. And in Los Angeles, it is 1:21. In San
Diego, it is 1:123--Los Angeles is 1:121. San Diego is 1:122.
Long Beach is 1:360.
And Ms. Esty, in New Haven, it is 1:124. So, we need some
work, given the existing program. I think in this hearing, we
have heard how important the coordinators are in terms of
accessing service, so we really need to focus on that right
away, please.
And with that, I yield back.
The Chairman. I thank the gentlelady for yielding.
At first, again, thank you all for being here; I agree with
her, it has been an incredibly productive hearing and it helped
me focus on what is possible. You know, it is rare that I say
anything good about the press, but they actually, as I was
walking back over here, gave me some ideas for a pay-for for
this in a question that they gave me. There is some
possibilities there.
I would like to see us follow up with a roundtable. I have
found those very helpful, where we can just sit around and have
a free flow of information, not in such a formal setting, and
where we can hash out the details that the Secretary mentioned.
And we will--we will ask the Secretary, would you provide
us a framework of where you would like to see this to go. I
would like to include the VSOs and our members, so that we can
all be around that table and discuss that, along with any other
people that would like to be there.
And I think, also, it brings in--I didn't--I sort of forgot
about this--it has put some urgency on getting our Choice bill
passed so that we can get these contracts done. Thanks for
pointing that out again.
And I think there is a way forward. There may not be a way
forward to get everything everybody wants, just because of the
constraints that we have now. We still haven't after, what are
we, six months on--five months into the budget year, hammered
out the caps for this fall of this year's budget. We are going
to vote this afternoon on a continuing resolution.
So, I do--I begin to see a way forward with this Caregiver
Program for our post-9/11. I happen to be one of those. I see
my Vietnam-era brothers and sisters all the time at home and
they explain this to me, so I certainly understand that.
I appreciate, and let me just finish by saying how much I
appreciate what the caregivers do and have done, as you have
said, in many cases, for decades, not just a year or five
years, in Senator Dole's case, and, quite frankly, he, for me,
is the epitome of the poster child. One of the true heroes I
have is Senator Bob Dole. I have been in Washington, D.C. for 9
years; I have asked for one autograph, it was his. And he has
the only one I have and there is a reason for that. To me, he
is a true American hero and his wife, Ms. Dole, also.
So, I thank you for bringing that up, being an advocate,
and I look forward to continue this work, and with that, the
Committee is adjourned.
[Whereupon, at 12:43 p.m., the Committee was adjourned.]
A P P E N D I X
----------
HONORABLE DAVID J. SHULKIN, M.D.
Good afternoon Chairman Roe, Ranking Member Walz, and Members of
the Committee. I appreciate the opportunity to discuss the Department
of Veterans Affairs' (VA) Caregiver Support Program, specifically the
Program of Comprehensive Assistance for Family Caregivers (PCAFC). I am
accompanied today by Ms. Margaret Kabat, Acting Chief Consultant for
Care Management, Chaplain and Social Work Service, and Dr. Richard
Allman, Chief Consultant for Geriatrics and Extended Care
Introduction
Providing care for a family member is an issue facing many
Americans, but being a caregiver to a Veteran presents unique
challenges. Research has shown us that caregivers of Veterans differ
from caregivers of non-Veterans in several areas. Caregivers of
Veterans are often younger, provide care longer, and more likely to
attend to complex care needs.
VA, in close collaboration with our Federal agency partners,
leading national organizations, Veterans Service Organizations and
other nonprofit partners in communities across the country, remains
committed to promoting and enhancing Veteran wellbeing through the
provision of unprecedented services and support to caregivers of
Veterans who require the care and assistance of another.
VA recognizes the important role of caregivers and is proud to
support caregivers through PCAFC, as well as the Program of General
Caregiver Support. Last year, more than 400 VA staff, including 350
Caregiver Support Coordinators in VA Medical Centers across the country
provided support and services to individual caregivers. In addition,
57,803 callers contacted the Caregiver Support Line; more than 8,000
caregivers accessed a variety of services and supports including
telephone educational support, face-to-face classes, and peer support
programs; and more than 2,000 caregivers participated in evidence-based
clinical interventions. Also, VA provided services and support to more
than 26,000 family caregivers through PCAFC last year, including a
stipend paid directly to approve primary family caregivers. These
stipend payments totaled approximately $400 million and VA obligated
approximately $12 million for the Civilian Health and Medical Program
of VA for eligible primary family caregivers. PCAFC is a clinical
program that focuses on the needs of both the eligible Veteran/
Servicemember and the eligible primary and secondary family caregivers.
At its core, the program provides enhanced services for eligible
participants which may include a monthly stipend; access to health care
coverage; mental health services; and counseling, caregiver training,
and respite care. It is this program that is the focus of my testimony
today.
Strategic Review
In April 2017, VA launched a strategic review of the current state
of PCAFC. VA heard concerns about inconsistent implementation of the
program and took immediate action to identify challenges and implement
change. This three-month review included a temporary suspension of
specific types of revocations from PCAFC, listening sessions with a
variety of internal and external stakeholders and internal audits.
Results from the review revealed a need for better communication
between VA, caregivers and Veterans about eligibility determinations,
discharges, and the clinical appeals process. Additional findings
included a need for additional internal processes and procedures such
as templated notification letters, documents for VA staff to use with
caregivers to ensure consistency across medical centers, and additional
staff training in both clinical topics such as such as communication
with caregivers and staff safety as well as procedural topics regarding
implementation of policy.
Since that review, VA has made significant advancements in
communication about eligibility determinations; revocations and the
appeals process; and internal processes and procedures and staff
training. Specifically, those advancements include:
Increased communication and engagement with Veteran
Service Organizations, Military Service Organizations, members of
Congress, VA Veteran Integrated Service Network Directors, and other
stakeholders.
Redesigned the Caregiver Support Program Web site to
include a section about connecting caregivers and Veterans to home and
community based services.
Published Veterans Health Administration (VHA) Directive
1152, Caregiver Support Program, and shared it with 80,000 subscribers
to the Caregiver Support Program list-serve to promote transparency.
Issued a new, standardized letter to be used by all VA
medical facilities when communicating program revocations with Veterans
and family caregivers.
Implemented a new ``Roles, Responsibilities and
Requirements'' document that reaffirms that all family caregivers are
collaborative partners with VHA.
These efforts have improved the experiences of Veterans and
caregivers participating in PCAFC, but VA recognizes there is more work
to be done. Last month, with the goal of increasing the opportunity for
public input in the decision making process, VA published a notice in
the Federal Register seeking public comment on eight specific questions
related to the administration of PCAFC. These questions were driven by
feedback received during the strategic review. The public comment
period closed at midnight, February 5, 2018. VA will be reviewing all
comments received and will use the feedback to inform any updates or
changes to the program and its implementing regulations.
Current State
In addition to PCAFC, VA offers many different programs to support
caregivers of Veterans, including a peer support program where
caregivers are connected to one another as well as education and
training provided face to face, over the telephone, and on-line. VA
also offers a series of diagnosis specific caregiver support programs;
one example is our Resources for Enhancing All Caregivers Health
program. This is specifically designed to support caregivers of
Veterans with a variety of conditions including spinal cord injury,
dementia, and post-traumatic stress disorder.
To supplement these support services that are offered directly to
the caregiver, VA also offers services that are focused more on the
Veteran. These services also assist the caregiver in providing the best
care to the Veteran and help the caregiver stay informed, strong, and
organized as they care for the Veteran they love. These programs
include:
Adult Day Health Care (ADHC) Centers
ADHC Centers are a safe and active environment with supervision
designed for Veterans to get out of the home and participate in
activities. It is a time for the Veteran to socialize with other
Veterans while the family caregiver gets some time for himself/herself.
ADHC Centers employ caring professionals who will assess a Veteran's
rehabilitation needs and help a Veteran accomplish various tasks to
maintain or regain personal independence and dignity. The Veteran will
participate in rehabilitation based on his or her specific health
assessment during the day. The ADHC Centers emphasize a partnership
with the family caregiver, the Veteran, and the Centers' staff members.
Home-Based Primary Care
Home-Based Primary Care (HBPC) is a program designed to deliver
routine health care services at home when the Veteran has medical
issues that make it challenging to travel. Services include primary
care and nursing, managing medication, and dietary and nutritional
assessment. HBPC can also include physical rehabilitation, mental
health care for the Veteran, social work, and referrals to VA and
community services. This program can help ease the worry and stress of
having to bring a Veteran to and from a VA medical center for routine
medical appointments.
Skilled Home Care
The Skilled Home Care service provides a medical professional at
home to help care for a homebound Veteran. Some of the care a Veteran
can receive includes basic nursing services and physical, occupational,
or speech therapies. This service is generally appropriate for
homebound Veterans, which means the Veteran has difficulty traveling to
and from appointments and is in need of receiving medical services at
home. The Skilled Home Care service is similar to HBPC, but it involves
VA purchasing care for a Veteran from a licensed non-VA medical
professional.
Homemaker and Home Health Aide Program
The Homemaker and Home Health Aide Program is designed to help a
Veteran with personal care needs. The local VA medical center arranges
for a home health aide who will assist at home on a regular schedule to
allow the family caregiver to take care of their own needs.
Home Telehealth
The Home Telehealth program is designed to give ready access to
clinical providers and care coordinators by using technology (e.g.,
telephone, computers) in the home. The program is beneficial for
individuals who live at a distance from a VA Medical Center. Home
Telehealth services can also include education and training or online
and telephone support groups.
Respite Care
Respite care provides a much-needed break from the family
caregiver's daily routine and care responsibilities so that they have
some time for themselves. VA generally provides respite care to
Veterans in need of such care for up to 30 days per year (or for more
than 30 days, if needed). The care can be offered in a variety of
settings including at home or through temporary placement of a Veteran
at a VA Community Living Center, a VA-contracted Community Residential
Care Facility, or an Adult Day Health Care Center. Respite care may
also be provided in response to a family caregiver's unexpected
hospitalization, a need to go out of town, or a family emergency.
Future State
VA is striving to improve consistency in PCAFC and identify how
best to support family caregivers moving forward. Under current
authority, determining eligibility for PCAFC is extremely complex and
resource intensive; often requiring multiple treatment providers and
assessments. VA's goal is to make the eligibility criteria more
streamlined and easily understood by Veterans, caregivers and staff
members. VA is also currently focusing on how to leverage the 350
Caregiver Support Coordinators in the field to reduce administrative
burden and allow for interactions that focus on Veteran care.
VA is working to improve the PCAFC program by completing a three
pronged approach that is based on stakeholder feedback and
recommendations. The first aspect of the plan included a series of
Rapid Process Improvement Workshops, which involved interactions with
front line VA staff who interface with family caregivers on a daily
basis. During these workshops we identified issues, immediately
determined solutions and implemented them. The second component of this
plan of action included a face-to-face Process Improvement Summit
whereby internal and external stakeholders, including representatives
from various Veteran and Military Service Organizations, were invited
to share feedback and insights into potential improvement strategies.
VHA leadership spoke at the event and two local caregivers shared
personal stories of caring for a Veteran loved one. Finally, VA invited
the public to provide input on the PCAFC through a Federal Register
Notice, as discussed earlier.
Conclusion
When Veterans are unable to care for themselves, VA and its Federal
and community partners must work together to ensure that the Veteran is
receiving the appropriate care that they need. Sustaining the momentum
and preserving the gains made so far requires continued attention and
investments of financial resources. When the PCAFC launched in May,
2011 it was the first of its kind and incredibly innovative. It is
critical that we continue to move forward and support the program in a
well thought out and deliberate fashion.
Mr. Chairman, this concludes my testimony. My colleagues and I are
prepared to answer your questions.
Prepared Statement of Adrian Atizado
Mr. Chairman and Members of the Committee:
Thank you for inviting DAV (Disabled American Veterans) to testify
at this hearing of the House Veterans' Affairs Committee. DAV is a non-
profit veterans service organization (VSO) dedicated to a single
purpose: empowering veterans to lead high-quality lives with respect
and dignity. For many severely ill and injured veterans, leading such
lives would be difficult if not impossible to achieve without the love,
support and daily sacrifice of their family caregivers, and we
appreciate the opportunity to discuss their needs and the Department of
Veterans Affairs (VA) caregiver programs.
The Caregivers and Veterans Omnibus Health Services Act of 2010
(P.L. 111-163) required VA to establish a program of comprehensive
assistance for family caregivers (Comprehensive Program) of any
eligible veteran who has a serious injury, including traumatic brain
injury, psychological trauma, or other mental disorder, incurred or
aggravated in the line of duty on or after September 11, 2001, and is
in need of personal care services. Caregivers participating in the
Comprehensive Program can receive certain medical, travel, training,
support services, and financial benefits. The law also required VA to
establish a program of general caregiver support (General Program) that
provides limited services to caregivers of wartime veterans injured
prior to September 11, 2001.
In addition, the law required the Secretary to review the program
after two years and recommend whether it was feasible and advisable to
expand eligibility to severely disabled veterans of earlier eras, such
as World War II, the Korean, Vietnam and Gulf Wars. Unfortunately,
despite early indications at that time that the program was improving
the lives of eligible veterans and caregivers - and mounting evidence
since that the program continues to materially support so many veterans
and family caregivers - it still remains limited only to post-9/11
veterans.
Mr. Chairman, we are grateful that the Committee is holding today's
hearing to examine how to strengthen and modify the existing caregiver
program to become more efficient and effective and will offer a number
of recommendations to improve it. However, there is no issue more
important today than finally correcting the gross unfairness and
inequity that discriminates against veterans ill and injured prior to
September 11, 2001, as well as their family caregivers.
How can we look these men and women in the face - some of whom are
here with us today - and tell them that their service and sacrifices do
not merit equitable access to all caregiver benefits? How can we say
that their spouses, parents, siblings, children, and close friends who
also sacrifice to be their caregivers, do not deserve the same support
as those caring for post-9/11 veterans? There is simply no defensible
argument for maintain the arbitrary date placed into law, other than
the cold financial calculation of saving money, which transfers the
burden of caring for so many severely disabled veterans onto the
shoulders of family caregivers, many of whom have carried that heavy
responsibility for decades.
Mr. Chairman, today, DAV, along with virtually all of our VSO
colleagues, call on this Committee to take bold and decisive actions,
similar to what the Senate Veterans' Affairs Committee did last fall,
and pass legislation that will end this inequity by extending
eligibility for the full array of caregiver benefits and services to
veterans from all eras.
In addition to those ineligible because they were injured before
September 11, 2001, the law as implemented precludes disabled veterans
who became severely ill, regardless if that occurred on or after that
fateful day. As a result, thousands of post-9/11 veterans with
catastrophic illnesses, such as those on the Congressionally-mandated
Open Burn Pit Registry (P.L. 112-260) or those exposed in 2003 at
Qarmat Ali, Iraq to a chemical known to cause lung cancer and
respiratory problems. And if the cutoff date were changed but the
program remained limited to veterans who suffered injuries, it would
continue to exclude hundreds of thousands of veterans who suffer from
chronic diseases associated with exposure to herbicides like Agent
Orange, as well as those who are suffering from Gulf War Illness.
Fairness for all veterans requires that the law recognize the hazards
of military services by including not just those who suffered wartime
injuries, but also those who suffer debilitating wartime illnesses.
Effectiveness of VA's Caregiver Support Program
For today's hearing, the Committee has indicated its interest in
examining the Comprehensive Program for its effectiveness ``in serving
the highest-need veterans and their caregivers,'' the reforms needed to
successfully expand eligibility including alternative approaches to
expansion and opportunities to adopt best practices from other VA
programs and benefits without duplicating services, and the public
response to the Agency's request for public comment for any changes
needed to increase consistency across the Comprehensive Program, as
well as ensure it supports those family caregivers of veterans service
members most in need. However, to discuss effectiveness of the program,
we must first agree on the purpose and goal of the program.
When the legislation was being debated in Congress, the President's
Commission on Care for America's Returning Wounded Warriors found that
21 percent of active duty, 15 percent of reserves, and 24 percent of
retired or separated service members who served in Iraq or Afghanistan
had friends or family members give up a job to be with them as their
caregiver. In doing so, they had to give up their health insurance and
spend their savings at a time when they chose to stay home and
selflessly care for the veteran. Congress recognized that even without
a job or health insurance, and in very stressful situations, family
caregivers worked to fulfill the nation's obligation to care for its
wounded warriors at great personal cost. Both the VA Comprehensive and
General Program, collectively referred to as the Caregiver Support
Program, were created to mitigate this situation.
Last June, DAV released a comprehensive report on veteran
caregivers entitled ``America's Unsung Heroes'' (www.dav.org/wp-
content/uploads/Caregivers--Report.pdf) in order to document the
challenges and needs of veteran caregivers of all eras. The report
contained a qualitative online survey conducted by DAV, which received
1,833 validated responses from veterans and caregivers. The results of
the survey offer a deeper look at the hurdles all veteran caregivers
face, as well as the supports they receive and need to help care for
their loved ones. This report provides a clearer picture of the lives
of veterans' caregivers to help guide critical public policy changes in
the coming years. We include findings of this report pertinent to the
work of this Committee for this hearing.
In speaking to the effectiveness of the Comprehensive Program, the
survey DAV offered veterans and caregivers participating in the program
the opportunity to provide their perspective. The comments included
below exemplify the views we received of the effectiveness and value of
the Comprehensive Program:
Caregiver, Spouse, 38, teenage children
We depend on the Caregiver Program more than you can imagine. I
miss doing what I love (my career) but I love my husband and my
children, so it can be such a struggle some days. I have found that the
older the children get the more strenuous it is at home as well, due to
the typical ``teenage'' stuff, but it affects my husband and myself. My
husband depends on me in so many ways that there are days when I am
just so exhausted, but I continue on because I know he needs me. We
need so much support so we can continue to better ourselves, our
spouses, and our families as a whole.
Caregiver, Spouse, 39, teenage children
I am currently participating in the Caregiver program through the
VA. I have been extremely thankful for this program because of the
education provider gave me coping skills and helped me learn to achieve
stability in our family that was most certainly not there before.
Veteran, 37, spouse is caregiver
If we are speaking of quality of life, it would be quite the
contrast from living in fear and disparity, to living in hope and
security. Even the most responsible and capable person can be reduced
to a hopeless and destitute in the wake of traumatic events and
experiences. Having a familiar face, who is educated in the fields in
need, to help bring a positive daily expectation of life is my most
precious commodity today. Recovery is possible, but I cannot fathom
moving forward without the help provided by my spouse with the
assistance of the caregiver program.
Mr. Chairman, these are the real life results of the current
program indicating it is working as intended. But there is always room
for improvement, which is why DAV has advocated from the program's
inception to integrate a research component. Studies performed with the
VA Caregiver Support Program could help find answers such as how to
effectively support family caregivers of severely ill and injured
veterans in a cost-effective manner and could better inform program
managers, policy makers and the public.
To this end, VA should be commended for embarking on a research
initiative and funding the VA Caregiver Support Program Partnered
Evaluation Center in April 2014. This three-year collaborative
partnership project was to evaluate the short-term impacts of the
Comprehensive Program and the General Program along four aims: 1)
assessing the program's impact on the health and well-being of veterans
by examining health care encounters expected to be sensitive to
caregiver support (potentially avoidable utilization); 2) assessing the
impact of the both the Comprehensive and General Program on the health
and well-being of family caregivers; 3) understanding how caregivers
use and value components of both programs, and; 4) gain a preliminary
understanding of the relationship between the cost of Caregiver Support
Programs and their value to caregivers.
VA was able to compare a small number of caregivers enrolled and
not enrolled in the Comprehensive Program and found that caregivers in
the Comprehensive program felt more confident in their caregiving, were
more aware of resources to help in their caregiving role and felt more
confident in supporting their veteran.
According to VA, the short-term impact of program participation
includes an increase in utilization of VA primary, mental health, and
specialty care, and long-term services and supports. However, the cause
of increased utilization remains unclear as well as whether it will
lead to better health outcomes and thus fewer health care costs in the
long term.
VA also deemed it necessary in 2017 to extend VA-CARES with a long-
term evaluation project. This project will examine the effect of the
Comprehensive Program on a veteran's total health care costs at three
years, conduct a formative evaluation of the application process to
identify areas and approaches for improving consistency across VA, and
examine potential changes in the level of stress of caregivers
participating in the Comprehensive Program. DAV eagerly awaits the
deliverables of this project in 2019.
Such commitment by VA recognizes the Caregiver Support Program
embodies the most sweeping national support program for family
caregivers. We urge Congress to support VA's efforts to leverage this
first and only national program of its kind to better inform policy
makers and other health care systems considering supporting family
caregivers across the nation.
Understanding caregivers' burdens and needs can help identify those
most at risk for health and mental health effects and support them
appropriately. Effectively supporting caregivers can delay placing
veterans in more costly care settings such as emergency rooms and
nursing homes. It is imperative that Congress require and fund a
military and veteran caregiver research strategic plan to monitor the
health and well-being of family caregivers and the recipients of their
love and support; to study current and innovative interventions, their
availability, accessibility, and use in supporting family caregivers;
and study military and veteran caregivers from a public health
perspective.
Needed Reforms in the Comprehensive Program, VA
As has been reported, the need for comprehensive caregiver support
services by family caregivers of severely injured veterans was greater
than anticipated by Congress and the Administration when the
Comprehensive Program experienced significantly higher than expected
demand in the years following implementation. With insufficient
resources and funding, and higher than expected demand, additional
challenges emerged in the timely processing of applications,
consistency in applying the eligibility criteria, lack of program
staffing in central office and the field, inadequate Information
Technology (IT) support, and other issues.
We applaud VA's efforts to address each of these challenges, to
include amending regulations of existing programs such as ensuring
service members undergoing medical discharge with a qualifying primary
or secondary family caregiver is able to apply for the Comprehensive
Program \1\ and has access to VA's Home Improvements and Structural
Alterations (HISA) Benefits Program \2\, improving veterans and family
caregiver experiences with State Home adult day health care programs
\3\, and to ensure family caregivers would be able to maintain
eligibility on behalf of a veteran in the VA Veteran-Owned Small
Business Verification Program.
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\1\ 79 Federal Register 59562, October 2, 2014.
\2\ 78 Federal Register 69614, November 20, 2013.
\3\ 80 Federal Register 34793, June 17, 2015.
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To improve Comprehensive Program operations, VA amended existing
regulations in January 2015 to ensure veterans are notified in writing
should a family caregiver request to no longer be the caregiver,
extending from 30 to 45 days the time the family caregiver has to
complete all required training, and a change in the stipend calculation
to ensure that primary family caregivers do not experience unexpected
decreases in stipend amounts from year to year. \4\ VA also continues
to work on stabilizing the current IT supporting the VA caregiver
support program and identifying and implementing a more permanent
solution.
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\4\ 80 Federal Register 1357, January 9, 2015.
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Since the interim final regulations \5\ for the Comprehensive
Program were made final in January 2015, DAV had been strongly
advocating that more consistent guidance be issued to the field
governing local program operations including changing how VA
historically treated family caregivers, clearer staffing
responsibilities, consistent application of eligibility rules and
discharge procedures for the Comprehensive Program, and greater
transparency of calculating tier assignments. VA finally issued a
program directive in June 2017. \6\
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\5\ 76 Federal Register 26148, 26148
\6\ Veterans Health Administration Directive 1152, Caregiver
Support Program, June 14, 2017.
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This long overdue directive was distributed far and wide in the
midst of a temporary suspension initiated in April \7\ of discharging
or revoking caregivers out the Comprehensive Program and to conduct an
internal review to evaluate the consistency of the program nationwide.
We commend VA for the suspension and for conducting its review with
input from stakeholders, including caregivers across the country, DAV
and other VSOs. Upon its completion, VA reinstated full operation of
the program in July \8\ making significant changes to the program to
affect policy and execution moving forward. This change includes
mandatory VA staff training of the new directive, standardizing program
information, a Frequently Asked Questions webpage for the program and a
document outlining the roles, responsibilities and requirements for
Caregiver Support Coordinators, family caregivers and veterans
participating in the Comprehensive Program.
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\7\ VA Press Release, ``VA Announces Internal Review of Caregiver
Program,'' April 17, 2017.
\8\ VA Press Release, ``VA Caregiver Support Program Resumes Full
Operations,'' July 28, 2017
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Communications. Based on DAV's long-standing concerns regarding
appropriate and meaningful communication with veterans and family
caregivers in the Comprehensive Program, we are particularly interested
in VA's recent changes to its communications with stakeholders,
including a standard discharge letter to provide, in plain language,
the reasons for discharging participants from the Comprehensive
Program.
We recommend VA improve and standardize its Comprehensive Program
decision letter. To ensure veterans and caregivers understand the
reasons and bases of the decision, the letter should contain, at the
minimum:
Identification of the issues decided;
A summary of the evidence considered (to ensure
completeness of medical evidence);
A summary of applicable laws and regulations;
Identification of findings favorable to the applicant;
In the case of a denial, identification of elements not
satisfied leading to the denial;
An explanation of how to obtain or access evidence used
in making the decision; and
Identification of the criteria that must be satisfied for
a favorable decision.
With these basic elements included in VA's communication
articulated with reasonable clarity, veterans and caregivers would be
able to make a more informed decision to agree with or appeal the
decision. This is particularly important because of certain limitations
of the current clinical appeals process.
DAV identified early on the need for an independent mechanism
through which: (1) a caregiver can appeal a clinical decision; (2) the
decision can be carefully reviewed de novo; and (3) an unwarranted
decision can be reversed, altered, or sent back to the clinical team
with instructions to reassess or consider additional factors.
In this vein, we also applaud this Committee's work to address
other issues in the Comprehensive Program in 2016 when it passed H.R.
3989, the Support Our Military Caregivers Act, which was intended to
establish an expedited external review process for cases in which the
veteran or family caregiver disagreed with VA's decision. Accordingly,
DAV supported H.R. 3989.
Respite Care. When DAV survey participants were asked about the
importance of respite care, nearly 60 percent indicated it is important
or very important; however, only a small minority (seven percent)
receives respite care, of which only three percent believe they are
receiving enough respite, while the vast majority (93 percent) are not
receiving any respite whatsoever.
The DAV survey found that approximately one of every three veterans
with family caregivers also had children living at home; 20 percent had
children younger than 18 living with them. As expected, this was
principally the case for post-9/11 veterans where 67 percent had
children at home, including just over a third of the post-9/11
households (34.3 percent) who had children under 12 years old. However,
having children in the same household impacts respite care delivery to
the caregiver, particularly if agencies are utilized and do not provide
child care while caring for the veteran. That is, the caregiver is
unable to truly experience respite if their caregiving responsibilities
shift from the veteran to the children. Caregivers may not also be
using this critical benefit due to unavailability of service in their
community and because they are concerned about entrusting the health
and well-being for their veteran to a complete stranger.
It is imperative VA identify local barriers to receiving respite
care in the most convenient setting for the caregiver and veteran. We
fully support VA's current efforts to use every means available, such
as innovating an existing program, the Veteran Directed Home and
Community Based Services (VD-HCBS) to address this unmet need.
Stipend. Stipend funds under the Comprehensive Program are
determined primarily using Activities of Daily Living \9\ and
Instrumental Activities of Daily Living \10\ to assess the caregiver's
burden, which may not give adequate weight to caregivers of veterans
with behavioral health issues, including those with severe post-
traumatic stress disorder or traumatic brain injuries. These veterans
may be able to handle daily tasks, but need constant supervision and
support to ensure that they are not threats to themselves or others and
require more assistance with managing the administrative tasks of daily
living.
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\9\ Basic and fundamental functions of daily living (ADLs) such as
bathing, toileting, dressing, grooming, getting in and out of bed or
chair, walking, climbing stairs, and eating.
\10\ Functions necessary to live independently in the community
such as shopping, housekeeping, managing money and medication,
preparing meals, communicating with others, and driving or using public
transportation.
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In addition, the condition of some severely injured veterans
improves and declines over time, yet VA national policy is silent on
how to mitigate the effect of tier reductions and subsequent stipend
reduction. With tier reductions having the greatest potential for
adverse effect, VA should revise the immediacy of the effective date
for tier reductions/stipend reduction to lessen the financial impact on
veterans and caregivers.
We note that if revocation of the designation of primary caregiver
is due to improvement in the veteran's condition, death, or permanent
institutionalization, the family caregiver will continue to receive
caregiver benefits for 90 days. We recommend VA apply this procedure of
continuing the stipend rate for 90 days prior to reduction.
Needed Reforms in Comprehensive Program, Congress
In contrast to VA's Comprehensive Program, DoD's Special
Compensation for Assistance with Activities of Daily Living (SCAADL)
program covers injuries as well as illnesses. The program helps offset
the lost income of the primary caregiver who provides nonmedical care,
support and assistance for service members with catastrophic injury or
illness, but does not provide health insurance, respite care,
counseling, training or other benefits that accrue to caregivers under
PCAFC. Program participants transitioning from military to VA benefits
may be unprepared to deal with the significant differences in these
programs.
In addition, VA is authorized to provide counseling, training and
mental health services to members of the veteran's immediate family,
the veteran's legal guardian and to the individual in whose household
the veteran certifies as intending to live. In accordance with this
law, these services are only provided for: 1) veterans receiving
treatment for a service-connected disability if the services are
necessary in connection with that treatment; and 2) veterans receiving
treatment for a nonservice-connected disability if the services are
necessary in connection with the treatment, the services began during
the veteran's hospitalization, and the continued provision of the
services on an outpatient basis is essential for discharging the
veteran from the hospital. Such restrictions in law and resulting
policies may perpetuate the treatment of family caregivers as
incidental to the care of veterans rather than as the primary recipient
of such caregiver supports.
Needed Reforms in General Program
Severely ill and injured veterans of all war eras want the option
to live at home with appropriate supports for them and their family
caregiver. VA's efforts to provide long-term care in home- and
community-based settings will reduce the need for nursing home
admissions and preventable hospitalizations. However, like many home-
and community-based services that could support veterans and family
caregivers, Government Accountability Office (GAO) reports have
consistently described gaps in access and availability of these
critical services.
VA should be commended for finally issuing a unified policy for
providing long-term services and supports to include support services
for caregivers of severely ill and injured veterans who are not
eligible for the Comprehensive Program. VA offers a relatively robust
and innovative set of home-and community-based services that support
both the veteran and their family caregivers. The unified policy issued
in October 2016 is a strong step towards addressing the long-standing
issue of access and availability.
To execute this policy, VA must grow total spending for home- and
community-based services. While there have been tremendous strides
increasing spending on home- and community-based services as a ratio of
total long-term services and supports spending-nearly doubling from 16
percent in FY 2010 to 31 percent in FY 2015, with commensurate
decreases in the proportion of total long-term services and supports
spending on nursing home care, going from 84 percent to 69 percent, VA
must continue this effort if it is to provide appropriate supports for
severely ill and injured veterans and their family caregivers and see
the cost saving sociatedth \11\such \12\spending \13\.
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\11\ ``Toward a Model Long-Term Services and Supports System: State
Policy Elements.'' H. Stephen Kaye, PhD, John Williamson, PhD, The
Gerontologist, Volume 54, Issue 5, 1 October 2014, Pages 754-761.
https://doi.org/10.1093/geront/gnu013; H. Stephen Kaye, ``Gradual
Rebalancing of Medicaid Long-Term Services and Supports Saves Money and
Serves More People, Statistical Model Shows,'' Health Affairs, June
2012, http://content.healthaffairs.org/content/31/6/1195.
\12\ Kali Thomas and Vincent Mor, ``Providing More Home-Delivered
Meals Is One Way to Keep Older Adults with Low Care Needs out of
Nursing Homes,'' Health Affairs, October 2013, http://
content.healthaffairs.org/content/32/10/1796.ful
\13\ Carol V. Irvin et al., Money Follows the Person 2014 Annual
Evaluation Report, Mathematica Policy Research, Washington, D.C.,
https://www.mathematica-mpr.com/our-publicationsand-findings/
publications/money-follows-the-person-2014-annual-evaluation-report.
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Home Based Primary Care. Veterans and family caregivers would
benefit from VA's Home Based Primary Care (HBPC) program, which has
been shown to reduce total VA and Medicare costs by 12 percent. VA must
continue to expand access to this program and make it available at all
VA facilities.
Veterans-Directed Home & Community Based Services. Because of the
eligibility restriction to the Comprehensive Program, the statutory
requirement acknowledges VA must collaborate with other entities that
support caregivers. DAV has also advocated for VA to take full
advantage of Public Law 111-163, which states ``the Secretary shall
collaborate with the Assistant Secretary for Aging of the Department of
Health and Human Services in order to provide caregivers access to
aging and disability resource centers under the Administration on Aging
of the Department of Health and Human Services.''
The VD-HCBS is administered through a partnership with Health and
Human Services Administration for Community Living (ACL) and has proven
to be a program that can meet the needs of some of VA's most vulnerable
populations, including many who would likely be placed in nursing homes
without this option.
Through VD-HCBS, the veteran has the opportunity to manage a
monthly budget based on functional and clinical need, hire family
members or friends to provide personal care services in the home, and
purchase goods and services that will allow him or her to remain in the
home. We will hold Secretary Shulkin accountable for his commitment ,
made during his nomination hearing in February 2017, to expand access
to the VD-HCBS program, to make it available at every VA medical center
within the next three years.
A recent analysis of VD-HCBS participants' health care use in FY
2015 before and after enrolling in this program found 29 percent
reduction in inpatient days of care, 11 percent reduction in emergency
room visits and 14 percent reduction in other than home- and community
based services. While not conclusive, it suggests clear potential of
reducing health care costs.
However, this program, like many home- and community-based programs
supporting veterans in their home, relies on provider agreements. VA
currently has a temporary Choice Provider Agreement authority, which it
is using to the greatest extent possible with the number of veterans
served increasing 37 percent to 1,751 in fiscal year (FY) 2016. In FY
2016, 81 VD-HCBS providers have entered into VA Choice Provider
Agreements with VAMCs and 30 new VD-HCBS providers have been approved
to deliver VD-HCBS services to veterans, which has expanded access for
veterans in over 130 rural and highly rural counties.
Provider Agreement Authority. To help VA provide these and many
other cost effective home- and community-based services programs,
Congress must enact legislation granting VA permanent authority to
enter into provider agreements with community providers.
In addition, VA and Congressional oversight is necessary to
continue implementing effective strategies based on measuring veteran
and family caregiver needs for increased access to home- and community-
based services, creating an appropriate balance with nursing home care,
and ensuring veterans are able to stay in their own homes, with
appropriate supports for them and their family caregiver for as long as
possible.
DAV recommends VA monitor and publicly report progress of
individual facilities and regional networks toward meeting performance
measures that focus on rebalancing long-term care, which includes
increasing the availability and access to home- and community-based
services. VA should focus first on expanding HBPC and VD-HCBS, while
leveraging opportunities under the Veterans Choice Program.
Need to Expand Eligibility to Comprehensive Caregiver Support Program
Mr. Chairman, as discussed above, the most critical reform to the
program is expanding eligibility to veterans from all eras. Research
has shown that family caregivers delay, avoid, and, in certain
situations, can actually help transition disabled veterans out of,
expensive nursing homes. Allowing severely disabled veterans to remain
in their homes longer is economically smart and will more efficiently
use VA and taxpayer funds.
As this Committee is aware, their Senate counterparts approved S.
2193, the Caring for Our Veterans Act of 2017, which includes
provisions to improve and phase-in expanded eligibility for the
Comprehensive Program for family caregivers. According to CBO, stage
one of the expansion under this bill to eligible veterans who were
injured during service on or before May 7, 1975, would carry an average
cost per participant of $30,000 in 2020. Stage two of the expansion to
remaining eligible veterans-those injured during service after May 7,
1975, and before September 11, 2001, with an average cost per
participant of $29,000 in 2022.
The annual cost estimated by the Congressional Budget Office for
each veteran severely ill and injured before September 11, 2001, to
participate in the Comprehensive Program is about $30,000 compared to
the federal cost of nursing home care of over $60,000 in State Veterans
Homes (matched by equal or greater state funding), $100,000 in
community nursing homes, and about $400,000 in VA nursing homes.
To those who are concerned about the cost of doing the right thing
for all severely disabled veterans and their family caregivers, we
cannot now turn our back on the obligation to care for those who fought
to defend our way of life. The cost of veterans benefits and services
is a true cost of war and must be treated as such. It is an obligation
this nation must shoulder and share by supporting disabled veterans and
their family caregivers.
After a lifetime of caregiving for Gulf, Vietnam, Korean and World
War II veterans, many family caregivers are aging and their ability to
continue in their role is declining. With bipartisan support in the
Senate, and growing support in the House, now is the time to finally
provide fairness to caregivers of veterans from all eras.
Mr. Chairman, we call on this Committee to expand eligibility for
VA's comprehensive caregiver support program to veterans severely ill
and injured from all eras and their family caregivers.
This concludes my testimony and I would happy to respond to any
questions that you may have.
Prepared Statement of Sarah S. Dean
Chairman Roe, Ranking Member Walz, and members of the Committee,
Paralyzed Veterans of America (PVA) would like to thank you for the
opportunity to present our views pertaining to the Department of
Veterans' Affairs Comprehensive Family Caregiver Program. PVA
appreciates the Committee's interest in the improvement and potential
expansion of this unique and critical program. No other group better
understands the value of caregiver support than PVA members.
While the Department of Veterans Affairs (VA) provides essential
health care services to severely disabled veterans, it is their
caregivers that provide the day to day services needed to sustain their
wellbeing. Caregivers are the most important component of
rehabilitation and maintenance for veterans with catastrophic injuries.
Their welfare directly impacts the quality of care veterans receive.
The VA Program of Comprehensive Assistance for Family Caregivers
(PCAFC) is one-of-a-kind in the United States. It is the only
integrated program that is required to provide health care, a stipend,
travel expenses, mental health care, respite care and injury specific
training. Without these support services the quality of care provided
by the caregiver is likely to be compromised and the veteran is more
likely to experience frequent medical complications and require long
term institutional care. Veterans who access PCAFC are medically stable
enough to live outside an institution, but lack the functionality to
care for themselves on an ongoing basis.
When the program started in 2011 it was estimated 4,000 veterans
would apply. Over 45,000 applied, clearly demonstrating the critical
need for the program. There are currently 22,000 participants. Given
the unique nature of the program and the larger than anticipated
demand, VA has encountered several complications including staff
shortages, unclear procedures, and an antiquated IT system. Seven years
later, after a comprehensive review in 2017 and the issuance of VHA
Directive 1152, we believe VA has done a creditable job enacting the
intent of Congress. Those PVA members participating in the program have
reported positively on their experience. Their caregivers are better
equipped to serve the veteran and they experience fewer financial and
emotional stresses because of the availability of respite, mental
health care and a monthly stipend.
Improvements to the current program
Public conversations around the efficiencies of the program often
do not include its function and design. It was clinically modeled for
older, catastrophically injured veterans. It is equal parts temporary
rehabilitation program and permanent long term care program. The
experience of this program is inherently variable. Some post-9/11
veterans are in the beginning of their rehabilitative journey and are
establishing a new normal. They may improve to the point of no longer
needing assistance with activities of daily living. However, over time
their health may slip, their injuries may exacerbate, and they may
return to the program and fluctuate between tiers. Other veterans with
more static conditions will remain a steady cohort of program
participants. The majority of program discharges are because the
veteran is no longer clinically eligible.
PVA notes there has been some inconsistency of admittance and
revocation. We believe this is a result of fractured practices at the
local level and the use of a sole clinician assessing eligibility. We
encourage the use of multidisciplinary teams in eligibility assessments
at every facility. Individual providers making the eligibility
determination allow for a great deal of subjectivity. The use of
multidisciplinary teams in assessments and tier assignments offers more
objectivity and stricter adherence to the seven eligibility criteria.
For all the genuine concern regarding wrongful revocation, it is
our understanding very few clinical appeals were successful. It appears
that the manner in which the local facilities informed the veterans and
caregivers of revocation was poorly done, with little warning, if at
all. VA must give consistent, and transparent information to veterans
regarding eligibility and tier reduction. In the news stories leading
up to the suspension of revocations, one theme was explicitly clear; VA
must do a better job conveying to the veteran and caregiver that this
program is not an earned benefit. It is a medical service based on
clinical need. We were pleased to see the updated Roles,
Responsibilities, and Requirements form published in July 2017 helps to
do just that.
As with any newly established program, it will have flaws. These
were exacerbated by the lack of clear policy guidelines until June of
2017 when VHA Directive 1152 was issued, finally providing consistent
policy to the field regarding eligibility and discharge requirements.
For six years it was unclear who was operationally responsible for what
program elements. Now clear lines have been drawn for the VA medical
centers, VA primary care services and the Caregiver Support
Coordinators.
PVA is pleased with the progress and continual improvement of this
program. While there is debate as to how future eligibility and process
should look, the program is executing the intent of the law with the
authorities and resources it has. We believe the program has proven its
value to the thousands of veterans and caregivers already served. Yet
the majority of veterans who rely on caregivers to complete activities
of daily living are not eligible.
End the Inequity: Caregiver Expansion
We know the ability of a veteran to remain home, with one's spouse
and children, among friends and in a community, is critical to overall
wellbeing. At the same time, we know caregivers have sacrificed their
own health, their career opportunities, and their financial standing to
care for veterans. Because these caregivers have stepped up, some for
half a century, they have saved the taxpayer billions of dollars. It is
unconscionable that the needs of one group of veterans and the work of
their caregivers be recognized and supported, while another group
continues to labor in the shadows, unacknowledged with no reprieve,
after decades of service.
PVA understands the costs associated with expansion are
significant. And in a time of warranted scrutiny of spending by VA,
lawmakers are hesitant to support such an expense, no matter how just
the cause. But perhaps what should be considered in a challenging
budget environment is how much would be saved by delaying a veteran's
entry into an institutional setting. If a caregiver can no longer
afford it, or becomes ill, their veteran likely has no other option but
to be placed in an institution. VA is obligated to pay the full cost of
nursing home services for veterans for a service-connected disability.
The cruel irony is VA is not allowed to delay such an admission by
supporting their caregiver. Consider the long term cost savings for the
taxpayer by delaying disabled veterans admittance to the following--
Average Annual Cost per Veteran for VA Community Living
Center: $379,853.71
Average Annual Cost per Veteran for Community Nursing
Home: $101,132.20
Average Annual Cost per Veteran for State Veteran Nursing
Home: $56,042.52
Average Annual Cost per Veteran for PCAFC: $19,000
Congress continues to find excuses to deny access. It has never
been more urgent for those excuses to stop. As the largest cohort of
veterans ages, our Vietnam-era veterans, the demand for long-term care
resources will grow significantly. Catastrophically injured veterans
will require the most intensive and expensive institutional care. By
providing their caregivers the means to keep them at home with family,
they will live healthier lives, and delay higher costs.
The issue of caregiving will at some point touch all of us. What is
unique for service-connected disabled veterans as a group, is that
their experience with caregivers will last decades. The Bureau of Labor
Statistics projects the home health aide industry to double to meet the
need of aging baby boomers. Local agencies will not have sufficient
staff to meet the needs of veterans who require a high level of care,
but are not yet ready for institutional setting. For veterans like
PVA's members, their family caregivers are already there, and they want
to continue the job, if we can make it a viable option.
An estimated 40,000 veterans, and their caregivers, are in need of
the clinical services of this program. If the cost of expansion is $3.4
billion over five years (CBO, S. 2921) or $3.1 billion over five years
(CBO, S.2193), then that is what this country owes. Because we are the
beneficiaries of their sacrifice. I suspect the majority of Americans
would agree. Catastrophically injured, WWII, Korean, and Vietnam
veterans, for more than half a century, have been living a life they
couldn't possibly have planned for. Their caregivers, most often
spouses and now grown children, gave up or never pursued careers and
dreams of their own in order to care for their loved ones disabled in
support of this nation. They have been made vulnerable, financially and
physically, after decades of work. They have saved the taxpayer
billions of dollars that otherwise would have been the burden of VA.
Congress will eventually pay for this care one way or another. If
it isn't through the caregiver program it will be through overwhelmed
home health programs, or high cost VA nursing homes that do not have
the necessary capacity. The caregiver program is by far the most just,
cost effective, and efficient course of action for the veteran and
taxpayer.
Survey data suggests caregivers of pre-9/11 veterans perform more
activities of daily living and instrumental daily living skills than
post-9/11 caregivers. These caregivers are more likely to endure
physical strain; maintaining a veteran with severe physical
disabilities means they are bending and lifting for a duration that is
likely to jeopardize their own health.
As hard as it has been, and as hard as it will continue to be if
Congress does not act, the caregivers of veterans with spinal cord
injuries are proud of what they've accomplished. For decades they have
maintained the health and wellbeing of a population whose condition
once meant a slow death. They have gained skills they never planned to
need, they are the reason their children were raised with two parents
at home, the reason neighborhoods and churches and family reunions
stayed whole. They deserve a break.
Recent years have seen a great deal of discussion about veteran's
choice and care in the community; that veterans should have more
options for how and where they receive care. This committee has
advanced those efforts, many were proposals far more costly than
caregiver expansion. What is a more fundamental element of veteran's
choice than the choice to receive quality care at home from the people
they trust most?
In the seven years since this program began, the barriers to its
expansion have always been cost. There will likely never be a
projection that isn't significant. But it is what this nation owes and
should pay without delay. Admittance to this program is based on
clinical need. Denying one group of people a medical service because of
era served, and then continuing to deny it because of potential cost is
indefensible.
The program is an imperfect solution in place of the perfect
solution of healing their wounds. Anecdotal examples of flaws in the
program concern us less than the overwhelming degree of satisfaction
and gratitude among our members who are currently in the program. As
long as human beings are making decisions of eligibility and process
there will be flaws. Let us not allow perfection to be the enemy of the
good. The majority of PVA members and their caregivers will prefer
something over nothing rather than wait for Congress to deem something
perfect enough. Let them have better. Their health and the health of
their families depends on it. You have a moral obligation to do this.
Cost and program imperfections are unacceptable excuses.
PVA would once again like to thank the Committee for the
opportunity to submit our views on the programs affecting veterans and
their caregivers. We look forward to working with you to ensure our
catastrophically disabled veterans and their families receive the
medical services and support they need.
Prepared Statement of Steve Schwab
Chairman Roe, Ranking Member Walz, and Members of the Committee,
the Elizabeth Dole Foundation is pleased to present its views on the
Department of Veterans Affairs' (VA) Program of Comprehensive
Assistance for Family Caregivers (PCAFC, ``the Program'').
The Elizabeth Dole Foundation was founded in 2012, just two years
after the VA established the Program, and we have followed its
trajectory ever since. As the only national organization exclusively
focused on the military and veteran caregiver population - the 5.5
million spouses, family members, and other loved ones caring for
wounded, ill, or injured veterans at home - the Foundation is uniquely
positioned to speak to their point of view. We thank you for the
opportunity to provide this testimony.
Our understanding of the military caregiver population is data-
driven; in 2012, we commissioned the RAND Corporation to conduct the
first-ever needs assessment of military caregivers to better understand
this hidden population and the challenges they face caring for our
nation's wounded warriors. The findings of this comprehensive two-year
study still drive the work of the Foundation today and the work of many
of our partners. But while the 2014 landscape survey gave us critical
insights into the military and veteran caregiver population, there is
still so much that we do not know about supporting these hidden heroes
in the long-term.
For the last six years, the Foundation and our Dole Caregiver
Fellows, a remarkable group of military caregivers from diverse
backgrounds and representing all 50 states, Puerto Rico, and
Washington, D.C., have been on the forefront of communicating the
caregiver population's experiences and concerns with the Program
directly to the VA Central Office. We have worked with both the VA and
military caregivers to understand the current systemic challenges,
address them, and facilitate an open dialogue between the caregiver
population and the VA. We also continually take the pulse on the ever-
changing questions and concerns through our Fellows Program and online
networks like the Hidden Heroes Caregiver Community; a safe, secure
social network where caregivers can find peer support, seek advice, and
share stories.
With the passage of the Caregivers and Veterans Omnibus Health
Services Act of 2010 and the establishment of the PCAFC, veteran
caregivers were finally recognized on a systemic level for the
invaluable work they do to assist in the care, rehabilitation, and
recovery of our nation's veterans. The 2014 RAND study, commissioned by
the Foundation, found that military and veteran caregivers provide an
annual $14 billion in voluntary, uncompensated care for our nation's
veterans and service members, and often shoulder physical, emotional,
and financial strain to care for their loved one. Through the Program,
qualifying veteran caregivers receive the support they need to take on
the economic and personal costs that are intrinsic to caregiving, and
in turn, veterans can receive the care they need at home from a loved
one, rather than be institutionalized.
The implementation of the program has not been without its
challenges. Congress initially intended the PCAFC to serve a small
number of caregivers caring for only the most catastrophically wounded
veterans. Upon executing the program, the VA realized that many more
caregivers needed this program than initially anticipated, and the
program expanded to serve the more than 26,000 caregivers that it does
today - nearly three times the number of caregivers for which the VA
initially planned. The VA uncovered a previously unaddressed need and
soon found themselves deluged with veteran caregivers who had, until
this point, been caring for their veterans without much support.
Because of this, the implementation and administration of the PCAFC
have suffered from growing pains as it attempts to accommodate the
growing number of veteran caregivers that qualify for the stipend
program.
Today, the Foundation has been asked to provide its insight into
the challenges that have prevented the Program from giving the maximum
level of support that these hidden heroes need. And while we are
pleased to have the opportunity to provide our recommendations to help
correct these deficiencies, the most significant deficit is that only a
limited number of veterans are eligible under the current law. It is
unfair that pre-9/11 caregivers, who make up 80 percent of our nation's
5.5 million veteran and military caregivers, are barred from accessing
the PCAFC because of their veterans' era of service or diagnosis with a
service-connected illness.
We acknowledge that the Program is experiencing significant demand,
and the Foundation remains committed to being a part of the solution.
But we urge Congress not to overlook the millions of veteran caregivers
barred from access to the program merely due to their era of service.
Congress should act simultaneously to pass an expansion of the Program
to include service-connected illnesses and all periods of service,
while also addressing the issues of standardization and clarity. These
efforts should not be a zero-sum game.
On November 29, 2017, the Senate Committee on Veterans' Affairs
overwhelming passed the Caring for Our Veterans Act of 2017, which
notably expands the Program to pre-9/11 caregivers. This change could -
quite literally - improve the quality of life of millions of Americans.
This legislation addresses the need to bolster the program and expands
it in a phased, thoughtful manner - while the VA simultaneously
implements an improved information technology system. We encourage the
House Veterans' Affairs Committee to take up and pass this legislation.
RECOMMENDATIONS
1. The VA should continue to work to improve consistency and
accountability in the administration and execution of the PCAFC.
For several reasons, the implementation of the PCAFC has suffered
from inconsistencies since its inception. Individual Veterans
Integrated Service Networks (VISN), of which there are 18 across the
country, have the autonomy to run their programs as they see fit. The
result is that, although the PCAFC is a national program, there are
many inconsistencies across VISNs in the implementation and
operationalization of the program. The discrepancies have caused
confusion and tension between caregivers, who hear from other
caregivers in other parts of the country of the irregularities in the
way the program is administered. And while the law is explicit about
including traumatic brain injuries, psychological trauma, and other
mental disorders in considering a veteran's eligibility, the lack of
standardization often causes disparities in the assessment of this
need. We've heard reports of caregivers removed from the program,
despite a lack of change in their veteran's functioning levels. Without
a standardized assessment tool or more explicit guidelines on the
determination of eligibility, the VA is hard-pressed to explain to
veterans and caregivers as to why they do not qualify for this program.
Much of this discrepancy stems from the reality that the caregivers
witness firsthand the issues their veterans deal with on a day-to-day
basis, such as not following a medication regime, driving erratically,
forgetfulness that endangers their safety or the safety of others. But
the review process - which can vary from VISN to VISN - does not always
take the caregivers' knowledge into account. This kind of assessment is
a difficult one. Understanding the full breadth of safety and
supervision takes a combination of clinical assessments of the veteran,
a records review that incorporates the notes and feedback of the
primary care team and any outside providers, and a real conversation
with the caregiver.
Last July, the VA took several steps to address the persistent
inconsistency issues. We applaud the VA for devoting the time and
resources required for such an extensive program review to ensure that
the many voices of military caregivers are heard and that we as a
nation can better meet the urgent needs of our veterans. We stand ready
to work with the VA to provide guidance, direction, and insight into
these demands. The steps taken by the VA in this review included;
issuing a national policy directive regarding program operations, staff
responsibilities, as well as veteran and caregiver eligibility
requirements; developing a standardized letter used by all VA medical
centers when communicating program discharges; and taking steps to
demonstrate to caregivers that they should be collaborative partners
with the VHA in ensuring overall care and well-being of veterans. The
changes introduced increased standardization, but the Program still
lacks centralization.
The lack of accountability has also led to variations in the way
that the program is administered. Even with the development of a
standard policy, the Caregiver Support Program Office cannot enforce
its directive. They may only advise the local centers that they are in
violation of the law or not in compliance with the VHA Directive. The
new directive even notes that the Program is structured for each
medical center to develop processes to carry out the Program. We
understand that the ability of each medical center to self-determine
its own needs is central to the operation of the VA system. When
operational authority supersedes policy implementation, however, it
creates an inconsistent - and at times prejudicial - program
environment for caregivers.
The Foundation as far back as three years ago began to hear
concerning stories of caregivers unexpectedly dropped from the PCAFC.
We started to collect these stories, mapped out the scope of the issue
and helped to connect caregivers to essential resources to help them
appeal these decisions. We referred the most grievous cases to the
Department of Veterans' Affairs for further review and reevaluation,
and in some instances, the program revocation overturned. We owe our
work to the many caregivers who have stepped up, shared their
experiences, and provided all of us the necessary insight into the
challenges the Program was experiencing. We must continue to support
those caregiver voices through the standardization of this critical VA
Program.
2. Congress and the VA should work to more clearly define and
communicate PCAFC program eligibility requirements.
PCAFC is the stipend program offered through the VA Caregiver
Program. This is currently limited to eligible veterans injured in the
line of duty on or after September 11, 2001. Eligibility for the
program is a clinical determination that the program will significantly
enhance the veteran's ability to live safely in a home setting, support
the veterans' potential progress in rehabilitation, and create an
environment that promotes the health and well-being of the veteran.
Under current law, the clinical determination is based off the
veterans' need for personal care services from another individual for
at least six continuous months based on A) an inability to perform one
or more activities of daily living (ADLs), B) a need for supervision or
protection based on a neurological or other impairment/injury, and/or
C) is service connected for a severe injury that was incurred or
aggravated in the line of duty in the active military, naval, or air
service on or after September 11, 2001, has been rated 100 percent
disabled for that serious injury, and has been awarded special monthly
compensation that includes an aid and attendance allowance.
The current statutory language allows for broad interpretation of
the eligibility requirements and subjective assessment - particularly
for activities of daily living and the need for supervision or
protection. While this provides for accommodation of a wide range of
physical and cognitive issues, it also allows for variability of
implementation that is both time-consuming to the care team making the
decision, and often inconsistent concerning the veteran and caregiver.
We've heard cases where a caregiver moved from one part of the
country where they had been determined eligible for the program, to
another part of the country where they were found ineligible for
providing the same support. The eligibility requirements should be
clarified and standardized as much as possible, while still allowing
clinicians their discretion to make a decision that will lead to the
best outcome possible for the veteran. A focused look at how the
eligibility requirements are defined and interpreted is required. The
directive the VHA released in July provides the definitions for the
individual activities of daily living and the need for safety and
supervision. However, it does not provide guidance on the assessment
and evaluation of those two particular eligibility criteria.
Standardized evaluation metrics and tools should be determined that
allow individual medical centers and VISN leadership to establish
processes that serve their specific local needs and prevent unfair
variance in the national implementation of the program.
3. The VA, along with members of the veterans' community, should more
effectively communicate to veterans and their caregivers the
programs and services available to them.
It is essential that interested veterans and their caregivers have
a good understanding that the Program is one vehicle for intervention
and not the only option for support available under the VA's Caregiver
Support Program. A confusion of the stipend program as a ``benefit''
rather than one part of a program meant to help facilitate the clinical
need for a caregiver often contributes to frustration on the part of
the caregiver. This misunderstanding about the Program results in
significant demand and thus an increased strain on the Program.
Miscommunication of the intent of the Program leads to another
issue as well. Eligibility for the PCAFC, or the lack thereof, can
create resentment among caregivers who feel as though their caregiving
role is being ``ranked.'' There is a sense that those who qualify for
the program are somehow ``better'' caregivers than those who are not -
when nothing could be further from the truth. The fact is that
caregiving occurs on a continuum, and while this program serves a
specific portion of that continuum, this does not invalidate the
selflessness or dedication of those caregivers who do not participate.
This incorrect assessment of the PCAFC is often due in part to a
misunderstanding that the Program is a benefit program, rather than a
program based on a clinical determination of the needs of the veteran.
By emphasizing the true clinical nature of the program, we can help
alleviate these misconceptions.
The Caregiver Support Program and the Caregiver Support
Coordinators are essential in communicating available support to
veterans and their caregivers. However, we must adopt a multi-tiered
approach to disseminating information about all programs within the
VA's Caregiver Support Program. The communications strategy should also
explicitly set expectations and help caregivers understand the growing
network of support - of which the PCAFC is just one part.
As a community - the Foundation, the Veteran Service Organizations,
the VA, and others - must also provide additional guidance and
awareness of other programs available for veteran and caregiver support
- which are not eligibility restricted. Within the VA, these programs
include in-home care, respite care, services to address mobility,
physical rehabilitation, education and training, financial support,
referral services, and other caregiver support services. (Table 1) We
must also focus our attention on programs and resources outside the VA
that can support military and veteran caregivers. Improving
communication cannot be a VA problem; we must all work towards a
culture of holistic support that meets caregivers where they are and
addresses their needs in both the short- and long-term.
The Elizabeth Dole Foundation has taken steps at addressing this
communications gap through our Campaign for Inclusive Care, in
partnership with the Department of Veterans' Affairs. The campaign
focuses on ensuring that veteran and military caregivers fully
integrated as part of their veteran or service member's medical team.
The Foundation is also working to develop a military caregiver journey
map, which maps the key milestones that each caregiver faced along
their journey. This map aims to shed light on some of the critical
crisis and decision points that the military caregivers go through, and
will assist in designing interventions to help caregivers in the
future. Additionally, through our Hidden Heroes Cities Program, Dole
Caregiver Fellows Program, and partnerships with other organizations,
we are bringing awareness and support to caregivers on the community
level.
Military and veteran caregivers are essential to the recovery and
rehabilitation of our nation's wounded warriors. But they cannot do it
alone. It is up to us to ensure that these selfless hidden heroes have
the tools they need to facilitate that support. The Elizabeth Dole
Foundation is committed to creating and strengthening a holistic system
of support that will position these selfless men and women for the best
possible outcome for their veteran and their family. We look forward to
working with the VA and our partners to make this vision a reality.
[GRAPHIC] [TIFF OMITTED] T5375.004
Statements For The Record
THE AMERICAN LEGION
Chairman Roe, Ranking Member Walz, and distinguished members of the
House Committee on Veterans' Affairs, on behalf of Denise H. Rohan,
National Commander of The American Legion, the country's largest
patriotic wartime service organization for veterans, comprising 2
million members and serving every man and woman who has worn the
uniform for this country; we thank you for the opportunity to testify
on the topic of the ``Department of Veterans Affairs' Program of
Comprehensive Assistance for Family Caregivers.''
Veteran Caregivers have long proven critical to the livelihoods of
disabled and severely wounded veterans. On a daily basis, veteran
caregivers help veterans bathe and dress, administer medication, or
removing barriers to free movement in the community, veteran caregivers
are the difference between a veteran being limited by a disability and
living productively. The passage of the Caregivers and Veterans Omnibus
Health Services Act of 2010 (Public Law 111-163), which provided
caregiver support to those who only served post 9/11 and has exceeded
original enrolment expectations has certainly shown us that there is a
greater than anticipated need for this critical program.
The American Legion has long advocated that the Caregiver Program
at the Department of Veterans Affairs (VA) be expanded to include all
generations of veterans. All veterans, regardless of what era they
served in, deserve equality in terms of benefits, including fair access
to the Caregivers Program. If a member of the armed forces was harmed
in the line of duty for their country, their benefits should not differ
because they served in Vietnam, the Gulf War, or Korea and not in Iraq
or Afghanistan. The American Legion calls on this committee to pass
meaningful legislation that removes the arbitrary rule preventing
equality among those veterans who have literally bled for this nation.
Background and Eligibility
On May 5, 2010, President Obama signed into law the Caregivers and
Veterans Omnibus Health Services Act of 2010. Among other things, title
I of the law established 38 U.S.C. 1720G, which requires VA to
``establish a program of comprehensive assistance for family caregivers
of eligible veterans,'' as well as a program of ``general caregiver
support services'' for caregivers of ``veterans who are enrolled in the
health care system established under [38 U.S.C. 1705(a)]. Among other
things, the law authorized the Secretary to provide family caregiver
services of an eligible veteran if the Secretary determines it is in
the best interest of the eligible veteran to do so. The law defined an
eligible veteran as any individual who-
``(A) is a veteran or member of the Armed Forces undergoing medical
discharge from the Armed Forces;
``(B) has a serious injury (including traumatic brain injury,
psychological trauma, or other mental disorder) incurred or aggravated
in the line of duty in the active military, naval,
or air service on or after September 11, 2001; and
``(C) is in need of personal care services because of-
``(i) an inability to perform one or more activities of daily
living;
``(ii) a need for supervision or protection based on symptoms
or residuals of neurological or other impairment or injury; or
``(iii) such other matters as the Secretary considers
appropriate.''
The purpose of the 2010 caregiver benefits program was to provide
certain medical, travel, training, and financial benefits to caregivers
of certain veterans and servicemembers who were seriously injured in
the line of duty.
VA initially estimated that roughly 3,596 veterans and
servicemembers would qualify to receive benefits under the program
during the first year, at an estimated cost of $69,044,469.40 for
FY2011 and $777,060,923.18 over a 5 year period. VA distinguished
between three types of caregivers based on the requirements of the law:
Primary Family Caregivers, Secondary Family Caregivers, and General
Caregivers.
A Primary Family Caregiver is an individual designated as a
``primary provider of personal care services'' for the eligible veteran
under 38 U.S.C. 1720G(a)(7)(A), who the veteran specifies on the joint
application and is approved by VA as the primary provider of personal
care services for the veteran.
A Secondary Family Caregiver is an individual approved as a
``provider of personal care services'' for the eligible veteran under
38 U.S.C. 1720G(a)(6)(B), and generally serves as a back-up to the
Primary Family Caregiver.
General Caregivers are ``caregivers of covered veterans'' under the
program in 38 U.S.C. 1720G(b), and provide personal care services to
covered veterans, but do not meet the criteria for designation or
approval as a Primary or Secondary Family Caregiver.
On May 3, 2011, VA rolled out the program by issuing a National
Press release entitled, VA to Take Applications for New Family
Caregiver Program.. VA announced that it was opening the application
process on May 9, 2011 for eligible post-9/11 Veterans and
Servicemembers to designate their Family Caregivers. \1\
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\1\ May 3, 2011 VA Press Release https://www.va.gov/opa/pressrel/
pressrelease.cfm?id=2088
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In September 2014, the Government Accounting Agency issued its
first report on VA's Caregivers program, Government Accountability
Office (GAO) report-14-675, entitled, Actions Needed to Address Higher-
Than-Expected Demand for the Family Caregiver Program. \2\ According to
GAO, Veteran Health Administration (VHA) officials originally estimated
that about 4,000 caregivers would be approved for the program by
September 30, 2014. However, by May 2014 about 15,600 caregivers had
been approved-more than triple the original estimate.
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\2\ GAO Report-14-675, https://www.gao.gov/assets/670/665928.pdf
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In 2015, veterans and their caregivers began sharing reports where
they were being cut from the Program of Compressive Assistance for
Family Caregivers (PCAFC). On April 17, 2017, VA announced it would
suspend revocations of benefits initiated by VA medical centers for the
PCAFC, pending a full review of the program. The announcement came two
weeks after media coverage revealed that some VA medical centers have
been dropping Caregivers from the program at alarming rates, likely due
to budget constraints.
The suspension of revocations would last three weeks, according to
VA. Secretary of Veterans Affairs David Shulkin ordered the internal
review. Secretary Shulkin stated the review was intended to ``evaluate
consistency of revocations in the program and standardize communication
with Veterans and caregivers nationwide.'' \3\
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\3\ VA Announces Internal Review of Caregiver Program https://
www.va.gov/opa/pressrel/pressrelease.cfm?id=2889
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On July 28, 2017, the VA announced it was resuming full operations
of the PCAFC. The resumption follows an April 2017 decision to
temporarily suspend certain clinical revocations from the program to
conduct a strategic review aimed at strengthening the program. \4\
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\4\ VA Caregiver Support Program Resumes Full Operations - https://
www.va.gov/opa/pressrel/pressrelease.cfm?id=2933
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VA's three-month review indicated a need for better communication
about clinical revocations, improved internal processes and procedures,
as well as additional staff training. Following the review, VA issued a
new directive outlining staff responsibilities, veteran and caregiver
eligibility requirements, available benefits and procedures for
revocations from the program.
VA also conducted mandatory staff training on the new directive and
implemented standardized communications and outreach materials to
educate veterans and their caregivers about the program.
The new directive provided background on the Caregiver Support
Program authorized by title I of Public Law 111-163, Caregivers and
Veterans Omnibus Health Services Act of 2010, and Title 38 United
States Code (U.S.C.) 1720G. The directive specified VA staff
responsibilities for the implementation of the Program of Comprehensive
Assistance for Family Caregivers and the Program of General Caregiver
Support Services, collectively referred to as the Caregiver Support
Program. The directive also described aspects of program operations,
including the different kinds of caregivers, the eligibility of
veterans for the program, the eligibility and requirements for
caregivers, and the benefits available to caregivers.
Moving forward, in January of 2018 the VA announced it was seeking
public comments on how it could further strengthen and improve the
caregiver support through the PCAFC. The American Legion is looking
forward to reviewing those comments in concert with VA and assisting in
making the necessary changes to alter the program for the better.
Recommendations
The American Legion has long advocated and stood on the right side
of providing those who have been disabled through military service the
services and assistance needed to live as much a normal life as
possible. Through our advocacy, and the support of this committee,
legislation has been signed into law that created the current program,
that does indeed provide quality support to those who are deserving.
Without question there has been concern, but when necessary, the VA
made the corrections to furnish the care and support needed by our
nation's heroes.
1. National Standard: One concern that has not only been brought to
the attention of The American Legion, but also the VA, and others is
that each Medical Center Director has the authority to approve or deny
veterans into the PCAFC. This means that there are 167 different
standards of eligibility held by the 167 different VAMC (Veterans
Affairs Medical Center) Directors. When there is not a national
standard, or consistency, it leads to a system that is unfair, granting
access or denial by dissimilar levels of eligibility, and that is not
reasonable. Though VAMC Directors often express that each case brought
to them for approval or denial should truly be decided on a case-by-
case situation, The American Legion urges this committee to instruct VA
to have a national standard, that is consistent, fair, and reasonable.
Having a consistent base of eligibility for all VAMC's would approve
those needing access to this critical program, all while preventing
fraud and abuse the best VA can.
2. S. 591: In May of 2017, The American Legion testified before the
U.S. Senate Committee on Veterans' Affairs in support of S. 591, the
Military and Veteran Caregiver Services Improvement Act of 2017. This
legislation, just as other legislation supported by The Legion, is a
great step forward in expanding and improving the PCAFC.
3. S. 2193: In December of 2017, Chairman Johnny Isakson introduced
the Caring for our Veterans Act, S. 2193. This bill, which was
supported by The American Legion and other VSO's, would expand and
improve the caregivers program, all while improving care from VA in
general. The American Legion was proud to stand in support of this bill
while attending and speaking at a press conference in support of the
legislation.
4. Independent Audit: Lastly, The American Legion is concerned that
VA's Caregivers policies were not clearly defined which led to
ineligible veterans being enrolled in the program, and eligible
veterans being dropped from the program, who were still in need of the
services offered through the program. We recommend an independent audit
of VA's Caregivers program to determine what is working or not working
and what changes are required to improve the program.
Conclusion
Chairman Roe, Ranking Member Walz and distinguished members of this
committee, The American Legion looks forward to working with this
committee on how to best improve and expand PCAFC program. The original
program received nearly triple the applications than the VA expected,
highlighting a real need for veterans to have access to this life
altering and lifesaving program. Veterans have a much better quality of
life if they are at their home, instead of a VA or private care
facility. Veterans prefer to live at home with a caregiver of their
choice compared to inpatient care, and statistics have also shown that
this route of care is even more fiscally responsible and feasible for
the VA.
The American Legion thanks this committee for holding this
important hearing and for the opportunity to explain the views of the 2
million veteran members of this organization. For additional
information regarding this testimony, please contact Mr. Matthew
Shuman, Director of The American Legion's Legislative Division at (202)
861-2700 or [email protected].
VETERANS OF FOREIGN WARS OF THE UNITED STATES
KAYDA KELEHER, ASSOCIATE DIRECTOR
NATIONAL LEGISLATIVE SERVICE
Chairman Roe, Ranking Member Walz and members of the committee, on
behalf of the women and men of the Veterans of Foreign Wars of the
United States (VFW) and its Auxiliary, thank you for the opportunity to
provide our remarks on how to improve and expand the Department of
Veterans Affairs (VA) Program of Comprehensive Support for Family
Caregivers.
Whether providing assistance to a veteran who served in Korea or
Afghanistan, Caregivers help lower costs of care and increase the
health and quality of life for veterans who were seriously injured in
the line of duty. Family caregivers who choose to provide in-home care
to severely disabled veterans veterans truly epitomize the concept of
selfless service. They choose to put their lives and careers on hold,
often accepting great emotional and financial burdens. They do this
recognizing their loved ones benefit greatly by receiving care in their
homes, as opposed to institutional settings.
The VFW strongly believes the contributions of family caregivers
cannot be overstated, and our Nation owes them the support they need
and deserve. That is why the VFW strongly supported the Caregivers and
Veterans Omnibus Health Services Act of 2010, which provided a monthly
stipend, respite care, mental and medical health care, and the
necessary training and certifications required for caregivers of
severely disabled Post-9/11 veterans. We did so, however, with the
understanding that eligibility would be later expanded to include
veterans of all eras. Severely wounded veterans of all conflicts have
made incredible sacrifices, and all family members who care for them
are equally deserving of our recognition and support. The fact that
caregivers of previous era veterans are excluded from the full
complement of program benefits implies that their service and
sacrifices are not as significant, and we believe this is wrong.
One of the requirements of the Caregivers and Veterans Omnibus
Health Services Act of 2010 was for VA to submit a report to Congress
examining the feasibility of expanding eligibility for comprehensive
caregiver benefits to those who care for severely injured veterans of
previous eras. That report, issued in September 2013 and stated that
expansion would be operationally feasible, so long as Congress gives VA
the necessary funding to administer the programs and hire the required
additional staff. Subsequently, the Secretary of Veterans Affairs and
the members of this committee have publically supported expansion of
this important program. It is past time for Congress to follow through
and expand this important benefits.
Eligibility and Current Recipients
Current eligibility criteria requirements for acceptance into the
caregiver program are rigorous. This is shown in the fact that there
are currently only 22,000 participants in the program, which is less
than three percent of the 1.06 million Global War on Terror veterans
who have received a service-connected disability rating from VA *as of
September 30, 2016. Additionally, 86 percent veterans who are enrolled
in the caregiver program have a service-connected disability rating of
70 percent or higher. To be eligible, the veteran must have incurred or
aggravated a serious injury while serving in the military on or after
Sept. 11, 2001. Due to the serious injury the veteran must also now
require assistance with the management of their personal care and
functions involved in daily life. This assistance must be needed for a
minimum of six continuous months based on a clinical decision, and then
receive ongoing care from a Patient Aligned Care Team or another VA
health care team which is in the best interest of the veteran. The
veteran must also agree to receive ongoing care at home by the
designated family caregiver, and those services provided by the
caregiver may not be provided by any other individual or entity.
During the evaluation process VA also conducts a home visit to help
the agency make a sound decision regarding eligibility that is not
solely based on service-connected disability ratings or statements made
by the veterans and/or their caregivers. During the assessment for
eligibility process VA may request additional evaluations from
behavioral health, occupational therapy, physical therapy and other
medical specialty offices to assist in completing the assessment. If
approved for the program, a designated caregiver must be an immediate
family member or somebody who lives with the veteran full time and is
at least 18 years of age. These individuals must also undergo training
and be able to demonstrate the ability to assist their veterans.
For those who are approved for the program, VA then requires their
medical centers to monitor all participants. This involves quarterly
check-ups for monitoring, which are done through various platforms such
as phone calls, clinic, telehealth and/or home visits.
The VFW agrees that the requirements for VA's caregiver program
must be tough to assure only veterans who need the program are able to
partake, though we do have some concerns. Aside from the VFW's strong
support of expanding the caregiver program to veterans who served
before Sept. 11, 2001, the VFW also supports expanding the eligibility
criteria of ``seriously injured'' to ``seriously ill or injured''.
According to the Code of Federal Regulations, VA defines a serious
injury for participation in the caregiver program as, ``any injury,
including traumatic brain injury, psychological trauma, or other mental
disorder, incurred or aggravated in the line of duty in the active
military, naval, or air service on or after September 11, 2001, that
renders the veteran or servicemember in need of personal care
services.''
This definition does not successfully define the inclusion of those
who need the assistance of a caregiver due to dehibilitating illensses
which render a veteran unable to perform activities of daily living
without the assistance of a caregiver, such as Parkinson's Disease and
Amyotrophic Lateral Sclerosis (ALS). While VA has never considered non-
mental health illnesses when determining eligibility for the caregiver
program, the Department of Defense's Special Compensation for
Assistance with Activities of Daily Living (SCAADL) program does. The
SCAADL program does not distinguish between illness and injury for
eligibility determination. Veterans who have recntly transitioned from
military service who were enrolled in the SCAADL program becuase of a
serious illness are rightfully outraged when they are rejected from the
VA program simply because they suffer from an illness istead of an
injury. Including illness in VA's eligbility would allow for more
equity between the two programs which are needed by the same
population.
Quality of Life
It is not secret the majority of people requiring assistance for
daily living prefer being at home, and our members are not afraid of
letting the VFW know. There is a comfort in being surrounded by one's
familiar setting and personal belongings and there is a sense of
happiness having the opportunity to remain in proximity to loved ones.
This is why those who have fought for our Nation rightfully deserve
every opportunity to remain comfortably at home with their loved ones
before being forced into an assisted living situation most do not want.
Cost
Aside from how important it is to improve the quality of our
heroes' lives, it is also more cost effective. According to the
Congressional Budget Office, the average annual cost per patient for
the caregiver program is $18,300. This is the average cost when adding
together stipend payments and Civilian Health and Medical Program of VA
coverage. For veterans not using the caregiver program but in need of
assisted living, VA may offer them VA Community Living Centers,
Community Nursing Homes or State Veteran Nursing Homes.
As of 2016, the cost of the latter three options is exponential.
The State Veteran Nursing Homes average at $56,042.52 per patient per
year, Community Nursing Homes average at $101,132.20 per patient per
year and VA Community Living Centers average at $379,853.71 per patient
per year. This means the average veteran caregiver saves VA and our
government anywhere from nearly $38,000 per year to $362,000 per year -
all while maintaining a comfortable and higher-quality lifestyle for
severely injured veterans. The VFW believes investing money in VA's
caregiver program is not only the correct thing to do, but it is the
financially responsible thing to do.
Revocations and Tier Reductions
Members of the VFW and VA's Caregiver Support Line hear on a nearly
daily basis from veterans and their caregivers about their frustrations
with the revocation of their eligibility and tier reductions. The VFW
is thankful VA has worked on improving these issues, but there is still
work that must be done.
The VFW understands there will be veterans who are able to graduate
from the caregiver program - and not needing the program anymore should
be viewed as a positive. The problem lies with the handling and
communication of a veteran improving enough to not need the assistance
of the program. Program stipends were never intended to be a permanent
benefit for all caregivers in the program, yet VA must work to assure
caregivers of veterans who have grown to be dependent on the caregiver
stipend are able to obtain meaningful employement that pervents
fiinancial hardship. Through its Unmet Needs financial grant, the VFW
has helped countless caregivers make ends meet becuase they were
abruptly discountined from the caregiver program and were unprepared to
obtain employment that would replace the lost financial stipend.
That is why the VFW believes VA must provide services to better
assist caregivers in transitioning from being on the program, to a
different tier or completely off the program. While VA is currently
providing a period of time after notification before the caregiver
loses their monetary stipend, VA needs to educate these individuals
about opportunities for vocational training, employment possibilities
and health care options.
The VFW commends Representative James Langevin for his efforts to
improve and expand the caregiver program through H.R. 1472, the
Military and Veteran Caregiver Services Improvement Act of 2017, which
would expand the caregivers program to wounded veterans of all eras.
The VFW frequently hears member feedback regarding eligibility for this
important program. Their message is clear: veterans of all eras deserve
caregiver benefits. As an intergenerational veterans' service
organization that traces its roots to the Spanish American War, this is
not surprising.
Our members are combat veterans from World War II, the Korean War,
the Vietnam War, the Gulf War, the wars in Afghanistan and Iraq, and
various other conflicts. They rightly see no justifiable reason to
exclude otherwise deserving veterans from program eligibility simply
based on the era in which they served. Accordingly, we strongly urge
you to swiftly consider and pass a bill to end this inequity.
WOUNDED WARRIOR PROJECT
Chairman Roe, Ranking Member Walz, and Members of the Committee,
Thank you for inviting Wounded Warrior Project (WWP) to offer our
input to your discussion and review of the Department of Veterans
Affairs' (VA's) Program of Comprehensive Assistance for Family
Caregivers (the Program). We appreciate the forum to highlight the
service and sacrifice of our country's military caregivers. Too often,
these men and women serve in the shadows, rarely getting similar
recognition as the injured veterans they care for. We are grateful for
your focus on this deserving population and are pleased to offer the
following statement for the record.
WWP's mission is to honor and empower wounded warriors. Through
community partnerships and free direct programming, WWP is filling gaps
in government services that reflect the risks and sacrifices that our
most recent generation of veterans faced while in service. Advancements
in battlefield medicine and body armor have saved more service member
lives than ever before. While the road to recovery for these men and
women can be long, a generation of caregivers has risen to help them
meet the challenges along the way. As the needs of this community are
great and growing, WWP's mission and corporate purpose indicates that
our focus is related to family caregivers of veterans and service
members who have been wounded, ill, or injured since September 11,
2001.
In 2010, our advocacy on behalf of this community helped pave the
way for the Caregivers and Veterans Omnibus Health Services Act of 2010
(Public Law 111-163). Our comments today follow from distinctions
outlined on November 19, 2009, when bill sponsor, then-Senate Committee
on Veterans' Affairs Chairman, and World War II veteran, Senator Daniel
Akaka addressed the Senate chamber with the these remarks:
While it is correct that the caregiver provisions target the
veterans of the current conflicts, I do not believe that constitutes
discrimination. The reasons for this targeting, at the least, are
three: one, the needs and circumstances of the newest veterans in terms
of the injuries are different - different - from those of veterans from
earlier eras; two, the family situation of the younger veterans is
different from that of older veterans; and three, by targeting this
initiative on a specific group of veterans, the likelihood of a
successful undertaking is enhanced.
While we support and advocate for our fellow veterans of previous
generations, each of Senator Akaka's distinctions remain salient today,
more than eight years after these comments and nearly seven years since
the Veterans Health Administration (VHA) launched the Program in May
2011 at each of its VA medical centers across the United States.
Recent research validates two of the Program's initial premises
that - though not more ``deserving'' - the caregiving needs and family
situations of post-9/11 veterans are different. RAND Corporation's 2014
report, Hidden Heroes: America's Military Caregivers, illustrates
several demographic differences between pre- and post-9/11 family
caregivers. Among the differences most relevant to the Program:
Relationship to caregiver: Pre-9/11 caregivers are most
often the care recipient's child (36.5 percent) whereas post-9/11
veterans are most likely to receive care from a spouse/partner/
significant other (33.2 percent) or a parent (25.1 percent)
Support networks: Pre-9/11 caregivers are more likely to
have a support network (71 percent) than post-9/11 caregivers (47
percent)
Effects on mental health: More post-9/11 caregivers (38
percent) meet the criteria for probable depression than pre-9/11
caregivers (19 percent)
Access to health insurance: Post-9/11 caregivers are more
likely to be without health insurance (32 percent reported no coverage)
than pre-9/11 caregivers (18 percent)
These points highlight how the Program has and continues to address
post-9/11 family caregiver needs, and how Program components have
hopefully driven down concerning statistics since the RAND report was
published three years ago. To wit, while caregivers from all eras may
be eligible for aid and attendance benefits, respite care, social
support services, and training, the Program provides additional
services to eligible post-9/11 caregivers, including a monthly stipend
based on the amount and degree of personal care services provided to
the veteran, access to the Civilian Health and Medical Program of the
Department of Veterans Affairs (CHAMPVA) if they have no health
insurance, mental health counseling, and an expanded respite care
benefit. These benefits have been a crucial resource for post-9/11
caregivers, and with appropriate funding, could and should be made
available to all generations of military caregivers.
While the Program's offerings address the needs of many post-9/11
family caregivers, its success has been tempered by substantial growth.
From fiscal year 2013 to fiscal year 2015, the number of primary family
caregivers enrolled in the Program grew from 12,710 to 24,711. This
growth was matched by increased spending, which grew from $226M to
$454M in annual outlays over the same period , yet only modest
increases in staffing. At the end of fiscal year 2013, the number of
Caregiver Support Coordinators (CSCs) - those who administer the
Program at the medical facility level - stood at 225. The CSC count
grew to 267 by the end of fiscal year 2014, and was projected to grow
to 328 for fiscal year 2016.
During this period of remarkable growth in Program participation,
the U.S. Government Accountability Office (GAO) published a report in
September 2014 concluding that ``staffing shortages impeded timeliness
of key functions and negatively affected services to caregivers despite
actions taken to address them.'' Accordingly, GAO concluded that:
After three years of operation, it is clear that that VHA needs to
formally reassess and restructure key aspects of the Family Caregiver
Program, which was designed to meet the needs of a much smaller
population. This would include determining how best to ensure that
staffing levels are sufficient to manage the local workload as well as
determining whether the timeliness and procedures for application
processing and home visits are reasonable given the number of approved
caregivers.
As the Committee is aware, even with its current scope serving only
post-9/11 caregivers, VA has had significant challenges implementing
the Program. In 2017, these challenges came to a head, and VA paused
all revocations from the Program pending a complete review. Although VA
has concluded its review, the impact of new VHA Directive 1152
(``Caregiver Support Program'') and associated training have not become
clear.
Like all Members of the Committee, and like all organizations who
have testified or submitted statements for the record, we are deeply
invested in the success of the Program. Family caregivers, including
those of the pre-9/11 generation not currently eligible for the
Program, help conserve state and federal agency resources by keeping
seriously injured veterans at home, avoiding costly forms of care
including institutionalization. In many cases, these caregivers
sacrifice their own life experiences and successes, including careers,
education, and retirement savings, in order to properly care for the
veterans they support at home.
Though WWP's mission is to assist caregivers of the post-9/11
generation, we recognize caregivers of the pre-9/11 generation are no
less deserving of praise, recognition, or access to vital services and
benefits provided by the Program. WWP supports legislation that would
improve the lives of pre-9/11 caregivers without harming caregivers of
the post-9/11 generation. As such, WWP firmly believes that proposals
to expand the Program must be accompanied by sufficient funding to
cover additional staffing and information technology needed to properly
administer the Program and meet the needs of the caregivers and
veterans it serves. At this time, however, we would like to address
several points about the Program raised during public comment on
Federal Register announcement 2018-00004 (``Notice of Request for
Information on the Department of Veterans Affairs Program of
Comprehensive Assistance for Family Caregivers'').
Appealing a Decision made by PCAFC:
One essential mechanism for consistency and fairness is a
meaningful appeals process in which veterans can challenge erroneous
eligibility and tier level determinations. Despite allegations of
wrongful revocations that gave rise to VA's recent Program review, in
our experience, successful appeals through the VHA system have been
extremely rare. Given the nature of the Program, adjustments should be
made to the clinical appeals process for review of eligibility and tier
level determinations.
Require Communication with Caregivers:
Caregivers must be present and involved in assessments that give
rise to change in tier level or revocation. Especially where mental
health or cognitive challenges are involved, caregivers can provide the
insight necessary to reach correct and comprehensive conclusions.
Nonetheless, we have heard many accounts of caregivers who were not
allowed to participate. While VHA Directive 1152 addressed this issue,
we are waiting to see how effective the new instructions and staff
trainings have been in encouraging and increasing dialogue between
caregivers and the veteran's health care team.
Review Revocations and Tier Reductions:
We know you are aware of the many veterans and caregivers who have
reported erroneous determinations, and that is why you are conducting
this review. Given these reports, in the interest of fairness, we ask
for review of all revocations and tier reductions that have taken place
since program inception. We understand that this would place a
significant workload on program staff and therefore propose a triaged
approach in which cases, where tier 3 veterans were completely revoked,
are addressed first. An adjustment this dramatic should be extremely
rare and suggests irregularities.
The Inclusion of ``Illness'' in Qualifying for Caregiver Assistance:
Another issue to be addressed in Program eligibility is the
inclusion of the word ``illness'' in qualifying for caregiver
assistance. Under Sec. 71.15, a serious injury is defined as ``any
injury, including traumatic brain injury, psychological trauma, or
other mental disorder, incurred or aggravated in the line of duty in
the active military, naval, or air service on or after September 11,
2001, that renders the veteran or servicemember in need of personal
care services.''
By excluding the term ``illnesses'' in the qualifying language for
caregiver, a large population of post-9/11 and pre-9/11 veterans are
precluded from a benefit they might well deserve. We see this as in
inherent flaw in the access to much-needed care for veterans. Much like
generational expansion, we believe the Program should grow to
accommodate those with service-connected illnesses - particularly those
linked to toxic exposures - provided such expansion is accompanied by
proper funding.
Servicemember Eligibility:
WWP not only assists veterans but also current serving military
members of the Armed Forces. There are instances where severely injured
servicemembers do not qualify for Caregiver support due to the VA's
interpretation of ``undergoing medical discharge.'' Section 1720G
indicates that servicemembers are eligible for benefits under the
Program if they are undergoing medical discharge from the Armed Forces:
``For purposes of this subsection, an eligible veteran is any
individual who . . . is a veteran or member of the Armed Forces
undergoing medical discharge from the Armed Forces.'' 38 U.S.C.
1720G(a)(2)(A). With any expansion of the Program, we would request
that the definition of ``undergoing medical discharge'' include
families in need of a caregiver before receiving a medical discharge
date by the Department of Defense. By considering eligibility at an
earlier date, this would ensure that proper training opportunities are
available for caregivers of the injured servicemember throughout the
entire treatment of the servicemember. We feel that the sooner families
can receive training on caregiver programs and techniques, the more
successful families will be.
Overall Compensation for Caregivers:
Increasing the hourly cap of 40 hours a week and the hourly wage
rate set by VA should also be addressed. Caregivers have continually
indicated that 40 hours a week is not a fair representation of the
amount of time it takes to assist a severally injured veteran requiring
fulltime caregiver support. Additionally, VA calculates the hourly wage
rate by using the 75 percent rate of pay established by the Bureau of
Labor Statistics. We would ask Congress and VA to review these two data
points to ensure that caregivers are being properly compensated for
their time.
Improve Transition Services:
As program stipends were not intended to be a permanent benefit in
all situations, there will certainly be cases where veterans are no
longer eligible for the Program due to changed circumstances. Where
this occurs, VA should provide transition services and education
regarding health care options, employment possibilities, and vocational
training. CSCs should be provided with a comprehensive list of
transition services available in their community through VA, state
veterans agencies, and the private and nonprofit sectors.
WWP Alumni Survey:
To provide context for the above, WWP draws data and insight from
our longitudinal and most recent Alumni Survey. In 2017, we received
34,822 completed surveys that have helped draw data and insight about
the more than 110,000 warriors registered for WWP programs and
services. The information gathered gives us critical information about
our alumni - the name we assign to our warriors - and their caregivers.
Of the alumni that responded to our 2017 survey, 7.9 percent
indicated they were permanently housebound. All the survey participants
were asked to indicate their current requirements for assistance from
another person for a range of daily living activities. We found that
four activities require more assistance than others. These included
doing household chores, managing money, taking medication properly, and
preparing meals.
Among alumni who needed assistance, 61.8 percent needed help with
three or more actives. The breakdown is as follows:
One to two activities - 38.2 percent
Three to four activities - 28.1 percent
Five to eight activities - 24.6 percent
Nine to all eleven activities - 9.1 percent
In addition, 27.5 percent of responding alumni reported a need for
aid and attendance of another person. On average, almost one-fourth
(24.7 percent) needed help for 10 or fewer hours per week. However,
25.4 percent needed more than 40 hours of aid per week. We highlight
these important data points to give you a clearer understanding of the
needs and circumstances of the current post-9/11 warrior using in-home
care, as reflected by the information we have recently gathered.
Conclusion:
Wounded Warrior Project will remain diligent in addressing the
needs and concerns of today's caregiver community. As the leader in
assisting wounded servicemembers transition to civilian life, we are at
the forefront of caregiver issues. We remain steadfast in our
commitment to expanding the caregiver program without putting current
caregivers at risk by expanding a program without appropriate funding.
Wounded Warrior Project thanks this committee for their diligence
and commitment to our nation's servicemembers and veterans. We
appreciate the efforts this committee has made in understanding and
addressing the gaps in caregiver support. We are thankful for the
ability to speak on behalf of our constituency and stand ready to
assist when needed.
Sincerely,
Rene C. Bardorf
Senior Vice President of Government and Community Relations
footnotes
i 155 Cong. Rec. S11538 (daily ed. Nov. 19, 2009) Congressional
Record, November 19, 2009, S11538
ii Terri Tenielian, et. al., Hidden Heroes: America's Military
Caregivers, RAND Corporation, 2014, p. 34.
iii Id. at 40.
iv Id. at 75.
v Id. at 73.
vi Department of Veterans Affairs, FY 2015 Budget Submission, VHA-
66; Department of Veterans Affairs, FY 2017 Budget Submission, VHA-99-
100.
vii Department of Veterans Affairs, FY 2015 Budget Submission, VHA-
11; Department of Veterans Affairs, FY 2017 Budget Submission, VHA-98.
viii Department of Veterans Affairs, FY 2015 Budget Submission,
VHA-66; Department of Veterans Affairs, FY 2016 Budget Submission, VHA-
104-05; Department of Veterans Affairs, FY 2017 Budget Submission, VHA-
99-100VHA.
ix GAO, VA Health Care: Actions Needed to Address Higher-than-
Expected Demand for the Family Caregiver Program, GAO-14-675, 18
(Washington, D.C.: September 2015).
x April Fales, et. al., 2017 Wounded Warrior Project Survey,
Westat, 2017, p. 33 (available at https://
www.woundedwarriorproject.org/media/172072/2017-wwp-annual-warrior-
survey.pdf).
xi Id. at 35.
xii Id.
RAND
Supporting Military and Veteran Caregivers from All Eras
Insights from RAND's Research
Terri Tanielian
CT-487
Testimony submitted to the House Veterans' Affairs Committee on
February 6, 2018
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testimonies/CT487.html
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Supporting Military and Veteran Caregivers from All Eras: Insights
from RAND Research
Statement of Terri Tanielian \1\
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\1\ The opinions and conclusions expressed in this testimony are
the author's alone and should not be interpreted as representing those
of the RAND Corporation or any of the sponsors of its research.
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The RAND Corporation \2\
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\2\ The RAND Corporation is a research organization that develops
solutions to public policy challenges to help make communities
throughout the world safer and more secure, healthier and more
prosperous. RAND is nonprofit, nonpartisan, and committed to the public
interest.
Before the Committee on Veterans' Affairs
United States House of Representatives
February 6, 2018
There are more than 20 million veterans living in the United States
today, many of whom have service-connected conditions or disabilities
that require ongoing support and care. Supporting these wounded, ill,
and injured warriors are the nation's ``hidden heroes''- caregivers who
provide unpaid, informal support with activities that enable current
and former U.S. servicemembers to live fuller lives. These caregivers
are an essential, but often overlooked, component of the nation's care
for returning warriors.
Starting in 2010, new federal programs were created to ensure
improved support for caregivers; however, at the time, little was known
about the characteristics and needs of this population. My comments
today derive from three studies sponsored by the Elizabeth Dole
Foundation and conducted by the RAND Corporation. In this statement, I
highlight some of the notable findings and recommendations from this
work in an effort to help the Committee consider specific opportunities
to improve existing federally supported programs that support military
and veteran caregivers.
Shaping Program Support Based on the Characteristics of Military and
Veteran Caregivers
RAND's first study, Hidden Heroes: America's Military Caregivers,
\3\ was the first to rigorously assess how many caregivers were aiding
current and former servicemembers, the characteristics of these
caregivers, the value they contribute to society, and the risks they
face as a result of their caregiving roles. We estimate that there are
5.5 million military and veteran caregivers in the United States. Of
these, 19.6 percent (1.1 million) are caring for someone who served in
the military after the terrorist attacks of September 11, 2001 (post-9/
11 caregivers).
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\3\ Rajeev Ramchand, Terri Tanielian, Michael P. Fisher, Christine
Anne Vaughan, Thomas E. Trail, Caroline Batka, Phoenix Voorhies,
Michael Robbins, Eric Robinson, and Bonnie Ghosh-Dastidar, Hidden
Heroes: America's Military Caregivers, Santa Monica, Calif.: RAND
Corporation, RR-499-TEDF, 2014. We use the term military and veteran
caregiver to include both those caring for a current member of the
military (including active-duty, reserve, and National Guard members)
and those caring for a former member of the military (commonly referred
to as a veteran).
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The remaining 4.4 million are providing caregiving support to
veterans who served prior to September 11 (pre-9/11 caregivers).
We compared post-9/11 and pre-9/11 military and veteran caregivers
with each other and with those providing care to nonveterans (civilian
caregivers). Pre-9/11 military and veteran caregivers tend to resemble
civilian caregivers in many ways. By contrast, post-9/11 caregivers
differ systematically from the other two groups. Table 1 details some
of the key differences among these populations, and Figure 1 highlights
the variation in the types of conditions of their care recipients.
[GRAPHIC] [TIFF OMITTED] T5375.001
[GRAPHIC] [TIFF OMITTED] T5375.002
Our study revealed that military and veteran caregivers provide
critical assistance with activities that enable U.S. veterans to live
more independently. It also documented that, while caregivers provide a
valuable service to their loved ones and the United States, they also
face unique challenges as result of their duties and may need an
appropriate level of support to help reduce the burden. Understanding
the differences between pre-9/11 and post-9/11 caregivers, and among
other caregiver subgroups (for example, spouses and parents), is
essential for targeting interventions that can most optimally support
both caregivers and those for whom they are caring. For example, these
caregivers may vary in terms of their demographics, rates of problems,
and the nature of the conditions that they are caring for.
Understanding and considering these differences can help ensure that
educational content, benefits provided, and services offered can be
tailored to specific subgroups. Doing so may improve the effectiveness
of such interventions and increase the overall efficiency of programs.
VA Caregiver Support Programs
The Hidden Heroes report also examined the existing programs and
policies that support military and veteran caregivers and highlighted
gaps in that support landscape. We identified 120 organizations that
were delivering services, resources, or other programs for these
caregivers.
Among these organizations was the VA, which offers a wide array of
services and benefits for military and veteran caregivers, including
the Program of Comprehensive Assistance for Family Caregivers.
While our study documented the types of services offered through
these organizations, we did not evaluate the efficacy or effectiveness
of the services delivered. Thus, we do not have any data or findings to
support specific recommendations for how to improve the VA's existing
programs that support caregivers. However, we did observe variation
in eligibility for and utilization of available programs for caregivers
(see Figure 2). For example, there is little uptake of stipends and
social support for pre-9/11 military and veteran caregivers, while
religious support is used by roughly one-fourth of all caregivers.
[GRAPHIC] [TIFF OMITTED] T5375.003
Programs often have varying eligibility criteria or content areas
of focus that may be applicable to only some subgroups of the caregiver
population (e.g., those married to their recipients, those caring for
someone over age 65). Understanding how all programs, including those
that are publicly funded and those sponsored by nongovernmental
entities, align across these characteristics allows not just for
identifying gaps in service availability for the subgroups but also for
understanding redundancies and how to better integrate and coordinate
across sectors.
Moving Forward to Create Better Support for Military and Veteran
Caregivers
Based on the characteristics and needs of caregivers, we made
several recommendations for improving the overall landscape of programs
that support military and veteran caregivers. These recommendations,
outlined in Hidden Heroes, called for strategies that would empower
caregivers, create more-supportive environments (in the workplace and
in health care settings), fill specific gaps in existing programs
(e.g., expand respite care services, align eligibility criteria, and
evaluate program effectiveness), and plan for the future (in terms of
ensuring caregiving continuity for veterans and enabling research to
continually inform programs and policies).
While the overall recommendations were broad in terms of their
objectives, the variability and nuances across the different subgroups
of caregivers highlight the fact that there is no one-size- fits-all
solution that will serve the needs of all caregiver subgroups equally.
Our findings and recommendations indicate that, in order to be
optimally effective, programs and resources need to be tailored to the
specific needs of different populations. For example, a program that is
focused on helping a caregiver attend to the needs of a care recipient
who experiences posttraumatic stress disorder will not be appropriate
for a caregiver who is attending to the needs of someone with a spinal
cord disorder, and vice versa. Similarly, programs and services
primarily designed for individuals who are married to or living with
their care recipient may not be suitable for caregivers who have
different relationships or live elsewhere.
In 2017, RAND conducted a follow-on study to Hidden Heroes, titled
Improving Support for America's Hidden Heroes: A Research Blueprint.
\4\ The goal of this study was to identify a series of research
priorities to more efficiently fill remaining knowledge gaps and
improve policies and programs. I shared insights from that study with
the Senate Special Committee on Aging in May 2017. \5\ In that study's
report, we reiterated a recommendation we also made in Hidden Heroes
that ongoing research is needed to inform improvements in the policies
and programs that support military and veteran caregivers. This is
especially true because caregiving is a dynamic responsibility, with
specific tasks and demands that shift over time, and the impacts
associated with it also wax and wane. The Blueprint also outlined ten
priority questions, all of which, if pursued, could provide empirical
evidence and guidance on how to most effectively expand and improve
programs. Those priority questions, and the other recommendations made
in that report, are also relevant to your considerations, particularly
as you consider specific recommendations to improve VA programs.
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\4\ Terri Tanielian, Kathryn E. Bouskill, Rajeev Ramchand, Esther
M. Friedman, Thomas E. Trail, and Angela Clague, Improving Support for
America's Hidden Heroes: A Research Blueprint, Santa Monica, Calif.:
RAND Corporation, RR-1873-TEDF, 2017. As of February 1, 2018: https://
www.rand.org/pubs/research--reports/RR1873.html
\5\ Terri Tanielian, ``Creating Better Support for Our Nation's
Hidden Heroes: A Research Blueprint for Military and Veteran
Caregivers,'' Santa Monica, Calif.: RAND Corporation, CT-478, 2017. As
of February 1, 2018: https://www.rand.org/pubs/testimonies/CT478.html
Federal Register Insert
[GRAPHIC] [TIFF OMITTED] T5375.005
HVAC Letter to Mr. Michael Shores
February 5, 2018
Mr. Michael Shores
Director
Office of Regulation Policy and Management
Department of Veterans Affairs
810 Vermont Ave. NW
Room 1063B
Washington, DC 20420
Dear Mr. Shores, April 23, 2019April 23, 2019
We write this comment in response to the January 5, 2018, Federal
Register notice seeking comments as to how the Department of Veterans
Affairs can purportedly improve the Program of Comprehensive Assistance
for Family Caregivers (Caregivers Program). We offer the following
recommendations and comments regarding any potential changes being
considered to the Caregivers Program. We want to strongly caution the
agency against considering any modifications to eligibility that would
lead to any decrease in benefits provided or number of beneficiaries
served. Given our concern regarding eligibility, in particular, we
tailor our recommendations and comments to that topic.
1. Should VA change how ``serious injury'' is defined for the
purposes of eligibility?
a. Should the severity of injury be considered in determining
eligibility to ensure VA is supporting family caregivers of Veterans
most in need? If so, how should the level of severity be determined?
If Congress intended to scale-back eligibility for the Program
based on the type of injury, it would have specified it in statute. The
severity of the injury is assessed not by artificially grouping the
type or cause of injury, but by its impacts on the veteran and the
resulting caregiving needs. In particular, the Senate Report for P.L.
111-163, the Caregiver and Veterans Health Services Act of 2009,
specifically expressed that eligibility be grounded in the veterans'
need for personal care services based on their ability to perform the
independent activities of daily living or in their need for supervision
or protection as a result of neurological or other impairments. These
qualifications are not necessarily related to the type or mechanism of
the injury, but rather the veteran's ability to perform daily
activities and other important functions without help.
Further, we do not support restrictions on eligibility absent
congressional approval. It is VA's job to implement the laws as
Congress writes them, not to artificially narrow the law in
regulations. As evidenced by our including an expansion of eligibility
to veterans in the pre-9/11 service eras in an ANS Ranking Member Walz
offered at a recent mark-up, and requiring studies on expanding the
program to veterans of all eras in the enactment of the first
caregivers legislation, expanding eligibility for the Caregivers
Program is a priority for the Minority Members of the House Committee
on Veterans' Affairs. Had we intended to scale-back eligibility for the
Program based on the type of injury, we would have done so prior to
offering legislation expanding the number of eligible individuals.
b. How should VA define veterans who are most in need?
The Department should not attempt to create such a definition.
Focusing on a purported scale of need is outside the intent of the law
as written. Any new criteria based on this would artificially limit the
eligible population when these types of restrictions appear nowhere in
the statute. When we know that there are already few options for the
delivery of care for severely disabled and injured veterans, we should
seek to expand their care options not restrict them. Further, it is not
the Department's purview to create such artificial restrictions,
contrary to current law. Rather, VA is obligated to request sufficient
funds and other resources to fulfill its obligations under the law.
Instead of attempting to limit eligibility or support, we expect the
Department to submit a comprehensive budget request sufficient to cover
all eligible veterans and caregivers, with services of the quality the
American people demand for our veterans, and to prepare for future
expansion of the program as clearly recommended by our Members and the
veteran community.
c. Should eligibility be limited to only those veterans who without
a family caregiver providing personal care services would otherwise
require institutionalization? If so, how should this be determined?
Limiting eligibility to include only those veterans who would
otherwise require institutionalization is antithetical to the
principles of the original caregiver's program which was designed to
help ease the burdens on caregivers who can provide a better
environment and outcomes, not to supplant institutionalization. In
fact, Congress specifically rejected a criteria of limiting eligibility
to only those veterans who would otherwise require institutionalization
in developing the final Caregivers and Veterans Omnibus Health Services
Act.
VA is already obligated to provide institutional care for veterans
in need of such care and meet one of the following criteria: a service-
connected disability rating of seventy percent or more; a need for
nursing home care for a service-connected disability; or a rating of
sixty percent when either unemployable or permanently and totally
disabled.
The intent of the law was not to replace institutionalization but
support family members willing to sacrifice and provide the opportunity
for the veteran to receive care at home. The law was designed to help
keep veterans in the safest, most appropriate setting for their health
and care needs. The need for institutionalization is not synonymous
with the severity of illness or injury, and takes into consideration a
number of factors that are not necessarily the same as a caregiver
situation and would therefore be arbitrary if applied to Caregivers
eligibility.
We are concerned that this solicitation's focus on eligibility,
combined with the administration's recent concerns regarding ``fiscal
constraints'' as noted in its recent redline document provided to the
Senate Committee on Veterans' Affairs regarding S. 2193, Caring for
Veterans Act of 2017, and emphasis on focusing resources on ``Veterans
who need it most'', amounts to an attempt to justify cuts or changes to
the Program at the expense of our most vulnerable veterans rather than
an opportunity to assess the program's strengths and weaknesses. We
urge the administration to consult with Congress on the nature of these
issues before moving forward with any modifications to eligibility.
We appreciate your consideration of this comment. If you have any
questions, please reach out to Ms. Megan Bland, Democratic Professional
Staff Member, at (202) 225-9756 or via email at
[email protected].
Sincerely,
TIMOTHY J. WALZ
Ranking Member
MARK TAKANO
Vice-Ranking Member
JULIA BROWNLEY
Member of Congress
ANN M. KUSTER
Member of Congress
KATHLEEN RICE
Member of Congress
J. LUIS CORREA
Member of Congress
GREGORIO KILILI CAMACHO SABLAN
Member of Congress
Questions For The Record
HVAC to The Honorable David Shulkin
January 29, 2018
The Honorable David Shulkin
Secretary
United States Department of Veterans Affairs
810 Vermont Ave. NW
Washington, D.C. 20515
Dear Mr. Secretary:
In advance of your testimony at the upcoming Full Committee
oversight hearing entitled, "A Caregiver Support Program: Correcting
Course for Veteran Caregivers," please respond to the following - in
writing - by no later than close of business on Friday, February 2, 201
8.
1.On January 27th, three separate statements were issued on your
behalf concerni ng the Family Caregiver Program. What is your position
in comparison to the stated Administration's position? Does the program
need to be improved or expanded? Does the program need to be improved
before any expansion can be considered?
2.You state your desire for the Famil y Caregiver Program to
``[focus] its resources on Veterans who need it most.'' Which veterans
do you believe ``need'' the Family Caregiver Program ``the most'' and
why? Do you think the eligibility criteria for the current Family
Caregiver Program should be amended to better target these veterans?
How?
3.You also state your desire to engage with Congress to ``find the
right balance between the scope of the benefit, including clinical
appropriateness, and overall cost.'' Where do you believe that balance
lies? What specific information do you need to make an informed
decision whether to expand the Family Caregiver Program to pre-9/ 11
veterans in its current or amended form?
3. What are the fiscal implications - to include both cost savings
and cost increases - of expanding the Family Caregiver Program as it
exists today to pre-9/ 1 1 veterans and caregivers? Similarly, how many
more veterans and caregivers would qualify for the Family Caregiver
Program were it expanded, in its current state, to pre-9/ 1 1 veterans,
how would the Program 's budget and staff be impacted by such
expansion, and how did you arrive at this estimate?
4.What other existing long-term, extended, geriatric or other
programs or benefits serve pre-9/ 11 veterans and/or caregivers and,
should the Family Caregiver Program be expanded to pre-9/11 veterans,
how would you prevent duplication of those programs or benefits and/or
incorporate them into the expanded Family Caregiver Program?
5.When is the Information Technology (IT) system for the Family
Caregiver Program expected to be fully implemented and operational ?
What is the total cost of that system and how is it expected to be
used? Once data is compiled via that system, how long would you need to
analyze such data and determine potential program adjustments based on
that data?
Your timely response to these questions for the record and your
commitment to our nation 's veterans are both very much appreciated.
Ifyou have any questions, please contact the Subcommittee on Health at
(202) 225-9154.
Sincerely,
DAYID P. ROE, M.D.
Chairman
VA Responses to Pre-Hearing Questions
Feb 6, 2018, HVAC Hearing - Caregivers Program
1.On January 27th, three separate statements were issued on your
behalf concerning the Family Caregiver program.
a.What is your position in comparison to the stated
Administration's position?
Response: My opinion is the same as the Administration's position,
which is that expansion of the Program of Comprehensive Assistance for
Family Caregivers (PCAFC) is the right and equitable thing to do, but
we can't responsibly support it without ensuring funds will be
available.
b.Does the program need to be improved or expanded?
Response: We strongly support improving the Caregiver programs and
focusing its resources on Veterans who need it most regardless of when
they served. We are already working to improve the program. In January
of this year, the Department published a notice in the Federal Register
seeking public comment on ways to improve the Caregiver program. The
public comment period closes on February 5, and we will use the
feedback to inform future changes to the program.
c. Does the program need to be improved before any expansion can be
considered?
Response: VA has made significant improvements over the past year
and is currently working on additional improvements. VA cannot comment
on whether or not expansion can happen at the same time.
2.You state your desire for the Family Caregiver Program to
``[focus] its resources on Veterans who need it most.''
a.Which veterans do you believe ``need'' the Family Caregiver
Program ``the most'' and why?
Response: We think the program's eligibility criteria should target
Veterans who would require a higher level of care, outside of their
home were it not for the assistance of their family caregiver.''
b.Do you think the eligibility criteria for the current Family
Caregiver Program should be amended to better target these Veterans?
How?
Response: The eligibility should target those Veterans at risk for
having to leave their homes in order to receive care.
3.You also state your desire to engage with Congress to ``find the
right balance between the scope of the benefit, including clinical
appropriateness, and overall cost.''
a.Where do you believe that balance lies?
Response: The cost to expand the Family Caregiver Program under its
current eligibility is more than $3 billion annually. In order to
ensure that we provide the additional supports and services available
under the Family Caregiver Program to caregivers whose Veterans served
Prior to 9/11, we may need to limit eligibility to those Veterans who
cannot remain at home were it not for their family caregiver.
b.What specific information do you need to make an informed
decision whether to expand the Family Caregiver Program to pre-9/11
veterans in its current or amended form?
Response: New legislation is required for VA to expand eligibility
to pre-9/11 Veterans. VA would need to review the legislation closely
and have confidence sufficient resources will be available to properly
fund the program without compromising other core Veteran health care
programs.
4.What are the fiscal implications - to include both cost savings
and cost increases - of expanding the Family Caregiver Program as it
exists today to pre-9/11 veterans and caregivers?
a.Similarly, how many more veterans and caregivers would qualify
for the Family Caregiver Program were it expanded, in its current
state, to pre-9/11 veterans, how would the Program's budget and staff
be impacted by such expansion, and how did you arrive at this estimate?
Response: Care Management and Social Work Services collaborated
with the VHA Office of the Assistant Deputy Under Secretary for Health
for Policy and Planning, VHA Finance and the Office of Community Care
(formerly referred to as the Chief Business Office Purchased Care)
Caregiver Support Division to develop a stipend budget projection model
for the Program of Comprehensive Assistance for Family Caregivers.
Data, methodology and assumptions from this mid-year FY 2016 model were
updated in the spring of 2017. The model results have been expanded to
include projections through fiscal year 2027 for Veteran sponsor
counts, and total stipend expense by fiscal year for four different
eras of Veteran service including: prior to the Vietnam War, Vietnam
War, after the Vietnam War but before September 11, 2001, and after
September 11, 2001.These projections are applicable for the expansion
of the Program to all era Veterans with eligibility as the Public Law
111-163 is currently written, therefore projections and costing would
be significantly different if the eligibility was changed to
incorporate Veterans with a ``serious illness'' or if there were other
programmatic changes for additional benefits and/or services.
Total Pre and Post 9/11 Projections Combined
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Total projections: Inclusive of current eligibility
Year Veterans Stipend Only plus expansion to all eras (assumes stipend accounts
for 85% of the entire budget)
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2017 88,309 $1,246M $1,466M
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2018 130,371 $2,022M $2,379M
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2019 155,608 $2,507M $2,949M
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2020 165,807 $2,787M $3,279M
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2021 162,686 $2,790M $3,282M
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2022 155,742 $2,716M $3,195M
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2023 152,863 $2,719M $3,199M
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2024 150,169 $2,725M $3,206M
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2025 182,925 $2,735M $3,218M
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2026 182,723 $2,757M $3,244M
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2027 182,195 $2,785M $3,276M
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Methodology: Veteran counts are based on a combination of observed
enrollment patterns in the current Program of Comprehensive Assistance
for Family Caregivers and estimated enrollment patterns that would
occur if the PCAFC program were expanded to pre 9/11 Veterans. Annual
stipends per Caregiver sponsor (Veteran) and cost per stipend are
assumed to remain consistent with those projected under the current
Public Law 111-163.
Total sponsors estimated were split into the three stipend tiers
using the distribution of tiers by age band, gender, and service-
connected disability experienced under the current Caregiver Support
Program.
Projected number of stipend payments was determined by multiplying
the projected sponsor counts by tier by the average number of stipend
payments per year projected for FY 2017 through FY 2027 under the
current Caregiver Support Program.
Total stipend payments were multiplied by the expected cost per
payment projected for FY 2017 through FY 2027 under the current
Caregiver Support Program in order to determine the total projected
stipend cost by service era and tier for FY 2017 through FY 2027.
The pool of eligible Veterans was estimated using both VetPop2014
and the VA/DOD Identity Repository (VADIR) database. The VADIR data was
incorporated into this development since VetPop2014 does not have
information by separation date, which was required to identify the post
9/11/2001 Veterans. Veteran counts from VADIR were limited to Veterans
separating from active duty after September 11, 2001 and prior to the
start of FY2012 through FY2015.
Enrollment probabilities were estimated based on the PCAFC data and
Census Bureau data provided in the Public Use Microdata Sample (PUMS).
The PUMS data includes information on Veterans by broad degree of
disability categories, as well as needing assistance with three or more
ADLs (activities of daily living). This modeling relied on the PUMS
data for the change in assistance with ADLs by age.
Assumptions: Projections do not have a built in ramp up period. The
probability of needing assistance with three or more Activities of
Daily Living increases as a Veteran's age increases. Annual stipends
per Caregiver sponsor (Veteran) and cost per stipend are assumed to
remain consistent with those projected under the current Caregiver
Support Program which is about 85% of the overall Program's operating
budget.
5.What other existing long-term extended, geriatric or other
programs or benefits serve pre-9/11 veterans and/or caregivers and,
should the Family Caregiver Program be expanded to pre 9/11 veterans,
how would you prevent duplication of those programs or benefits and/or
incorporate them into the expanded Family Caregiver Program?
Response: VA purchases a mix of services that assist Veterans and
caregivers when Veterans need assistance with activities of daily
living or have cognitive impairments. These personal care services are:
Homemaker/Home Health Aide (H/HHA); Veteran Directed Care (VDC);
Community Adult Day Health Care (CADHC); and, Home Respite.
These programs are currently available to Veterans and caregivers
participation in the Family Caregiver Program. If the Family Caregiver
Program is expanded to pre-911 Veterans, these programs would continue
to be available to those participating in the Family Caregiver Program.
The amount of care provided will be established through the case
mix instrument VA introduced in August 2017. The instrument assists VA
providers in making a clinical decision on the amount of care (hours or
days or a budget amount) needed for the Veteran to remain safely at
home, based on the Veteran's need for personal care services.
Duplication of service is avoided by having a standardized tool
inclusive of all personal care services, based on a Veteran's need for
care.
VA also provides Home Based Primary Care (HBPC) for Veterans with
complex, chronic disabling conditions when routine clinic-care is not
effective. This enables VA to provide comprehensive, longitudinal, and
interdisciplinary primary care in the home when Veterans are unable to
go to clinic. HBPC service provides primary care to Veterans and lowers
caregiver burden by reducing the need for caregivers to arrange clinic
visits and also by providing educational and emotional support to
caregivers that is complementary to the Family Caregiver program.
These services do not duplicate those provided by the Family
Caregiver program.
6.When is the Information Technology (IT) system for the Family
Caregiver expected to be fully implemented and operational?
a.What is the total cost of that system and how is it expected to
be used?
Response: The Caregiver Support Program is pursuing a two-pronged
approach to enhance and improve its IT platform. The Caregiver
Application Tracker (CAT) Rescue is a short term solution targeted on
enhancing and stabilizing the current Caregiver Application Tracker
(CAT) application. This project has encountered significant delays, and
is currently targeting a June 2018 deployment. Product testing is
currently underway. The success of CAT Rescue lays the foundation for
the longer term solution, the Caregivers Tool, or Care-T. CAT Rescue
provides robust error-checking features and moves the system into a
data center with stronger disaster recovery and failover features. It
also provides enhanced reporting functions for the Caregiver Program
Office. Care-T is currently in the development phase and scheduled to
deploy in September 2018.
CareT is designed to significantly enhance data integrity by
instituting business rules and data validation. It has equivalent or
enhanced features relative to the CAT Rescue application, including
robust error-checking and strong disaster recovery and failover
features. CARE-T will use a web-based architecture. It is designed to
be scalable and capable of accommodating significant growth in numbers
enrolled in the Caregiver program, including an expansion of
eligibility of a pre-9/11 Veteran population. It is designed to be a
more intuitive system for enhanced user experience, with interfaces
designed based on the most likely inquiries for a given user
population. CareT has role-defined data views, which will enable the
tool to be used by Veterans, Caregivers, and VA staff administering the
program alike, thus enabling its use as an interactive tool between
these groups of users and enhancing the efficiency of communications
between these groups. In short, CareT enables cleaner data collection,
improved reporting, enhanced communication between Veterans,
Caregivers, and VA staff administering the program, excellent reporting
and audit tools, and improved data analytics for program managers.
Breakdown of total costing for CAT Rescue by fiscal year (contract
and FTE costs)
------------------------------------------------------------------------
Fiscal Year (FY) Cost
------------------------------------------------------------------------
FY12 $4,211,352.76
------------------------------------------------------------------------
FY13 $137,000
------------------------------------------------------------------------
FY14 $137,000
------------------------------------------------------------------------
FY15 $1,793,274
------------------------------------------------------------------------
FY16 $1,135,897
------------------------------------------------------------------------
FY17 $1,550,952
------------------------------------------------------------------------
FY18 Estimated $1,273,131
------------------------------------------------------------------------
FY19 Estimated $547,000
------------------------------------------------------------------------
FY20 Estimated Zero. System retired
------------------------------------------------------------------------
Breakdown of total costing for CareT by fiscal year (contract and
FTE costs)
------------------------------------------------------------------------
Fiscal Year (FY) Cost
------------------------------------------------------------------------
FY15 $2,119,785
------------------------------------------------------------------------
FY16 $2,639,037
------------------------------------------------------------------------
FY17 $2,026,065
------------------------------------------------------------------------
FY18 Estimated $1,105,640
------------------------------------------------------------------------
FY19 Estimated $1,637,000
------------------------------------------------------------------------
FY20 Estimated $1,692,000
------------------------------------------------------------------------
a.Once data is compiled via that system, how long would you need to
analyze such data and determine potential program adjustments based on
that data?
Response: Despite the delays in implementing a new IT system, VA
has made multiple, significant, program adjustments based on data that
is available, stakeholder input, and continuous improvement processes.
Program evaluation is also underway to inform program changes without
this existing robust data mining capability in the Caregiver
Application Tracker. The Caregiver Support Program has partnered with
Health Services Research and Development to assist not in traditional
research but quality improvement efforts. More recently the Program
Office has pursued a contract to survey Veterans and Caregivers
requesting their direct feedback about services and supports offered.
In addition, in January 2018 the Program Office pursued a Federal
Registry notice and has formally asked for public comment on a variety
of program issues seeking input to potential program changes.
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