[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


 VA CAREGIVER SUPPORT PROGRAM: CORRECTING COURSE FOR VETERAN CAREGIVERS

=======================================================================

                                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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                     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 
hearing records of the Committee on Veterans' Affairs are also 
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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

                              ----------                              


                       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\
---------------------------------------------------------------------------
    \1\ May 3, 2011 VA Press Release https://www.va.gov/opa/pressrel/
pressrelease.cfm?id=2088
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \2\ GAO Report-14-675, https://www.gao.gov/assets/670/665928.pdf
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \3\ VA Announces Internal Review of Caregiver Program https://
www.va.gov/opa/pressrel/pressrelease.cfm?id=2889
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \4\ VA Caregiver Support Program Resumes Full Operations - https://
www.va.gov/opa/pressrel/pressrelease.cfm?id=2933
---------------------------------------------------------------------------
    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

    For more information on this publication, visit www.rand.org/pubs/
testimonies/CT487.html

    Testimonies

    RAND testimonies record testimony presented or submitted by RAND 
associates to federal, state, or local legislative committees; 
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oversight bodies.

    Published by the RAND Corporation, Santa Monica, Calif.

    c Copyright 2018 RAND Corporation is a registered trademark.

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and linking permissions, please visit www.rand.org/pubs/
permissions.html.

    www.rand.org

    Supporting Military and Veteran Caregivers from All Eras: Insights 
from RAND Research

    Statement of Terri Tanielian \1\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    The RAND Corporation \2\
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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
----------------------------------------------------------------------------------------------------------------
                                                             Total projections: Inclusive of current eligibility
       Year              Veterans          Stipend Only     plus expansion to all eras (assumes stipend accounts
                                                                        for 85% of the entire budget)
----------------------------------------------------------------------------------------------------------------
             2017              88,309             $1,246M                                               $1,466M
----------------------------------------------------------------------------------------------------------------
             2018             130,371             $2,022M                                               $2,379M
----------------------------------------------------------------------------------------------------------------
             2019             155,608             $2,507M                                               $2,949M
----------------------------------------------------------------------------------------------------------------
             2020             165,807             $2,787M                                               $3,279M
----------------------------------------------------------------------------------------------------------------
             2021             162,686             $2,790M                                               $3,282M
----------------------------------------------------------------------------------------------------------------
             2022             155,742             $2,716M                                               $3,195M
----------------------------------------------------------------------------------------------------------------
             2023             152,863             $2,719M                                               $3,199M
----------------------------------------------------------------------------------------------------------------
             2024             150,169             $2,725M                                               $3,206M
----------------------------------------------------------------------------------------------------------------
             2025             182,925             $2,735M                                               $3,218M
----------------------------------------------------------------------------------------------------------------
             2026             182,723             $2,757M                                               $3,244M
----------------------------------------------------------------------------------------------------------------
             2027             182,195             $2,785M                                               $3,276M
----------------------------------------------------------------------------------------------------------------

    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.

                                 [all]