[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                    THE SILVER TSUNAMI: IS VA READY?

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                         TUESDAY, MARCH 3, 2020

                               __________

                           Serial No. 116-59

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]       

                    Available via http://govinfo.gov
                    
                               __________

                                
                    U.S. GOVERNMENT PUBLISHING OFFICE                    
51-635                      WASHINGTON : 2023                    
          
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                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tennessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York

                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

                         SUBCOMMITTEE ON HEALTH

                 JULIA BROWNLEY, California, Chairwoman

CONOR LAMB, Pennsylvania             NEAL P. DUNN, Florida, Ranking 
MIKE LEVIN, California                   Member
ANTHONY BRINDISI, New York           AUMUA AMATA COLEMAN RADEWAGEN, 
MAX ROSE, New York                       American Samoa
GILBERT RAY CISNEROS, JR.,           ANDY BARR, Kentucky
    California                       DANIEL MEUSER, Pennsylvania
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands

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 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                        
                        
                        C  O  N  T  E  N  T  S

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                         TUESDAY, MARCH 3, 2020

                                                                   Page

                           OPENING STATEMENTS

Honorable Julia Brownley, Chairwoman.............................     1
Honorable Neal P. Dunn, Ranking Member...........................     2

                               WITNESSES

Dr. Teresa Boyd, Assistant Deputy Under Secretary for Health for 
  Clinical Operations, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................     4

        Accompanied by:

    Dr. Beth Taylor, Chief Nursing Officer, Veterans Health 
        Administration, U.S. Department of Veterans Affairs

    Dr. Scotte Hartronft, Executive Director, Office of 
        Geriatrics and Extended Care, Veterans Health 
        Administration, U.S. Department of Veterans Affairs

    Dr. Elyse Kaplan, Deputy Director, Caregiver Support Program, 
        Veterans Health Administration, U.S. Department of 
        Veterans Affairs

Ms. Nikki Clowers, Managing Director, Health Care, U.S. 
  Government Accountability Office...............................     6

        Accompanied by:

    Ms. Karin Wallstad, Assistant Director, Health Care, U.S. 
        Government Accountability Office

Mr. Adrian Atizado, Deputy National Legislative Director, 
  Disabled American Veterans.....................................    18

Mr. Mark Bowman, President, National Association of State 
  Veterans Homes.................................................    20

                                APPENDIX
                    Prepared Statements Of Witnesses

Dr. Teresa Boyd Prepared Statement...............................    31
Ms. Nikki Clowers Prepared Statement.............................    35
Mr. Adrian Atizado Prepared Statement............................    47
Mr. Mark Bowman Prepared Statement...............................    53

                       Statements For The Record

Paralyzed Veterans of America....................................    61
The Elizabeth Dole Foundation....................................    64

 
                    THE SILVER TSUNAMI: IS VA READY?

                              ----------                              


                         TUESDAY, MARCH 3, 2020

              U.S. House of Representatives
                             Subcommittee on Health
                             Committee on Veterans' Affairs
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 2:32 a.m., in 
room 210, House Visitors Center, Hon. Julia Brownley 
[chairwoman of the subcommittee] presiding.
    Present: Representatives Brownley, Lamb, Brindisi, 
Cisneros, Sablan, Dunn, and Meuser.

        OPENING STATEMENT OF JULIA BROWNLEY, CHAIRWOMAN

    Ms. Brownley. Good morning, everyone, and welcome to the 
Subcommittee on Health, today's hearing on ``The Silver 
Tsunami: Is VA ready?''
    America's health care systems are bracing for the coming 
demands on its systems as one of the largest generations in 
American history enters their later years. Compounding this 
demand is an issue the subcommittee knows well, a harrowing 
shortage of providers. The Institute of Medicine predicts that 
by 2030 the United States will need an additional 3.5 million 
doctors, nurses, and other professionals to care for seniors. 
Of the roughly 19 million veterans alive in the United States 
today, 9 million are 65 years or older. While the total number 
of senior veterans is projected to decline into the foreseeable 
future, this population is the largest age cohort and will 
remain so for decades.
    About 3.2 million veterans over 65 are enrolled in Veterans 
Health Administration (VHA) and one half of those have service-
connected disabilities that entitle them to VA's institutional 
care services. In recent years, stakeholders have largely 
focused on VA's community care and caregiver programs. While 
these are essential areas for VA to get right, the scale of the 
Silver Tsunami is something VA cannot afford to get wrong.
    Millions of veterans and their families are relying on us 
to ensure their later years are as dignified and healthy as 
possible. I am concerned that in the year since our field 
hearing in my district on long-term care nothing about VA's 
overall strategy or communication of any strategy has been made 
clear. To make matters more confusing, at last week's budget 
hearing Dr. Stone told the committee that VHA is preparing an 
elder care strategic plan that will be released soon, yet there 
is no mention of it in VA's testimony today.
    Over the next 17 years, VA will have doubled its spending 
on long-term care services, nearly $15 billion, as the largest 
cohort of veterans, those of the Vietnam era, come into their 
older years. These veterans, mostly baby boomers, will live 
longer in old age than any generation before, but with more 
complicated health needs and disabilities than any American 
health system has ever had to contend with.
    In 2019, a half a million veterans used VA's long-term care 
services; of these veterans, 28 percent were 85 years or older. 
Most have a disability, a chronic disease, or are low income, 
and around one third live in rural areas. Eighty percent of 
VA's community living centers had vacancies for nurse 
assistants and home health aides. In 4 years, one million 
veterans with service-connected conditions will be eligible for 
nursing home care from VA, but this upswing in demand has 
already begun. Nearly half of VHA users are over the age of 65 
and in just the previous 4 years VA's long-term care spending 
has increased 33 percent from $7 billion to $9 billion.
    Long-term services and support is what VHA spends the most 
money on; that spending will only continue in the following 
decades. How VA plans to meet the complicated needs of veterans 
in these difficult and expensive years is what we hope to learn 
today.
    Additionally, as we discussed last month, the veteran 
population is changing and this cohort of aging veterans is 
more diverse than ever before. We are eager to learn how VA's 
geriatric and extended-care program is working to ensure its 
programs, institutional and non, are designed to meet the needs 
of more women, more LGBT folks, more Native veterans, and more 
veterans with complex mental health needs.
    Last month's Government Accountability Office (GAO) report 
on VA long-term care highlighted three key challenges: a 
workforce shortage, geographic mismatch of where services are 
and where veterans are, and a struggle to meet the need for 
specialty care, particularly behavioral health, in the 
geriatric population. VA must address these challenges. The 
scope of the Silver Tsunami is unlike anything the United 
States has ever seen before. VA has been and I hope will 
continue to be the leader for the rest of America's health care 
systems to model after, from innovative home-based programs to 
community partnerships, to holistic institutional care, VA has 
the tools to meet the needs of this large, diverse patient 
population, how they plan to get there is what we wish to 
discuss today.
    With that, I would like to recognize Dr. Dunn for 5 minutes 
for any opening remarks he may wish to make.

       OPENING STATEMENT OF NEAL P. DUNN, RANKING MEMBER

    Mr. Dunn. Thank you very much, Chairwoman Brownley. I 
appreciate being here with you this morning to discuss the 
provision of long-term care to the increasing number of 
veterans who are elderly and members of the so-called Silver 
Tsunami. I do not know who came up with that, but it is kind of 
close to the bone.
    There is no question that the veteran population is getting 
increasingly older. In fact, according to the Veterans Affairs 
Department, almost half of all the veterans enrolled are 65 
years old or older. Many of the veterans devoted the prime of 
their life to our country, defending our freedom, and it is our 
privilege and our duty to repay that service by ensuring that 
those same men and women are well taken care of now.
    I am pleased to see that the VA has a number of services 
and supports to offer these veterans, including an increasing 
number of programs that allow them the opportunity to age in 
place in home rather than in nursing homes or other 
institutional settings. Our veterans earn their VA health care 
benefits and, whenever possible, we should honor their choices 
in how best to use those benefits.
    I do share concerns detailed in the Government 
Accountability Office's recent report about the challenges 
facing the VA in meeting the significantly growing veteran 
demand for long-term care in a health care market that is 
increasingly tight. In addition to concerns about workforce 
shortages and difficulty meeting specialty-care needs, GAO also 
found a geographic misalignment between demand for those 
services and capacity for long-term care within the VA health 
care system. Such serious misalignment between where the 
veterans are and where the VA medical facilities is not limited 
to long-term care only, but I think we have addressed that with 
the AIR Act, the Asset and Infrastructure Review Act, which was 
included as a component of the MISSION Act in the last 
Congress.
    AIR creates a blueprint for the VA health care system can 
be realigned and brought up to date to meet not only the needs 
of today's veterans, but also the provision of long-term care 
as we proceed into the 21st century. Today's hearing is another 
sobering reminder of the importance of the AIR Act and I 
appreciate GAO for once again noting the serious repercussions 
that our Nation's will face if it fails.
    In addition to AIR, MISSION also included a provision that 
would expand the Family Caregiver Program to the pre-9/11 
veterans. That expansion has been long awaited and I understand 
that a proposed rule may be published in the Federal Register 
as early as this week. I look forward to that.
    The expansion of the Family Caregiver Program will be life-
changing to the elderly veterans who are eligible for it and 
their caregivers, who for far too long have been laboring on 
behalf of their loved ones without the help and support of the 
VA and the Family Caregiver Program.
    As we discuss in detail during today's hearing the needs of 
our Nation's veterans, many of whom have co-morbid conditions 
as a result of their time in uniform, their care only gets more 
complicated near the end of their life. An expanded Family 
Caregiver Program will have to be ready to meet those needs, as 
well as the needs of the caregivers themselves who are 
themselves aging. I expect we will have a hearing in the coming 
months on the Department's proposal for expansion, but given 
the serious impact that it will have on the growing numbers of 
elderly veterans, I look forward to beginning that discussion 
this morning with you as well.
    I am grateful to all of my colleagues for being here and to 
the witnesses for being here. With that, Chairwoman, I yield 
back. Thank you.
    Ms. Brownley. Thank you, Dr. Dunn.
    We have two panels today. With us is Dr. Teresa Boyd, the 
Assistant Deputy Under Secretary for Health for Clinical 
Operations at the Department of Veterans Affairs. She is 
accompanied by Dr. Beth Taylor, Chief Nursing Officer at VHA. 
Dr. Scott Hartronft--close, but--the Executive Director of the 
Office of Geriatrics and Extended Care at VHA. Dr. Elyse 
Kaplan, the Deputy Director of the Caregiver Support Program at 
VHA.
    Joining us from GAO we have Ms. Nikki Clowers, the 
Management Director of GAO's Health Care team, and she is 
accompanied by Ms. Karin Wallestad, Assistant Director of the 
Health Care team.
    With that, I now recognize Dr. Boyd for 5 minutes. Welcome.

                    STATEMENT OF TERESA BOYD

    Dr. Boyd. Thank you and I appreciate the opportunity.
    Good morning, Chairwoman Brownley, Ranking Member Dunn, and 
distinguished members of the subcommittee. I appreciate the 
opportunity to discuss VA long-term care and veterans' choices 
for care as they age or face catastrophic injuries or 
illnesses.
    I am accompanied today by Dr. Beth Taylor, Chief Nursing 
Officer; Dr. Scotte Hartronft, Executive Director, Office of 
Geriatrics and Extended Care; and Dr. Elyse Kaplan, Deputy 
Director, Caregiver Support Program. We proudly represent the 
professional team approach provided within VA's 
interdisciplinary and integrative health care system.
    VA is committed to optimizing the health and well-being of 
veterans with multiple chronic conditions: life-limiting 
illness, frailty or disability associated with chronic disease, 
aging, or injury. Geriatrics and Extended Care (GEC's) programs 
maximize each veteran's functional independence and lessen the 
burden of the disability on veterans, their families, and their 
caregivers.
    As veterans age, approximately 80 percent will develop the 
need for long-term services and supports. Most of this support 
in the past has been provided by family members, with women 
providing most of that care. The average number of potential 
family caregivers per older adult in America is currently 
seven, but that will likely decline by 2030. The availability 
of these potential family caregivers can be jeopardized due to 
work responsibilities outside the home. Moreover, many veterans 
are divorced, have no children, are estranged from their 
families, or live long distances from family members.
    The aging of the veteran population has been more rapid and 
represents a greater proportion of the VA patient population 
than observed in other health care systems. Addressing the 
needs of aging veterans was recognized as a priority in 1975, 
which led to the development of 20 currently existing centers 
of excellence called Geriatric Research, Education, and 
Clinical Centers, or GRECCs, within VA. These GRECCs have 
served as an incubator for research into health and health 
systems relevant to older veterans and spawned innovative 
clinical programs that have been shown to optimize veterans' 
function, prevent unnecessary and costly nursing home 
admissions and hospitalizations, reduce unwanted and 
unnecessary tests and treatments, and thereby reduce health 
care costs where they have been made available.
    While VA remains proud of our achievements in caring for 
our aging veterans, we acknowledge GAO's report highlighting 
areas where improvement is needed. We believe our existing GEC 
programs leave room for meeting the report's recommendations 
and our veterans' preferences. We will be meeting with Dr. 
Richard Stone, VHA's Executive in Charge, at the end of this 
month and presenting a way forward in developing those 
measurable goals. Moreover, the Choose Home Program, which 
began in 2018 with 21 pilot sites, will figure heavily into our 
strategic plan. We sincerely believe we have an opening to turn 
this Silver Tsunami into a golden opportunity.
    VA provides a comprehensive spectrum of GEC services that 
surpasses all other U.S. health care systems. VA integrates 
care provided in the home, the clinic, the hospital, the 
nursing home, and incorporates care at the end of life spanning 
all settings.
    In addition to integration of care, VA's spectrum of 
services effectively combines both Medicare and Medicaid, but 
includes social support and personal care services based on 
need rather than on income through services such as Veteran-
Directed Care. Additionally, VA provides services such as home-
based primary care, caregiver support, and Medical Foster Home, 
in addition to the Veteran-Directed Care that are not routinely 
available in other health care systems.
    VA's various long-term care programs provide a continuum of 
services for older veterans designed to meet needs as they 
change over time. Together they have significantly improved the 
care, well-being, and dignity of our veterans.
    Like many of my colleagues here from VA, this is personal 
and it is a humble mission. My father was a World War II 
veteran, aviation mechanic, and country physician, who was 
supported with community nursing home care and respite care in 
his final months of life. My eldest brother, who was a Vietnam 
veteran and a West Point graduate, who died at home with 
dignity thanks to VA Hospice.
    Moreover, the care for our growing population of women 
veterans and our Native Americans can be considered in this 
vein and their independent needs are also continuing to be met 
such as the 101-year-old female veteran, an original Women Army 
Corps veteran who resides in one of our medical foster homes.
    The gains VA has made in providing long-term care to 
veterans would not have been possible without consistent 
congressional commitment. Your continued support is essential 
to providing high-quality care for our veterans and their 
families, present and future. We also thank our partners at GAO 
for the excellent work they continue to do to assist in 
ensuring our veterans are being met with the best care 
possible, as well as a partnership with National Association of 
State Veterans Homes and Disabled American Veterans, who are 
sitting on the second panel today.
    The previously mentioned 101-year-old female veteran has 
said, ``I just can not believe that my service in the military 
all those years ago got me here in this nice place with all 
these nice people.'' VA's goal is to provide a level of service 
and care commiserate to the sacrifices veterans have made for 
our country. The bar is high, but we do intend to meet the 
mark.
    Chairwoman Brownley, this concludes my testimony. My 
colleagues and I look forward to discussing this important 
topic further. Thank you.

    [The Prepared Statement Of Teresa Boyd Appears In The 
Appendix]

    Ms. Brownley. Thank you, Dr. Boyd.
    I now recognize Nikki Clowers for 5 minutes.

                   STATEMENT OF NIKKI CLOWERS

    Ms. Clowers. Chairwoman Brownley, Ranking Member Dunn, and 
members of the subcommittee, thank you for having me here today 
to discuss VA's efforts to address veterans' long-term care 
needs. I am pleased to be joined by my colleague Karin 
Wallestad, the lead investigation for our February report on 
this topic; my comments today will be based on that report.
    Long-term care can address a range of needs, from 
occasional help around the house to ongoing clinical care. In 
2018, VA provided or paid for long-term care for over 500,000 
veterans, an increase of 14 percent since 2014. VA's spending 
on long-term care increased by 33 percent during this timeframe 
from almost $7 billion in 2014 to over $9 billion in 2018. VA's 
model projects growing demand for long-term care in the future. 
For example, VA projects that utilization of its Homemaker/Home 
Health Aide Program will increase by 84 percent from 2017 to 
2037. With increased demand for long-term care, VA also 
projects that spending on these programs will more than double 
during this timeframe, topping $14 billion by 2037.
    According to VA's projections, the expected growth in these 
programs will not be uniform, with demand for care continuing 
to shift from institutional settings, such as nursing homes, to 
more non-institutional settings, such as aging at home with 
home health aides. As a result, spending on non-institutional 
programs is expected to increase by 170 percent through 2037, 
while spending on institutional programs will increase by about 
70 percent during this timeframe.
    Like other health care providers, VA faces challenges in 
meeting this demand. Our report highlighted three challenges. 
First, VA faces workforce shortages in certain positions such 
as nursing assistants. According to VA, these shortages have 
contributed to wait lists for appointments for some long-term 
care programs. Second, VA faces challenges making sure services 
are available where veterans live, especially in rural areas. 
Third, VA faces challenges finding appropriate long-term care 
for veterans with specialty care needs such as veterans on 
ventilators.
    We made recommendations to VA to help them address these 
challenges. In particular, while VA has taken some steps to 
address the identified challenges, such as increasing the use 
of telehealth, VA lacks measurable goals to assess progress. We 
recommended that VA develop targets for these efforts. We also 
recommended that VA develop a consistent approach for managing 
all of its 14 long-term care programs and implement a 
standardized tool for assessing non-institutional program needs 
of veterans. Taking these steps would help ensure equitable 
treatment of veterans regardless of location. VA agreed to 
implement these recommendations.
    Chairwoman Brownley, Ranking Member Dunn, and members of 
the committee, this concludes my prepared remarks. Karin and I 
would be happy to take any questions at the appropriate time. 
Thank you.

    [The Prepared Statement Of Nikki Clowers Appears In The 
Appendix]

    Ms. Brownley. Thank you, Ms. Clowers.
    I will now recognize myself for 5 minutes for questions. 
This first is for you, Dr. Boyd.
    The data proves out that the VA is not moving as fast as 
states are in terms of shifting its investments from 
institutional programs to non-institutional programs, and this 
tends to be a trend across the country and it is, from my 
perspective, which I have said over and over and over again in 
many, many hearings, non-institutional care, in-home care, 
whatever it might be, is more cost-effective and it is win-win, 
because that is what our veterans and their families want and 
desire. Institutional care is the largest program that the VA 
actually requires in terms of budgeting and making provisions 
in providing that kind of support to our veterans.
    I am just wondering if there has been some thought, I do 
not see it in the current budget proposal, but some thought in 
terms of repositioning, you know, where we should be spending 
our resources. It seems to me that we should be shifting more 
of those resources out of institutional care and shifting those 
moneys into non-institutional care, which we will get a better 
bang for our buck and we will make veterans and their families 
happier. Can you speak to that at all?
    Dr. Boyd. Sure. Thank you. You are absolutely right and, 
once we have our strategic plan presented and vetted with Dr. 
Stone, we would be more than happy to come back and discuss 
with the staff as well, but in the interim what we have learned 
from our Choose Home pilot validate exactly what you just spoke 
of. Veterans want to spend as much time, as much of their life 
at home and that will require a shifting the focus from 
institutional care into plussing up and helping VA facilities 
in the field geographically to partner either with adult day 
health care centers or with the medical foster homes, with the 
Veteran-Directed Care. These are types of programs that will 
see absolutely plussing up because, you are right, they will 
save us money on the one side, but it is the right thing to do 
for veterans' preference, as well as their whole health.
    Ms. Brownley. Thanks. You know, I am really talking about a 
statutorily shift in requirement, because of all of the other 
non-institutional care programs there are only a few that are 
statutorily required. It is my understanding that if you look 
at VA medical centers across the country you will find, if they 
have any leftover funds, those funds may go to some of those 
other programs.
    You know, in the data that you have provided I have really 
no sense of, you know, what that looks like across the country, 
where we have areas of excellence, where we have great, great 
need, because that is not being provided. As we continue this 
discussion, these are some of the things that I am going to be 
inquiring about.
    Were you involved at all in Dr. Stone's Elder Care 
Strategic Plan that he mentioned at the budget hearing?
    Dr. Boyd. I am involved in that presentation. It is 
interdisciplinary, including strategic planning, our Office of 
Policy and Planning, of course GEC----
    Ms. Brownley. You were involved?
    Dr. Boyd. We are involved in that and it is a dynamic work 
in progress. We have not presented the actual final 
recommendations----
    Ms. Brownley. When do you plan on presenting it?
    Dr. Boyd. Later this month. In keeping with the GAO's 
recommendation, that is our time line----
    Ms. Brownley. The timing of this hearing was poor.
    Dr. Boyd. I know.
    Ms. Brownley. Okay. To the GAO, Ms. Clowers. I think you 
made some very good recommendations. It sounds like the VA is 
going to respond to those recommendations in terms of time 
lines and so forth that I think are absolutely critically 
important.
    The shortage of personnel, you know, is a big issue, it is 
an ongoing issue, and something that we need to work really 
hard at. The thing that popped most for me in your report was 
this geographic--shift geographically of where support and 
facilities are. In your investigation in that, did you find any 
data that the VA has in terms of, you know, where these shifts 
are occurring, what the needs are where populations have 
shifted, where the voids and needs are and, you know, what--it 
sounds like there are facilities perhaps out there that are 
being under-utilized, and if that data was available?
    Ms. Clowers. Yes, ma'am. When we were looking at this 
issue--and in fact we see this issue across programs at VA, not 
just in the long-term care, but we see where veterans have 
moved out of the Northeast to the South, so you do have in some 
places over-utilization or over-demand, and then you have the 
opposite in other areas as well.
    Ms. Brownley. Have you got specific data on that?
    Ms. Clowers. I will turn to Karin.
    Ms. Wallestad. We do not have much more specific data than 
that than sort of general trends.
    Ms. Brownley. Just that there is a shift?
    Ms. Wallestad. Right. They are doing their market 
assessment, which they have told us will give them more detail, 
which then we could request in the future to have more 
specifics.
    Ms. Brownley. I am sorry, I did not hear the last----
    Ms. Wallestad. They are doing their market assessment, 
which would provide them with more specific data, which we 
could also help to review and answer these questions.
    Ms. Brownley. You will receive that at some point in time 
after this hearing?
    Ms. Clowers. The market assessments, we are working with 
VA, so we can start looking at those initial results this 
summer.
    Ms. Brownley. Okay, very good.
    Ms. Clowers. Chairwoman, if I could just go back real quick 
to your question about the states. We have noticed the same 
observation across sectors with states being more aggressive in 
moving to non-institutional care. Medicaid being the largest 
provider of long-term care services, when you look at that 
program, that shift from spending on non-institutional care 
versus institutional care crossed over in 2013, meaning they 
started spending more on non-institutional care during that 
period.
    Ms. Brownley. 2013.
    Ms. Clowers. Yes, ma'am.
    Ms. Brownley. Thank you. I certainly have gone over my 
time, but I will now recognize Dr. Dunn for a little over 5 
minutes.
    Mr. Dunn. Thank you very--you are so kind.
    Dr. Boyd--I am going to ask if everybody can kind of keep 
their answers tight, because I have a number of questions--Dr. 
Boyd, I understand the VA's proposed regulations pertaining to 
the expanded Family Care Program will be posted sometime this 
week, can you give us a sneak peek at what those might look 
like?
    Dr. Boyd. I wish I could. I can defer to----
    Mr. Dunn. If you can not, that is all right, I can wait the 
week.
    Dr. Boyd. Okay.
    Mr. Dunn. I just thought we might have some----
    Dr. Boyd. We can have a drumbeat, Okay.
    Mr. Dunn.--big news breaking here.
    Dr. Boyd. A drum roll.
    Mr. Dunn. Let me move on then. On our second panel, the----
    Ms. Brownley. Nice try, though. Nice try.
    Mr. Dunn. Well, I mean, you know, I always want to get the 
scoop.
    On our second panel, the Disabled Veterans, DAV, are going 
to testify their concern that the VA's Fiscal Year 2021 budget 
request for the Family Caregiver Program, in quotes, ``assumes 
a reduction in the number of existing program participants,'' 
end quote. Does it really do that and, if so, where or why?
    Dr. Boyd. I can defer to Dr. Kaplan for that.
    Mr. Dunn. Okay, Okay. Good. Dr. Kaplan----
    Dr. Kaplan. Sure.
    Mr. Dunn.--go right ahead and answer.
    Dr. Kaplan. Good morning and thank you for that question. I 
just want to let you know that I will be back next week to talk 
about the regulations in depth and the proposed rule. We have 
that scheduled, I believe, for next Tuesday. In terms of the 
budget for----
    Mr. Dunn. Are you assuming a reduction in----
    Dr. Kaplan. No, we are not.
    Mr. Dunn. Okay, that is a good answer. I did not think so 
either.
    Ms. Clowers, can you elaborate on GAO's finding regarding 
the need for the VA to better co-locate its long-term care 
services with the veteran population that needs them?
    Ms. Clowers. Yes. This goes to the challenge that we see 
where some facilities and programs are not located where 
veterans are now residing. I think the Chairwoman mentioned 
about a third of all veterans live in rural areas and so those 
are often veterans that do not have access to these programs, 
as well as veterans moved out of the Northeast to the South, we 
see gaps as well. Looking for opportunities to reach those 
veterans through different programs such as telehealth or maybe 
also----
    Mr. Dunn. We in rural Florida thank you for that----
    Ms. Clowers. Yes.
    Mr. Dunn.--that attention.
    Let me also--and I am not sure if this is for you or for 
Dr. Boyd--are you comfortable that the market assessments are 
being carried out pursuant to the AIR Act, which is part of the 
MISSION Act, considering the location demand capacity as we are 
doing these assessments?
    Ms. Clowers. I think that would be best for VA. We do have 
a request that we look at the market assessments for this 
committee and we will be starting that later this summer.
    Mr. Dunn. Okay, so you are going to be looking at the 
marketing side of that.
    Dr. Boyd, your testimony noted there is an urgent need to 
accelerate the availability of home-based care, what actions 
are you taking in order to meet that need?
    Dr. Boyd. A couple things just before we get to the 
strategic plan that we will be glad to brief you on. We do know 
that with home-based primary care is far better services with 
regards to fiscal cost and it is what the veterans want. What 
we are doing is looking at the standardized approach to the 
staffing of that, as well as the delivery of that, and in 
addition to encompass the other programs that wrap around.
    Remember, elder veterans, our elderly population do not 
just get one service, you know, so we are plussing up as well.
    Mr. Dunn. That is good. What can we do to help you here on 
this committee?
    Dr. Boyd. Your continued commitment----
    Mr. Dunn. What can this--legislatively----
    Dr. Boyd. Well, your continued commitment to having these 
hearings is very important, believe it or not, this is good for 
us, and we look forward to coming back and talking to you about 
this.
    Mr. Dunn. Again, I think, to Dr. Boyd now. When a veteran 
is in need of nursing home care, what steps are taken to honor 
that veteran's preferred setting and location, whether it is at 
home or in a center and where the center is, what steps?
    Dr. Boyd. I can briefly give that to Dr. Hartronft, who 
lives this.
    Mr. Dunn. Yes.
    Dr. Hartronft. Yes, sir. Usually, it is the discussion with 
a primary care provider is the starting point with many of 
these cases, who then works with a group, the social worker and 
other clusters on the Patient Aligned Care (PAC) Team, and then 
they really--then they put in a consult for our non-
institutional care programs. Again----
    Mr. Dunn. You are comfortable a real effort is made to meet 
their requirements. I will say that in our constituent services 
back home we get dragged into the--you know, on the back end of 
these when the veteran is someplace he does not want to be or 
she does not want to be. I see that on the far end of that, so 
I do not get to see it work well on the front end; I hope it 
does mostly.
    This is my important question I want to get to--thank you 
for my extra 30 seconds here--the coronavirus, COVID-19 is 
coming at us. The nursing homes, the VA nursing homes are a 
set-up risk for that kind of thing and we are talking about 
people with multiple co-morbid conditions, what are we doing to 
prepare for that and what advice would you give a veteran who 
is in a VA nursing home system right now?
    Dr. Boyd. I can start off on that very quickly. This is 
near and dear to us every single day. While COVID-19 is a new 
virus for us, we have tremendous experience with highly 
infectious diseases----
    Mr. Dunn. Flu, right.
    Dr. Boyd.--within those, whether it be influenza, 
norovirus, so much of that is the same. If nothing else, please 
wash your hands, do not touch your eyes, do not cough, you 
know, outwardly, cough into the crook of your arm, and get the 
flu vaccine. While that will not help with the COVID-19, we do 
know that influenza is highly contagious as well.
    Mr. Dunn. I think the same precautions help with COVID-19. 
We expect a thoroughly professional response, as usual, from 
the VA on that.
    With that, Madam Chair, I yield back.
    Ms. Brownley. Thank you, Dr. Dunn. I will just add in terms 
of this geographic shift, there is also a tremendous void in 
Indian territory, in our territories, United States 
territories. With that, I recognize Mr. Sablan for 5 minutes.
    Mr. Sablan. Thank you.
    Ms. Brownley. You are welcome.
    Mr. Sablan. Thank you. Good morning, everyone. Dr. Boyd, if 
I may----
    Ms. Brownley. Microphone, Mr. Sablan.
    Mr. Sablan. All right, start over.
    Dr. Boyd, let me--by law, the Veterans Millennium Health 
Care and Benefits Act required the VA to provide institutional 
care to certain service-connected veterans and also requires 
the VA to offer certain non-institutional long-term care 
packages as part of the VA medical benefits package. I come 
from a place where we take care of our own parents. We do not 
have--I will be honest, we do not have any aging homes or 
hospice homes. Maybe the population is not there or it is 
because we take care of our own parents. The Department 
currently sends veterans from my district to Guam, Honolulu, or 
the contiguous states for services that are unavailable in the 
Marianas. There are no VA local or community residential long-
term care facilities and in-home care services are limited.
    What is the VA doing now or what can the VA do now for my 
veterans needing long-term care? How is the VA supporting the 
veteran and his or her family? Connected with that is, while I 
am also lacking long-term care facilities and services, will 
the VA be moving Marianas veterans who need such care to 
Honolulu or the mainland, any idea?
    Dr. Boyd. You bring up a really good point. Just so you 
know, this was actually discussed in many of our meetings that 
we have had over the prior months, so it is almost like you 
have been channeling this for us. I do not have all the answers 
yet, we do not have all the answers, but this is definitely on 
our forefront and what we are discussing, because whether it be 
in your area, the North Mariana Island areas, or some pockets 
even within the states where it is--I know it is different, but 
maybe far away, we are struggling with those and we do need to 
continue those conversations.
    I look forward to discussing that more with you, sir, with 
your staff----
    Mr. Sablan. That is probably why they call this the Silver 
Tsunami, because--I am not going to complain again. I was 
really frustrated in the last hearing with the lack of services 
my veterans get.
    I have a question and maybe--I have a veteran who is 
retired also and he is diabetic, so they--Pacific Islanders, 
almost over half are diabetic--so they cutoff both his legs, I 
think right at his knees. He is kind of big, a little--almost 
as large as I am, I think--no, actually, as large as I am. His 
son quit working so he could help his dad, you know, get up 
from bed in the morning, get washed up, dressed, you know, come 
outside, meals, everything. Is there a program where that son 
could be compensated for providing that service or is there 
like a visiting home, nursing home? See, those nurses just come 
and check on the patient and the need for this veteran is 24/7.
    Dr. Boyd. Very good question and Dr. Kaplan could have 
that--I mean, we could all answer that, but since she is here, 
I am going to take advantage----
    Mr. Sablan. Okay, thank you.
    Dr. Boyd.--of her presence.
    Dr. Kaplan. Thank you for that question. While I can not 
speak to someone's eligibility for the program of comprehensive 
assistance, the MISSION Act has really afforded us the 
opportunity to expand our comprehensive program to veterans of 
any eras. Right now we are limited to veterans that have been 
injured in the line of duty after September 11th, 2001 and with 
the first phase of MISSION Act we will be expanding that to 
pre--so for May 7th, 1975 and prior, and then 2 years later 
injuries between May 7th, 1975 and September 11th, 2001.
    There is an opportunity for support and services within the 
caregiver program, whether it is the comprehensive program or 
our enhanced general caregiver support and services.
    Mr. Sablan. Yes, thank you.
    My time is up, Madam Chair, but thank you, thank you very 
much.
    Ms. Brownley. Thank you, Mr. Sablan.
    Mr. Lamb, you are recognized for 5 minutes.
    Mr. Lamb. Thank you, Madam Chair.
    I just want to say first, there has been a lot of attention 
so far at, I guess, non-institutional care or care at home, 
which I think is really important and I want to come back to, 
but I did want to plug quickly the VA hospital in my district, 
which is in Aspinwall, Pennsylvania, just outside the city of 
Pittsburgh. I visited their long-term care section I think 
twice and it is just such a credit to the VA as an institution. 
You know, they have these men in particular mostly who have 
been living there for quite a while and the nurses will bring 
food from home or food from the outside and cook like a home-
cooked meal for them in this kitchen that they have set up. 
These people really go out of their way to make it feel like an 
actual home and not an institution and, to me, that is the 
model.
    There is always going to be some people who are going to 
need that institutional care and the more--I think VA is so 
uniquely positioned to make it just a lot sort of better and 
more informal and comfortable than it might be anywhere else. I 
just wanted to compliment that nursing staff in particular in 
Western Pennsylvania.
    I think it does help remind us, the way you get there, it 
is partially about culture, but it is partially about, I think, 
the way those nurses have been treated throughout their career. 
You know, they have been paid well, they are members of a 
union, they are looked after, they have job security; they 
obviously feel very passionately about the veterans they are 
serving, you know, they care about the cause. I remember a lot 
of them telling me their fathers were veterans and that sort of 
thing. That is just part of the VA institution that we cannot 
afford to lose and I think as we go forward we want to stay 
mindful of that, that when you treat people right, they treat 
the veterans right.
    With all that in mind, I did want to ask, there is clearly 
going to be a need to hire not only nurses, but also home 
health aides, because we are going to move less in the 
institutional direction probably in the future. That also 
happens to be the most growing and in-demand job in America as 
a whole, so everybody is trying to hire these people. I was 
wondering if you could just kind of clue me in. I know you have 
a plan coming out, but what is the plan for the VA to get the 
best of the best, so that the next generation of veterans is 
treated as well as the ones I have seen? Go ahead.
    Dr. Boyd. Congressman Lamb, first of all, thank you for 
that information about the Western Pennsylvania Community 
Living Center (CLC), I will definitely pass that on.
    I have with us today, of course, Dr. Taylor, and we are in 
constant conversation about this, so I would like her to help 
you with that.
    Ms. Taylor. Thank you very much, and thank you for your 
comments about the nursing staff in Western Pennsylvania. As a 
nurse with many veterans in my family, it is an honor for us to 
serve those who have served, and I know many of my colleagues, 
most of my colleagues across the country feel very passionately 
about our mission. Thank you, sir, for recognizing that.
    We are putting a lot of energy and effort into ensuring 
that we have our hiring initiatives and our positions filled. 
For long-term care in particular, from Fiscal Year 2018 to 
Fiscal Year 2019, we actually increased our on-board strength 
in nursing assistants by 5 percent. Not a lot, but certainly a 
good uptick from year to year, year over year. In that same 
time period year over year, we increased our RN on-board 
strength by 6 percent for long-term care programs. We recognize 
that it is really important to make an investment and to be 
very assertive in our recruitment efforts.
    The other thing that I just want to mention is we have in 
VHA a fairly healthy scholarship program that is attractive to 
nurses coming in the door, because they see us as not only a 
great mission where they can get fair compensation--of course, 
we can not be market leaders, but we can compensate fairly with 
good benefits----
    Mr. Lamb. That is great. I am sorry to interrupt, but we do 
have limited time. What about the home health aide category? 
Not really nurse, but the type of people who in the civilian 
world right now are sort of lucky to be making 13 or 15 bucks 
an hour.
    Ms. Taylor. Yes. Those fall into the same category as 
nursing assistants and so we have seen an uptick in our hiring 
for those. Thank you.
    Mr. Lamb. Okay, thank you.
    I just want to leave you with this thought to take back. I 
know this decision is not totally in your hands, but the VA is 
not being kind to Federal Employees union in a lot of places 
around the country. There is some variability based on local 
leadership, but under this Administration they have locked them 
out of offices, they have made it difficult for the union 
officials to do their jobs, and the type of the people who are 
going to take a home health aide or nursing assistant job are 
often the people who need that sort of protection and support 
the most. I think for us to recruit the best of the best in 
that category for the next generation you are going to want the 
people who are already there telling their friends, hey, VA is 
a great place to work; they stick up for us, they pay us well, 
they take care of our needs. If we get sick and we have to 
miss, we are covered, you know, that sort of thing. We are 
going to lose that if it becomes a hostile environment, 
particularly for people on the lower end of the scale.
    Please take that back and just try to reinforce that 
important part of the culture. Thank you.
    Madam Chair, I yield back.
    Ms. Brownley. Thank you, Mr. Lamb, and thank you for 
raising that important issue.
    Before I excuse the panel, I have a few more questions. If 
anybody else here has a few more questions, I will recognize 
you.
    I wanted to get back, you know, again to this moving from 
institutional to non-institutional, but even within the 
statutorily institutional care, Dr. Boyd, is there are--I know 
that the Association for State Veterans Homes will be on the 
second panel--there is the medical foster care program. The 
point I want to make is that state homes are less expensive 
than beds provided by the VA, which gets back to the economics 
of all of this, and maybe better care. I know I have a state 
home in my district and it is extraordinary. I do not know if 
every state home across the country is extraordinary, but the 
one in my district is truly extraordinary. We know state homes 
are cheaper, yet we are not providing the resources for them to 
expand, to renovate, so forth and so on. Again, medical foster 
care is less expensive.
    You know, just in terms of sort of that long-term care that 
is needed, why is the VA not again shifting, you know, just 
within that kind of category, shifting more toward some of the 
other--not shifting, but adding to, because it is clear there 
is not enough beds and there is not going to be enough beds, so 
to the degree that we can expand upon that through state homes 
and other programs. I am talking about people who are going to 
be in a place for a long period of time and are going to be 
eating and sleeping there, et cetera, that is kind of what I am 
talking about. Is the VA thinking about that or, you know, 
trying to evaluate this again for better service for the 
veteran and a more economical decision where those additional 
resources, savings, can be invested back into, you know, other 
programs for our aging population?
    Dr. Boyd. Absolutely, and I can address especially the 
Medical Foster Home Program, Chairwoman Brownley.
    Absolutely, and especially when we take GAO's observation, 
very insightful observations that indeed we have a mismatch 
where our brick-and-mortar from many, many, many years ago and 
as our veteran populations have moved, it makes the most sense 
that where veterans live they can go and seek out and find a 
medical foster home that feels right to them; it is less 
stimulation, it is more home-like. That is part of our 
strategic plan, just a little glimpse into that, is to push 
that most definitely.
    Ms. Brownley. What about the state nursing homes?
    Dr. Boyd. The state veterans homes, again--and I can let 
Dr. Hartronft jump in on that, if you would like to--sometimes 
some of the special populations that we have within a VA 
nursing home would probably not be the most appropriate for the 
state veteran home. I am not saying that is an all across the 
board. Dr. Hartronft, if you wanted to just mention that, 
because you are absolutely right, it is a valuable partner for 
us.
    Dr. Hartronft. Yes, we are very lucky to be able to work 
with our partners in the states to really identify which 
veteran populations. If you really look at it, the number of 
long-stay veterans who really live at the home for longer 
periods tend to be in the state veterans homes, versus our 
contract nursing home and our community living centers tend to 
be shorter stays, post-acute and other things like that.
    They definitely have a type of demographic that we work 
well together with them in. I agree, we work closely with the 
states whenever they apply for having an additional home, we 
have processes to look at that and encourage that.
    Ms. Brownley. You agree that we need more assisted living 
services, you know, for the VA, because as the population 
grows, you know, the need for that kind of thing on an ongoing 
basis and not a temporary basis, it is going to be greater and 
greater. Do you agree?
    Dr. Hartronft. Yes. I think especially the areas that we 
can work with, including not the nursing home part, but also 
the adult day health care and state veterans homes, and then 
also working with them and others as to really the domiciliary 
sections as to what are some of the best things we can maybe 
encourage and improve in those areas.
    Those are areas we are looking at and working toward.
    Ms. Brownley. Okay. Then just very quickly, I just have a 
request. I am not asking for an answer today, but if--between 
the GAO and Dr. Boyd--if we can identify all of the non-
statutory programs within the long-term care, if we can 
identify, you know, describe to me their uses, where there are 
voids in some of those services, and how much money on a Fiscal 
Year is being spent in all of those programs, so that I can get 
an idea of how these other non-statutory programs are being 
utilized.
    If you could provide that information, that would be very 
helpful to me.
    Dr. Dunn, do you have any additional questions?
    Mr. Dunn. Thank you very much, Madam Chair, so I do too. I 
am going to follow on the same conversation that Chairwoman 
Brownley had there about the cost of some of these things.
    I tried to parse out of the budget request what the, you 
know, numbers look like for in-patient and out-patient long-
term care. I could not really get the out-patient number on a 
per day, per patient number, so this is something, I think, 
that the average citizen can make sense out of. I think we got 
a pretty good grip on what the long-term in-patient nursing 
home care costs were for patients, per patient per day or per 
patient per year. In 1919, the nursing homes, the VA nursing 
homes, all the different varieties, the average was $1,183 a 
day, 365 days a year for those services. That is $431,800 per 
year per patient in VA long-term care. That went up in 2021, 
the Fiscal Year we are looking at budgeting right now, it goes 
up to $464,000 and change, a $33,000 increase, and for 2022, it 
is posited to go up to $493,000 per year per patient in the 
system. Now, if you think about it, you are spending over 
$1,300 a day per patient.
    Now, I have actually paid for family members in nursing 
homes and I feel quite comfortable that we got very good 
nursing homes and the numbers that we spent were nothing like 
that. Can you shed light on why it costs the VA so much to do 
that and what might that look like if it were done at home?
    Dr. Boyd. I will take the first part of that. Thank you for 
that, Ranking Member. What we do know, and we broke this out 
for you. It must have been hearing that. The medical foster 
home care that we talked about earlier, and if we add the 
requirement that the veteran is followed by home base primary 
care, that comes out to $53 a day.
    Mr. Dunn. So----
    Dr. Boyd. Verse, I mean, that is----
    Mr. Dunn. Versus $1,000, $1,200, $1,300 a day, $53 a day.
    Dr. Boyd. Absolutely.
    Mr. Dunn. That is a pretty favorable comparison.
    Dr. Boyd. That is why the push to try to--that is a great 
opportunity for us to have communities work with folks within 
those communities to set up those foster homes, the medical 
foster homes, and to partner.
    Then if we were just to go to our home base primary care, 
that is $44 a day on average, just that alone, versus our 
aggregate--and GAO gave us this information, it is about $15 a 
day for the non-institutional care program, just alone, by 
itself. There is a huge spectrum----
    Mr. Dunn. That comparison is very favorable. I want to 
thank you for that. I mean, wow, that is 20 times more 
expensive to go, or more.
    Dr. Boyd. Yes.
    Mr. Dunn. Anyway, what can we do to lower the number on the 
inpatient side, because surely that does not need to be that 
high?
    Dr. Boyd. Dr. Hartronft, who has managed those inpatient 
units can actually, and from his expertise can give you a 
little bit of insight about the Community Living (CL) fees 
cost.
    Dr. Hartronft. Yes. I think a lot of this is reflecting 
some of the populations that we continue to keep in the 
community living centers. As you know, the community living 
centers per bed day of care cost is more expensive than 
contracting nursing home in the community. I think right now 
what we are going to be doing is working with the Office of 
Nursing and others to really find out what is the best staffing 
models of care. We are going to be reviewing that as to, you 
know, how do we reflect differently from the community staffing 
and for what reasons, because part of it is having the right 
veteran of the right area. If they have to be in a facility, 
many times it may not be----
    Mr. Dunn. We are going to have this discussion more this 
year----
    Dr. Hartronft. Yes, sir.
    Mr. Dunn.--during this year. I just want to say, I mean, 
the difference here, I mean, you are talking--if I could find 
the nicest nursing home on Georgia Avenue in Northwest 
Washington does not cost half of that. I mean, this is not a 
marginal thing with the staffing thing. There is a huge 
disconnect here.
    I know you do not have the answer today, but please know 
that we are interested in hearing that answer, because we have 
to be more efficient than that.
    With that, Madam Chair, I yield back.
    Ms. Clowers. Dr. Dunn, may I add something very quickly on 
this particular issue. Even when you are looking at the 
institutional side with the averages, that can mask very 
different cost per setting.
    That is one of the things we provided in the report, and 
Karin could provide it per day, but you have at the very top 
level the community living centers in terms of cost, down to 
the state veterans home, which is significantly different.
    Ms. Wallestad. Sure. For the CLCs, it was about $1,074 a 
day; for the community nursing homes, $268; and for the state 
veteran homes, $166.
    Mr. Dunn. For the VA community living centers, $1,200 a 
day.
    Ms. Wallestad. Approximately.
    Mr. Dunn. That is--I mean, just the comparison along that 
line makes you think you want fewer VA community living 
centers. Right?
    Ms. Clowers. Well, it has to do with both--with who is 
paying for those services. With the state veterans homes, you 
have the States contributing money as well. There is a number 
of factors that could go into the cost, and we are happy to 
have additional conversations with you and your staff about----
    Mr. Dunn. Yes, yes. I see the proper, apples to apples 
numbers.
    Ms. Clowers. Right.
    Mr. Dunn. Thank you so much.
    Ms. Brownley. Thank you, Dr. Dunn. Mr. Sablan, you are 
recognized for an additional question.
    Mr. Sablan. Thank you, Madam Chair. My question earlier, I 
got the answer that VA can not help that individual whose son 
had to actually quit his job so he could take care of his dad, 
because there are no long term care facilities in my district, 
and since there are no permanent primary care provider, or non-
institutional programs like the caregiver programs or the home 
base primary care are not allowed for those veterans to program 
regulations.
    The problem is, I will take care of them--does not allow 
it. I am going to ask again. I am going to continue asking this 
until somebody hears what I am asking. In my district, and I am 
sure that there may be other parts in the country, very 
isolated, rural areas, in my district, there is I think one VA 
staff who does the admin appointments and those kind of things. 
No VA staff provides direct care services, or they are very 
limited now.
    We have no Community Based Outpatient Clinic (CBOC), no vet 
center, no Veterans Benefits Administration (VBA) staff. I 
really--I am trying to find who to talk to, where to start, 
where we could start building--like building blocks, you know, 
a vet center, for example. Dr. Shuylkin (phonetic) and I 
started working on this and then he lost his job. I can not 
hold Dr. Secretary Wilkie to it, but really just provide some 
kind of service to the veterans living there. The numbers are 
going to grow because, you know, there are many who are joining 
the service. There are many who are signing up in Honolulu, or 
Washington State, and then we are helping them change their 
record of--home record, I think is what it is called, so that 
when they exit, they get to go to the Northern Marianas.
    Thank you very much for your time. Yes, my answer to that 
kid who is helping his father out, because if he does not, no 
one else will, can not get anything because the regulations 
does not allow it, unless somebody at VA would like to change 
the regulation to allow it. Thank you.
    Dr. Boyd. If I could just a moment, Congressman Sablan, off 
line, I would be most interested in learning the name and the 
specifics about this veteran, and we can put our heads together 
and see what, in fact, might be available. I would do that off 
line.
    Mr. Sablan. May I contact him and ask him?
    Dr. Boyd. Absolutely. We would like to look at it for you.
    Mr. Sablan. Yes. That would be a huge load. He needs help.
    Dr. Boyd. Okay.
    Mr. Sablan. He takes it out here, this one. In my ear, but 
thank you very much. It is a veteran. He served 20 years, so--
--
    Dr. Boyd. Okay. Okay.
    Mr. Sablan. Thank you very much.
    Dr. Boyd. Thank you.
    Ms. Brownley. Thank you, Mr. Sablan, and thank you to the 
panel for being here today. We are going to excuse you and call 
the second panel. Take a few minutes to reorganize ourselves.
    [Recess.]
    Ms. Brownley. Welcome to our second panel. We have Mr. 
Adrian Atizado, the deputy national legislative director for 
Disabled American Veterans; and Mr. Mark Bowman, the president 
of the National Association of state Veterans Homes. Welcome. 
With that, I now recognize Mr. Atizado for 5 minutes.

                  STATEMENT OF ADRIAN ATIZADO

    Mr. Atizado. Madam Chair, members of the subcommittee, 
first, I want to thank you for conducting this critical 
oversight hearing and calling attention to an essentially often 
overlooked program that VA should very much be proud of. It is 
there long-term services and supports program.
    As has been mentioned by the previous panel, the VA has 
come a long way since two seminal laws were passed in the 
1990's that really transformed how VA provides care to 
veterans. In that sense, also changed the way the operating 
environment that VA's long-term services and supports system 
operates.
    Historically, aging veterans in a veteran population has 
had less of an impact on VA expenditures that might be 
expected, because reliance on VA by these veterans tend to drop 
off when they hit 65, because they become Medicare eligible.
    More recently, however, this trend has seen a reversing--in 
other words, the amount of reliance is no longer declining, it 
is actually--the decline is actually not in a downward--as much 
of a downward trajectory. Reliance on certain VA Long Term 
Services and Supports (LTSS) does not decline after Medicare 
eligibility due to the limited Medicare coverage for 
institutional long stay nursing home services, as well as non-
institutional services. Older veterans' preferences and needs 
remain--to remain in their home and community have evolved, and 
are generally no longer met by the Medicare program. 
Accordingly, VA's budget and expenditure projections assumes a 
slightly higher level of reliance from over 65 veterans.
    Now, in light of increasing numbers of veterans needing 
LTSS or long-term services and supports, their evolving 
preferences and needs, and VA's current long-term service and 
supports system of care, DAV's main concern is whether service-
connected veterans are getting the services and supports they 
need today, and if they can also do so in the future.
    Members of the DAV passed resolution as our most recent 
convention. The resolution recognizes three things: a large and 
glaring gap in VA's long-term services and supports program, 
with statutory authority prohibiting the department from paying 
for care in the community residential care facilities, despite 
referring veterans to these facilities and inspecting over 
1,300 of those facilities.
    It also recognizes the ability for veterans to remain at 
home is critically dependent on veterans' caregivers, whether 
they are families or friends. A third is that the resolution 
asserts VA home and community-based services, and their 
programs are not uniformly available at all VA facilities, 
resulting in inconsistent availability, as well as wait lists.
    This resolution allows us here today to call on Congress 
and the VA to improve and enhance the Department's LTSS system, 
and to ensure each VA medical facility is able to provide 
service connected civil veterans' timely access to both 
institutional and non-institutional services. DAV recognizes 
that most LTSS users have a high burden of service connected 
disability. They are catastrophically disabled or are of low 
income. About a third live in rural areas.
    LTSS is not just for aging veterans. Nearly 17 percent of 
VA's LTSS was provided to veterans under 65. Meeting their 
needs will require VA leadership at all levels to make LTSS a 
higher priority than it is today.
    In my written testimony, there are a number of bills 
seeking to improve and expand VA LTSS, as well as VA's 
caregiver support program, which is a critical long-term 
service and support component, not formally recognized my 
statute. We urge the subcommittee to consider them favorably.
    Finally, we call on VA to expand its veteran directed care 
program, which gives the veteran control over how their needs 
are met at home. Under this program, VA is able to serve three 
veterans for every one residing in a community nursing home at 
VA's expense. As of this writing, the veteran directed care 
program is available only at 69 out of a 170 VA medical centers 
across 37 states, DC, and Puerto Rico.
    Madam Chair, DAV is pleased to have had this opportunity to 
revisit the topic of VA LTSS and its system of care for 
veterans. We look forward to working with the subcommittee to 
ensure veterans continue to have access to a full array of 
long-term services and supports, no matter where they decide to 
reside. Thank you.

    [The Prepared Statement Of Adrian Atizado Appears In The 
Appendix]

    Ms. Brownley. Thank you, Mr. Atizado. I now recognize Mr. 
Bowman for 5 minutes.

                    STATEMENT OF MARK BOWMAN

    Mr. Bowman. Chairwoman Brownley, Ranking Member Dr. Dunn, 
and members of the subcommittee, thank you for inviting the 
National Association of state Veterans Homes (NASVH) to testify 
on the future of long term care. The state Home program is a 
partnership between states and Federal Government, with the VA 
providing a per diem payment, covering about 30 percent of the 
cost of care, with the states using a variety of sources to 
make up the difference.
    The VA also provides construction grants to cover 65 
percent of the cost to build, renovate, and repair homes with 
states matching 35 percent. Today, there are 157 state homes in 
all 50 states and the Commonwealth of Puerto Rico, providing 
skilled care, domiciliary, and adult day health care.
    State homes provide over half of all the VA funded 
institutional care, but account for less than one quarter of VA 
spending. According to VA, the institutional per diem for State 
homes is 40 percent lower than private community homes, and 
less than one-sixth of the VA's community living centers.
    Investing in state homes is the most cost effective way of 
maximizing Federal dollars to provide care for veterans who 
have no home based options. Chairwoman Brownley, to strengthen 
and sustain homes, Congress must provide adequate funding. For 
Fiscal Year 2021, VA requested just $90 million for state home 
construction grants, despite an estimated $1.2 billion Federal 
share for pending grant requests.
    NASVH asked Congress to appropriate $250 million to fund 
half of the priority one list, which includes life and safety 
projects. State homes must pass annual inspection surveys by VA 
in order to remain certified. However, homes that receive 
support from Medicare must also undergo a virtually identical 
annual inspection by Centers for Medicare and Medicaid (CMS), 
wasting time and resources.
    NASVH strongly supports HR-4138, bipartisan legislation to 
coordinate a single Federal inspection survey, conducted by VA 
and accepted by CMS. State homes are required to provide basic 
primary care, but specialty care remains VA's obligation. 
However, VA has been treating mental health care as a state 
responsibility. Given the high cost of psychiatrists and 
psychologists, who are specialists, state homes may be forced 
to stop admitting veterans with significant mental health 
issues, leaving fewer options at a time when veteran suicide is 
a national crisis and a top VA and congressional priority.
    Chairwoman Brownley, domiciliary care programs provide 
alternative long-term support for veterans who do not require 
skilled nursing care, but need help with food, shelter, and 
support of services. Currently, there are doms in 30 states, 
including California, Florida, and Pennsylvania.
    Unfortunately, regulations adopted in 2018 increased the 
cost to operate domiciliary programs without any increase in 
reimbursement, forcing a number of states to consider closing 
their doms, potentially putting thousands of veterans at risk 
of becoming homeless.
    We ask you to work with us and VA to address the 
eligibility and staffing problems causes by the new 
regulations.
    Looking to the future, state veterans homes are ready to 
partner in new and innovative ways to meet the changing needs 
and preferences of veterans. For example, a number of state 
homes would be willing and capable of providing care for 
veterans with behavioral issues or mental illness if a higher 
per diem were available.
    Many state homes have interest in providing enhanced 
domiciliary care to fill the gaps between skilled nursing and 
dom care, including for veterans with dementia. State homes 
providing adult day health care could also operate other home 
based programs to meet all the needs of veterans who want to 
remain in their homes. However, in order to fully utilize the 
capabilities of state veterans homes, the VA must commit itself 
to a true partnership. We are too often an afterthought in VA's 
planning and budgeting processes.
    For example, GAO found that the VA's future budget 
projection models do not even include state veterans homes. We 
had no representation on the VA's geriatrics and gerontology 
advisory committee, despite NASVH nominating three highly 
qualified individuals. With a budget topping $1.5 billion, it 
is time for VA and Congress to consider establishing an office 
for state veterans homes to oversee all aspects of our 
programs.
    Finally, it is important to realize that in total, VA 
supports about 40,000 nursing home beds. This is less than one 
half of 1 percent of the estimate 9 million veterans over the 
age of 65. While there is certainly a growing need for non-
institutional care, the need for traditional nursing home care 
is neither diminishing, nor will it ever go away.
    This concludes my statement. I would be happy to respond to 
questions.

    [The Prepared Statement Of Mark Bowman Appears In The 
Appendix]

    Ms. Brownley. Thank you, Mr. Bowman, and I will now 
recognize myself for 5 minutes for questions.
    Mr. Atizado, you know, I have sort of a broad question for 
you, just in terms of your members, and you are a good 
indicator, or your members are a good indicator of how we are 
doing and where we need to go. You pointed out some of that, I 
think, in your testimony.
    If you could talk a little bit about the experiences your 
members are having in terms of navigating care for Alzheimer, 
dementia, and other behavioral health issues. If you could talk 
a little bit about your membership in terms of State nursing 
homes. I do not know whether your members are in state nursing 
homes, or they predominantly use the CLCs.
    Mr. Atizado. Thank you for that question, Congresswoman 
Brownley. Yes, a lot of service connected veterans reside in 
state veterans homes. They are very satisfied. It is a great 
setting for them to--to have long stay nursing home care.
    I visited a handful of them myself, and I am always 
impressed with the commitment of the staff, and the environment 
of care. When it comes to a very special sub-population of the 
veteran population, like you said dementia, Alzheimer, 
behaviorally challenged, physically capable but behaviorally 
challenged veterans. I can tell you, every VA facility, nursing 
home facilities know these individuals by name. They can count 
them on their hand. They have a lot of--there are a lot of 
problems trying to find them supportive housing. The system is 
just not set up for them, because there is so few of them.
    I know VA has been struggling to address this situation, 
especially for the behaviorally challenged. It requires a 
different set of staffing models. I believe state veterans 
homes are experiencing this as well, and we are hopeful that 
both the state veterans homes and the VA can partner to try and 
find a way to address this.
    The only thing I want to caveat, though, is in the 
community, memory care facilities or patients with dementia who 
go to these memory care facilities generally are aligned with 
assisted living facilities. If a veteran in the community that 
is not close to a VA CLC or community nursing home requires 
some kind of memory care services, and the only thing that is 
available to them is an assisted living facility, VA can not 
pay for it, because they are not allowed to pay for assisted 
living.
    Those veterans, although while there is an option available 
to them, the statutory law actually disallows VA from paying 
that kind of service, even though they need it.
    Ms. Brownley. Thank you. Just to follow up on that. In 
terms of all of the non-statutorial programs that the VA has in 
terms of long-term care, do you have a sense of--in terms of 
your membership, the demand on these programs and are they 
being addressed?
    Mr. Atizado. On that side, Congresswoman, we actually 
surveyed back in 2007 about 1,100, almost 1,200 family 
caregivers and the veterans who have family caregivers. 
According to the survey, what they have told us is a very small 
percentage of them know they need it, but get it. I know VA 
has--and I want to make sure that VA gets credit in this. They 
have been trying to get their facilities across the country to 
have better visibility on veterans, such as the ones that we 
had surveyed, that are in need, but are not getting the 
services.
    I think it was mentioned that there is--VA's policy is that 
every facility is supposed to have a tool to quickly assess 
veteran's in-home needs, whether it is respite care, home aid, 
or home health aid. They leave it up to the facilities to 
choose which tool, even though there is one that is generally 
recognized in their policy.
    The variability and the availability of that, because of 
that tool and how it is implemented, is what we see across the 
VA health care system. I understand there is a balance between 
dictating the field and what they should do versus allowing the 
field to create a system that is suitable for their patients. 
Because our survey shows that the majority of these veterans 
are not getting the services they need, we think there has to 
be a little bit--that policy has to be revisited.
    Ms. Brownley. Thank you. Mr. Bowman, do you have a 
breakdown of your clients in terms of sort of their needs 
within your nursing homes? I know there is obviously a lot of 
sort of generalized needs, but when it comes to dementia, 
Alzheimer, these behavioral issues, do you kind of have a 
breakdown of need within or that you are, indeed, providing 
within the state nursing home population?
    Mr. Bowman. Certainly, each facility would have exact 
numbers for you, but I can assure you that a large part of the 
population that long-term care facilities serve, including 
state veterans homes, include dementia and memory-impaired 
veterans. That is just a large percentage of that population.
    I think everybody would agree that that is going to 
continue to grow. I think that is the value of what this 
committee is doing, and everyone sitting at this table is to 
come together, not with existing structure in what we are 
doing, but work as true partners in looking to modernizing the 
health care delivery system for the future, not where we are 
out now, and that is why I value this discussion.
    Those are--that is going to be a big component of that, and 
we have got to put our mind and our resources toward that end.
    Ms. Brownley. Thank you very much. My time is up, and so I 
yield to Dr. Dunn. That was much more than 5 minutes.
    Mr. Dunn. Thank you very much, Madam Chair. No. That was a 
fascinating discussion and I agree. We need to get to the 
bottom of that. We need to talk more this year about how we can 
help each other in that area. We all recognize that growing 
need.
    Mr. Bowman, in your testimony, you said that the state home 
model serves as a--they serve as laboratories of innovation 
that allows the VA and then other state models to take 
advantage of those programs. Can you give us a few examples?
    Mr. Bowman. Yes, sir. For example, in a domiciliary 
program, even though that is a--we receive a fairly low per 
diem funding for many of the dom programs throughout the United 
States, the states have taken on that challenge and many times 
provide care above and beyond what is mentally required. That 
is including funding that through state resources. It augments 
the shared agreement with the Federal Government, but it is a 
true partnership, but they go above and beyond.
    That is one of the issues that we also think is going to be 
a very valuable opportunity for all of us to look at is take 
that domiciliary program and like Adrian has talked about, a 
lot of the needs out there are outside the scope of that 
program. This is going to give us a perfect opportunity to say, 
``Look, when this program was instituted, it met a need. Is it 
meeting the needs for the veterans that we serve today?'' That 
answer is absolutely not. It has got room for mobility and 
innovation at the state, and the partnership with the Federal 
Government.
    I think we can come up with some solutions in a more cost 
effective manner.
    Mr. Dunn. I think I have seen some of that actually in my 
district. Tallahassee jumps out at me as a place that has done 
some of that work with co-locating and a lot of other services 
with the veterans domiciliary home. I applaud that effort.
    To get at Chairwoman Brownley's numbers, we know we have a 
huge and growing need for memory wards. What is the--how much 
more expensive than domiciliary is that kind of----
    Mr. Bowman. Well, when you look at a domiciliary level, 
that reimbursement does not even really touch the level of care 
that you need, say, in the nursing facility portion. Let us 
face facts. The only way to really address that problem is 
increased resources. It really comes in supervision and hands 
on care, because you can no longer apply the old models to that 
type of population that we serve.
    Mr. Dunn. We have some technology that has streamlined 
that. I am intimately familiar with some of these problems. Do 
you have a figure for us? Okay. If we have a domiciliary care 
and we have a memory ward, what is the delta in cost?
    Mr. Bowman. I can get those to you. I would be glad to 
submit some comparison numbers from our members. I would be 
absolutely glad to do that.
    Mr. Dunn. I am sure it also affects the construction as 
well, right?
    Mr. Bowman. Yes, sir.
    Mr. Dunn. The construction--it is my understanding that the 
VA typically in these affairs, it is a match VA to state. The 
state puts up 35 percent, the VA puts up 65?
    Mr. Bowman. Yes, sir. That is correct.
    Mr. Dunn. That is standard across the country? There is 
no----
    Mr. Bowman. Yes, sir. No, there is no deviation from that 
in the grant program.
    Mr. Dunn. What kind of--and you said there were $90 million 
in the next----
    Mr. Bowman. Yes, sir. That is what is proposed.
    Mr. Dunn. We had a--of money that we put up a few years 
ago. Is that all gone now?
    Mr. Bowman. Yes, sir. That was a great influx of money that 
really took away the backlog. The problem is, it is already 
back up to approximately $500 million on the priority one list. 
If you go down beyond that, it is almost $1.2 million.
    You know, that is why we are asking for $250 million, to at 
least hit half of that priority one group to stay up current.
    Mr. Dunn. I am going to ask you to share with us, either 
off line or in our next meeting here, if we are going to do 
some more of these hearings, I would sort of like to hear a 
plan for all of it, not just a year by year, $250 million a 
year, every year kind of--where are we going? Where do we think 
we need to be? When do we think we need to be there to address 
specifically the burgeoning problem of dementia in all of its 
presentations.
    Can you--Mr. Bowman, again, can you give us an update on 
the implementation of the state veteran home and adult day 
health care improvement act?
    Mr. Bowman. Yes. Actually, we just----
    Mr. Dunn. It is like 2 years old, though, I guess.
    Mr. Bowman. Yes, sir. At our annual convention, or winter 
conference just recently, we met with representatives from the 
VA about rate setting. Part of that discussion was very 
positive because as we move into permanent rate setting, it is 
going to really, I think, provide an impetus for other 
facilities and programs that have not been involved in that to 
expand to that, because everyone sees the value of adult day 
health care, because not only does it give respite to families, 
but most importantly, it gets back to this non-institutional 
care for those veterans that can remain at home, be a valuable 
member and engaged in their family, come and get the care that 
they need, and that includes more than just coming in for meals 
and, say, bingo. It also, under that medical model, allows for 
care that they would otherwise have to go to multiple 
appointments at various providers to get that care for.
    It is a--I think we are going to see an increase in that. 
We already have three states that since that meeting have 
indicated interest, and those are in Boise, Ogden, Utah, and 
Philadelphia. We are going to see more. There was a lot of 
interest in that. I think that is going to help when we talk 
about the continuum of care expansion.
    Mr. Dunn. I look forward to continuing that conversation. 
With that, Madam Chair, I yield back.
    Ms. Brownley. Thank you, Dr. Dunn. I have a few more 
questions, and if you do, I will--you certainly chime in. Mr. 
Atizado, I wanted to ask you, too, about the medical foster 
homes, and the veteran directed care program, and just in terms 
of your membership. Do they like these programs? Do they need 
to be expanded?
    Mr. Atizado. Yes on both. Our members are very much 
satisfied when they end up residing in a medical foster home. I 
have has the opportunity to talk to a handful of them across 
the state, and they are extremely happy with the small home 
like setting, being able to still be relatively independent and 
not feel like they are in an institution.
    The problem for a couple of them is that they have to pay 
for this out of pocket, and we are hopeful that the 
subcommittee and the full committee, like they have done in the 
last two congresses, will pass that bill that will allow VA to 
pay for that care, so they do not have to worry about 
impoverishing themselves for a benefit that otherwise, you 
know, had they decided to take up their nursing home benefit, 
it would cost VA more to do that.
    With regards to the veteran directed care program, that is 
a fantastic program that our--I can not seem to turn left or 
right without somebody asking when it is coming to their 
facility. For example, Congresswoman Brownley, in the state of 
California, only one VA facility runs a veteran directed care 
program: San Diego. It is a fantastic program. ACL, the 
administrative community living, actually went down and visited 
San Diego and their program down there, and is highlighting 
that.
    Mr. Dunn, Florida is doing much better. I think only one 
facility in Florida does not have a veteran directed care 
program. That requires a partnership between the facility and 
basically each county in its market area. Now, if a facility 
director does not feel it is important and the local clinicians 
do not have that support, the program is not going to exist or 
it is not going to expand.
    It is a fantastic program, like I said. It allows a veteran 
to control the services they get. VA assesses them for needs. 
They monetize that need. Their partnership with American 
Ambulance Associations (AAAs), AOCs, they are state funded 
entities, help them identify those services in their community. 
It could be their neighbor.
    You know, if we are talking about a health care workforce 
issue with regards to nurse assistance, and home maker, and 
home health aids, this is a great program to expand, because it 
relies on existing people in the community already.
    My biggest issue with in-home care is trust. You are in a 
very vulnerable situation, asking somebody to come and help you 
with their basic living skills. When you have a stranger coming 
in day after day, it can wear on you. That is why I think there 
is also a lot of turnover in that industry. We think our 
members think veteran directed care is one of the programs that 
really should be available at every VA facility.
    Ms. Brownley. You mentioned California having one program, 
Florida, I think you said, does not have any whatsoever. Can 
you----
    Mr. Atizado. No, I am sorry, Florida is very much better. 
Only----
    Ms. Brownley. You are doing well.
    Mr. Atizado.--one facility does not have the program.
    Ms. Brownley. Your leadership has been extraordinary, Dr. 
Dunn.
    Can you give me a sense, though, of what it looks like 
across the country?
    Mr. Atizado. The veteran directed care program?
    Ms. Brownley. Yes.
    Mr. Atizado. I think about 69 out of 170 facilities 
actually have it. As I mentioned, just because a facility has 
it, it does not mean they can cover all the veterans in their 
market area.
    Ms. Brownley. Yes.
    Mr. Atizado. What we are hoping is, because the MISSION Act 
that Congress passed a couple years ago, allows VA to use a 
veteran care agreement. Before it was a legal grey area, but 
the veteran care agreement allows now VA to go full bore. There 
is no legal barrier to this or liabilities.
    It really comes to the local facility being responsive to 
the veterans in their market area. We can only ask so much as 
veteran patients for the facility to have these programs. If 
there is a little bit more pressure and leadership support, I 
think we can actually grow this program to where it needs to 
be.
    One of the key things I wanted--I was hoping Mr. Sablan 
would still be here, because I think this would be very good in 
rural areas. I think it would be extremely useful, and in 
particular, the situation that he raised.
    Ms. Brownley. Yes. Thank you for that. Mr. Bowman, I would 
like to work with you with some of the issues that you have, 
you know, brought up, and certainly the grant program, but the 
issue around psychological services, the accreditation piece. 
You know, I would really like to work with you on that.
    The one question that I have for you is that the--according 
to the Center for Disease Control and Prevention (CDC), 
infection rates of sexually transmitted diseases are climbing 
exponentially among Americans 45 and older. I am just 
wondering, is this something that you see as a significant 
issue in your homes across the country?
    Mr. Bowman. Anecdotally, no. That has not really hit on our 
radar yet. I am not say it is not out there in pockets, but it 
has not hit our radar.
    Ms. Brownley. Okay. There is no data on that, then, from 
your perspective?
    Mr. Bowman. No.
    Ms. Brownley. Then last, I would just say, you know, you 
kindly said to Dr. Dunn, we can get that information for you. 
When I asked the question about data, you know, you are like, 
``Well, you can get those from the various state homes.'' So--
--
    Mr. Bowman. I----
    Ms. Brownley.--I am feeling a little rejected.
    Mr. Bowman. I apologize. Meaning that the state homes had 
those numbers. I will be glad to assimilate as much of that as 
I can and get it to you, ma'am. Sorry for----
    Ms. Brownley. Thank you very much. Thank you very much. Dr. 
Dunn?
    Mr. Dunn. Thank you, Madam Chair. I do not have anymore 
questions. I will say that I think this is an important 
hearing. I think that this is a big subject and everybody has a 
lot of focus on it.
    We work better when we have more information. I have some 
of the information. You heard both of us say that we want more 
information, you know, what we need, but also what it costs, 
and what we can do efficiently. That matters a lot to us. I 
mean, we really are all pulling in the same direction on this 
one.
    I will say anecdotally, since you brought up the subject, 
no urologist will let this go by--I am a urologist by specialty 
training, and I hear anecdotally about all of these elder 
population epidemics of STDs. In my specialty, we would tend to 
hear about that or know about that. In one of the areas that my 
group took care of, literally the entire urological care for 
the Villages, famous area in Florida, right, and all the rumors 
about exploding STDs down there, really they are for fun. They 
are salacious rumors, but that does not match the facts on the 
ground.
    I will just say that is--for what it is worth. It is in the 
congressional record now. I yield back.
    Ms. Brownley. Thank you. Thank you, Dr. Dunn. We will not 
end the committee hearing on that particular note, although you 
are right. I thank the panelists for being here and I, too, 
believe that this is a very important topic. I will be anxious 
to--we will try to schedule another hearing when the elderly 
strategic plan comes up.
    I hope some of the comments that were made today, you will 
take home, Dr. Boyd, in terms of that overall discussion. I 
know Dr. Stone believes that we should be, you know, shifting 
more from institutional to non-institutional care, but seeing a 
strategic plan for the first time obviously is very, very 
important. You know, this is a priority for me. It is a 
priority for Dr. Dunn. We are going to be diving, taking a 
deeper dive into this issue. I look forward to, you know, 
making some recommendations with regards to policy changes as 
we move forward.
    The statutorial issue, I think is one that really does need 
to be addressed. I believe that state nursing homes need to 
play a larger part, particularly in meeting sort of regional 
needs. I think from the sounds of it, state veteran homes have 
a pretty good reputation across the country.
    Anyway, I thank you all for being here. Thank you for your 
testimony and answers to our questions. With that, Dr. Dunn, if 
you have any closing comments, it is--you are on.
    Mr. Dunn. Thank you very much.
    Ms. Brownley. Well, thank you all for being here. This 
meeting is adjourned.
    [Whereupon, at 11:35 a.m., the subcommittee was adjourned.]
    
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                         A  P  P  E  N  D  I  X

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                    Prepared Statement of Witnesses

                              ----------                              


                   Prepared Statement of Teresa Boyd

    Good morning Madam Chairwoman, Ranking Member Dunn, and 
distinguished Members of the Subcommittee. I appreciate the opportunity 
to discuss VA long-term care and Veterans' choices for care as they age 
or face catastrophic injuries or illnesses. I am accompanied today by 
Dr. Beth Taylor, Chief Nursing Officer; Dr. Scotte Hartronft, Executive 
Director, Office of Geriatrics and Extended Care (GEC); and Dr. Elyse 
Kaplan, Deputy Director, Caregiver Support Program.

Introduction

    VA is committed to optimizing the health and well-being of Veterans 
with multiple chronic conditions, life-limiting illness, frailty or 
disability associated with chronic disease, aging, or injury. GEC's 
programs maximize each Veteran's functional independence and lessen the 
burden of disability on Veterans, their families, and caregivers. VA 
believes that these programs also honor Veterans' preferences for 
health and independence in the face of aging, catastrophic injuries, or 
illnesses by advancing expertise and partnership. For the increasing 
numbers of Veterans, of any age, facing the challenges of serious 
chronic diseases and disabling conditions, VA GEC offers a 
comprehensive spectrum of geriatrics, palliative care, and long-term 
services and supports (LTSS) that surpasses all other US health care 
systems by providing services in the home, community, clinics, 
hospitals, and nursing facilities. The overarching goal of GEC is to 
meet these Veterans' long-term care needs in the least restrictive 
setting through access to options that honor their choice while 
promoting their optimal independence, health, and well-being. Our 
strong history of innovation continues, advancing models of care, 
practices, training, and partnerships that improve care not only for 
Veterans but for all Americans.

An Aging Population

    Nearly 50 percent of the more than 9 million Veterans currently 
enrolled in VA's health care system are 65 years old or older. Between 
2018 and 2028, the number of enrolled Veterans aged 75 and older is 
projected to increase by 46 percent, from 2 million to an estimated 2.9 
million. During the same timeframe, the number of enrolled Veterans 
under age 75 is projected to decrease by 14 percent. The number of 
Veterans aged 85 and older enrolled in the system has increased almost 
300 percent between 2003 and 2018 and is projected to surge close to 
500 percent by 2038.
    As Veterans age, approximately 80 percent will develop the need for 
LTSS. Most of this support in the past has been provided by family 
members, with women providing most of the care. The average number of 
potential family caregivers per older adult in America is currently 7, 
but that number will likely decline to 4 in 2030. The availability of 
these potential family caregivers can be jeopardized due to work 
responsibilities outside the home. Moreover, many Veterans are 
divorced, have no children, are estranged from their families, or live 
long distances from family members. In one of our programs we care for 
some of our most medically complex and disabled Veterans, and although 
half are married, one-third of their spouses have chronic disabling 
conditions. This lack of a strong family caregiver is especially true 
for the increasing numbers of women Veterans who are at higher risk for 
needing LTSS due to their longer life expectancies and greater risk of 
disability than men at any age.
    The aging of the Veteran population has been growing rapidly and 
represents a greater proportion of the VA patient population than 
observed in other health care systems. Addressing the needs of these 
Veterans was recognized as a priority by 1975, which led to the 
development of 20 currently existing Centers of Excellence called 
Geriatric Research, Education, and Clinical Centers (GRECC) within VA. 
Where available, these GRECCs have served as an incubator for research 
into health and health systems relevant to older Veterans and spawned 
innovative clinical programs that have been shown to optimize Veterans' 
function; prevent unnecessary and costly nursing home admissions and 
hospitalizations; and reduce unwanted and unnecessary tests and 
treatments, thereby reducing health care costs. Finally, GRECCs 
continue to address the geriatric workforce shortage, providing 
thousands of students training hours and exposure to care for older 
adults. The advances from GRECCs and other GEC innovations continue to 
benefit not only Veterans, but all Americans.

Geriatrics and Extended Care Programs In-depth

    GEC's programs include a broad range of LTSS that focus on 
facilitating Veteran independence, enhancing quality of life, and 
supporting family members and Veteran caregivers. Many of the services 
provided via these programs are not available in any other health care 
system. The 4 categories of LTSS are: Home and Community-Based Services 
(HCBS); Facility-Based Care; geriatric services provided in outpatient 
clinics and hospitals; and Hospice and Palliative Care in all settings.

Home and Community-Based Services

    HCBS supports independence by allowing the Veteran to remain in his 
or her own home as long as possible. More than one service can be 
received at a time. These programs include, but are not limited to, the 
following:

      Adult Day Health Care: This is a day program provided to 
Veterans for social activities, peer support, companionship, and 
recreation. The program is for Veterans who need skilled services, case 
management, and help with activities of daily living. Most Adult Day 
Health Care is purchased from community providers, but some VA medical 
centers (VAMC) also provide this service within their facilities.

      Home Based Primary Care (HBPC): Through this program, 
Primary Care is provided to Veterans in their homes. A VA physician 
leads the interdisciplinary health care team that provides the 
comprehensive longitudinal health care. This evidenced-based program is 
for Veterans who have complex health care needs and routine clinic-
based care is not effective.

      Homemaker/Home Health Aide: A trained person comes to a 
Veteran's home and helps the Veteran take care of him or herself and 
their daily activities. These aides are not nurses, but they are 
supervised by a registered nurse who helps assess the Veteran's daily 
living needs.

      Palliative and Hospice Care: This program offers comfort 
measures that focus on relief of suffering and optimizing quality of 
life.

      Respite Care: This service pays for a person to come to a 
Veteran's home or for a Veteran to go to a program while their family 
caregiver takes a break. Thus, the family caregiver is allowed time 
away without the worry of leaving the Veteran alone.

      Skilled Home Health Care: These are mostly short-term 
health care services provided to Veterans if they are homebound or live 
far away from a VAMC. The care is delivered by Medicare or Medicaid-
certified community-based home health agencies.

      Telehealth: This service allows the Veteran's physician 
or nurse to monitor their medical condition remotely using monitoring 
equipment. Veterans can be referred to a care coordinator for Home 
Telehealth services by any member of their care team. Home Telehealth 
is approved by a VA provider for Veterans who meet the clinical need 
for the service.

      Veteran-Directed Care: This program gives Veterans of all 
ages the opportunity to receive the HCBS they need in a consumer-
directed way. Veterans in this program are given a flexible budget for 
services that can be managed by the Veteran or the family caregiver. As 
part of this program, Veterans and their caregiver have more access, 
choice, and control over their long-term care services.

    Adult Day Health Care, HBPC, Homemaker/Home Health Aide, Palliative 
and Hospice Care, Respite Care, and Skilled Home Health Care are all 
part of the standard medical benefits package all enrolled Veterans 
with clinical needs receive.
    While HCBS continues to improve care for Veterans, it has also 
helped reduce costs for the Department. VA financial obligations for 
nursing home care in Fiscal Year (FY) 2019 reached $6.3 billion. The 
number of Veterans with service-connected disabilities rated 70 percent 
or more, for whom VA is required to pay for needed nursing home care, 
is projected to increase from 1.9 million to 3.1 million Veterans 
between 2018 and 2028. Therefore, if nursing home utilization continues 
at the current rate among Veteran enrollees, without consideration of 
inflation, the costs to VA for providing nursing home care for enrolled 
Veterans are expected to significantly increase.
    Fortunately, evidence has shown appropriate targeting and use of 
the programs and services available through GEC, especially those 
services that are provided in HCBS, can reduce the risk of preventable 
hospitalizations and delay or prevent nursing home admissions and their 
associated costs substantially. Therefore, VA has increased access to 
HCBS over the last decade. There is an urgent need to accelerate the 
increase in the availability of these services since most Veterans 
prefer to receive care at home, and VA can improve quality at a lower 
cost by providing care in these settings.
    States have found that through their Medicaid programs, they have 
been able to reduce costly nursing home care by rebalancing their 
expenditures for LTSS between institutional and home and community-
based settings. As of 2016, national Medicaid expenditures for home and 
community-based services for the population most similar to VHA users, 
older adults and people with physical disabilities, represent 45 
percent of total LTSS - up from 17 percent 20 years prior. Comparable 
personal care services (Home maker/Home Health Aide, Respite, and Adult 
Day Health Care) accounted for 10.6 percent ($930 million) of VA's LTSS 
obligations in Fiscal Year 2019. The total budget of all HCBS, 
including personal care services, accounted for 31 percent of the LTSS 
budget obligations in Fiscal Year 2019. Current annual per Veteran 
costs for nursing home care are 8.6 times the annual costs for HCBS 
within VA.
    Residential Settings are supervised living situations that provide 
meals and assistance with activities of daily living. These settings 
require Veterans to pay their own rent, but HBCS can be provided if the 
Veteran has certified needs and is enrolled in VA's health care system. 
Medical Foster Homes (MFH) fall within this category. MFHs provide an 
alternative to nursing homes in a personal home at substantially lower 
costs. VA provides program oversight and care in the home through HBPC, 
while the Veteran pays on average $2,400 per month for room, board, and 
daily personal assistance. MFHs currently operate in 45 states 
providing care for over 1,000 Veterans each day at a significant cost 
savings as compared to care provided in community nursing homes. 
Additionally, Veterans express high levels of satisfaction from care 
provided through MFH, but many are limited from MFH because of the 
costs to the Veteran.
    In the Department's Fiscal Year 2021 budget request, VA submitted a 
legislative proposal to require VA to include in the program of 
extended care services the addition of care in MFHs; this would apply 
to Veterans for whom VA is required to provide nursing home care.

Facility-Based Care

    Nursing homes are settings in which skilled nursing care, along 
with other supportive medical care services, is available 24 hours a 
day. All Veterans receiving nursing home care (NHC) through VA, whether 
provided in one of the 135 VA-operated Community Living Centers (CLC), 
in a State Veterans Home (SVH), or purchased by contract or agreement 
in one of the over 2,000 available community nursing homes (CNH), must 
have a clinical need for that level of care. VA strives to use NHC when 
a Veteran's health care needs cannot be safely met in the home. 
Veterans who have service-connected disabilities rated at 70 percent or 
greater and need NHC for service-connected conditions or are being 
placed in a nursing home by VA staff for the delivery of inpatient 
hospice care have mandatory eligibility for NHC. Veterans with 
mandatory nursing home eligibility can be provided care in a VA CLC, an 
SVH, or in a private nursing home under contract with VA. Consideration 
is given for Veterans' preferences based upon clinical indication and/
or family/Veteran choice, when possible. Since 2012, each year more 
Veterans chose to die in VA CLC hospice beds than in all of VA Acute 
and Intensive Care Unit deaths combined. These CLC hospice beds provide 
specialized support for terminally ill Veterans in their final weeks 
and surveys of these Veterans' family members reveal high satisfaction 
with this care. Veterans without mandatory nursing home eligibility, a 
population that makes up the majority of Veterans, receive care on a 
resource available basis. If these Veterans are admitted to the CNH 
Program, placement at VA expense is generally limited to 180 days. 
Extensions are available in certain circumstances. More non-mandatory 
Veterans who need nursing home care usually receive that care in VA 
CLCs rather than in private nursing homes at VA expense.
    VA maintains strong, working relationships with every State in the 
oversight and payment of Veterans' care at SVHs. Through this effort, 
states provide care to eligible Veterans across a wide range of 
clinical care needs through NHC, domiciliary care, and adult day health 
care programs. VA can provide: construction grant funding for 
construction and renovation of the State home; continuing operating 
funds for eligible Veterans through a grant and per diem program; and 
ongoing quality monitoring to ensure Veterans in SVHs receive high 
quality care. Currently, there are 157 SVHs across all 50 states.

Ambulatory Care and Inpatient Acute Care Programs

    Finally, GEC offers Ambulatory Care programs (including Geriatric 
Patient-Aligned Care Teams (GeriPACT)); Inpatient Acute Care Programs 
(including Geriatric Evaluation and Management); and a variety of 
dementia and delirium programs. GeriPACT clinics provide longitudinal, 
interdisciplinary team-based outpatient care for high-risk, high-
utilization, and predominantly (but not exclusively) elderly Veterans. 
The teams have enhanced expertise for managing Veterans whose health 
care needs are particularly challenging due to multiple chronic 
diseases, coexisting cognitive and functional decline, as well as 
psychosocial factors. GeriPACT integrates and coordinates traditional 
ambulatory and institution-based health care services with a variety of 
community-based services and strives to optimize independence and 
quality of life for these particularly vulnerable Veterans in the face 
of their multiple interacting cognitive, functional, psychosocial, and 
medical challenges. GeriPACT panel sizes are one-third smaller than 
regular PACT teams and have a social worker and a pharmacist as core 
members. By helping Veterans maintain function, preventing unnecessary 
hospitalizations, nursing home admissions, and unwanted tests and 
procedures, the total costs of care for targeted high-risk Veterans are 
about 15 percent lower when they are managed in GeriPACT versus being 
managed by regular Primary Care Patient Aligned Care Teams. Currently, 
only about half of VAMCs have GeriPACT, and VA is working to expand 
this program to larger Community-Based Outpatient Clinics.

Caregiver Support Program

    Caregivers are eligible for a host of VA services including those 
offered under the Program of General Caregiver Support Services 
(PGCSS). These general services are available to support all 
caregivers, when the Veteran is enrolled for VHA healthcare regardless 
of illness or injury. In addition to the general services offered under 
the PGCSS, caregivers in the Program of Comprehensive Assistance for 
Family Caregivers (PCAFC) may also receive a monthly stipend, 
beneficiary travel, mental health counseling, enhanced respite 
services, and health insurance, if applicable. Under the VA Maintaining 
Internal Systems and Strengthening Integrated Outside Networks 
(MISSION) Act, we are working to give more family caregivers access to 
PCAFC and support them as they care for Veterans of all eras. 
Currently, PCAFC is only available to eligible Veterans injured in the 
line of duty on or after September 11, 2001. Prior to expanding 
eligibility for PCAFC, VA must upgrade its information technology (IT) 
system and implement other improvements to strengthen the program.
    The Caregiver Support Program's shoulder-to-shoulder work with VA's 
Office of Information and Technology has realized the successful launch 
of a replacement IT solution, termed the Caregiver Record Management 
Application (CARMA). This solution supports the administrative needs of 
PCAFC; PGCSS; and the Caregiver Support Line. The initial phase CARMA 
was successfully released in October 2019, with a follow up release in 
December 2019 to transition the remaining functionality from the former 
system to CARMA. Further functionality enhancement to CARMA in Fiscal 
Year 2020 will prepare the program for expansion--automating stipend 
payments, improving functionality that supports PCAFC processes, and 
solidifying integrations with key VA systems.
    In support of achieving the goals of program stabilization and 
expansion required by the VA MISSION Act of 2018, a strategic and 
expedited staffing plan was initiated to ensure a strong foundational 
infrastructure on which to expand the PCAFC program. By August 2019, 
over 680 positions had been approved for hire. This hiring phase 
included establishing facility staff such as program coordinators in 
the field for both PCAFC and PGCSS, as well as establishing Veterans 
Integrated Service Network (VISN) Leads and VISN Clinical Eligibility 
and Appeals teams. By the end of January 2020, 51 percent of those 
positions had already been filled. Completion of full staffing is 
targeted to occur in time for program expansion in the Summer of 2020.

Conclusion

    VA's various long-term care programs provide a continuum of 
services for older Veterans designed to meet their needs as they change 
over time. Together, they have significantly improved the care and 
well-being of our Veterans. These gains would not have been possible 
without consistent Congressional commitment in the form of both 
attention and financial resources. It is critical that we continue to 
move forward with the current momentum and preserve the gains made thus 
far. Your continued support is essential to providing high-quality care 
for our Veterans and their families. Madam Chair, this concludes my 
testimony. My colleague and I are prepared to answer any questions.
                                 ______
                                 

                  Prepared Statement of Nikki Clowers
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 

                  Prepared Statement of Adrian Atizado

    Madam Chair and Members of the Subcommittee:
    Thank you for conducting this critical oversight hearing and 
calling attention to the essential, but often overlooked, role of the 
long-term services and supports (LTSS) provided by or sponsored by the 
Department of Veterans Affairs (VA).
    As a predominantly hospital-based system three decades ago, about 
95 percent of VA's LTSS spending went toward furnishing nursing home 
care. But the VA health care system was about to be transformed in 
1996, through Public Law 104-262, the Veterans' Health Care Eligibility 
Reform Act. This law changed the operating environment in which VA LTSS 
was being delivered to veterans. This law pushed VA health care toward 
a more holistic approach in providing service-connected disabled 
veterans a lifetime of care, but did not appreciably alter veterans' 
eligibility for VA LTSS. \1\
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    \1\ www.Congress.gov/bill/104th-congress/house-bill/3118
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    It was not until 1999 with the Veterans Millennium Health Care and 
Benefits Act, Public Law 106-117, that the policy regarding VA LTSS was 
reformed and to a certain extent realigned to the larger VA health care 
system. This law significantly enhanced the VA's LTSS system, ensuring 
veterans have access to a full continuum of LTSS by requiring VA 
furnish nursing home care to any veteran who needs such care for their 
service-connected disability or if the veteran is service connected 70 
percent or greater.
    The law provided all veterans using the VA health care system 
access to home-and community-based services such as adult day health 
care, respite care and a general category of ``non-institutional 
alternatives to nursing home care.'' Notably, the law also required VA 
to look at assisted living as an option for veterans and to determine 
the effectiveness of different models of all-inclusive care-delivery. 
\2\
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    \2\ www.Congress.gov/bill/106th-congress/house-bill/2116
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    Because this new public policy was far reaching at the time, 
Congress added provisions in the law to ensure such transformation 
would not deplete VA's capacity to provide care to certain 
subpopulations of veterans or reduce its capacity to provide 
institutional care. These provisions collectively known as the 
``Capacity Law,'' require VA to report and document bed changes to 
Congress for specific categories of beds, and require that staffing and 
levels of extended care services remain, at a minimum, at levels 
provided during Fiscal Year (FY) 1998.\3\
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    \3\ Sections 101(c)(1) and 301 of the Veterans Millennium Health 
Care and Benefits Act, Public Law (Pub. L.) 106-117.
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    Despite this dramatic change in public policy, VA was still 
spending 89 percent of its LTSS budget on institutional nursing home 
care across three settings: VA community living centers (CLC), which 
are VA-owned and operated, State veterans homes (SVH), which are state-
owned and operated, and community nursing homes (CNH), with which VA 
contracts for care. Moreover, the landscape outside VA was changing 
with Medicare and Medicaid policy changes and State program expansion, 
which reduced nursing home expenditures to just over 70 percent. These 
changes included greater use of nursing home preadmission screening, 
expansion of the role of Medicaid home-and community-based (HCBS) 
waivers, development of assisted living, expansion of new programs such 
as the Programs of All-Inclusive Care for the Elderly, and changes in 
medical care delivery through expansion of Medicare and Medicaid 
managed care.
    Just over a decade later and due to our members' frustration, the 
delegates to DAV's national convention in 2011 passed a resolution 
urging Congress and VA to develop a strategic plan recognizing the 
rising cost of institutional care and the limited amount of programs 
and services that could support aging veterans' preference to remain at 
home and in their communities. Based on this mandate, our organization 
worked aggressively with VA to balance its LTSS system by shifting more 
resources, in the aggregate, from institutional nursing home care to 
non-institutional services.
    A major victory for DAV occurred the following year in 2012, when 
VA approved a plan in Fiscal Year 2015 to shift resource spending, 
recognizing the potential that increasing home-and community-based 
services could reduce nursing home and overall LTSS costs after six 
years.
    By Fiscal Year 2016, VA spent 71 percent of its LTSS budget on 
institutional care and 29 percent in home-and community-based care and 
for Fiscal Year 2021, VA plans to spend 67 percent of its LTSS budget 
on institutional care and 33 percent in home-and community-based 
services. This shift to honor veterans preference by increasing access 
to home-and community-based services means 354,995 veterans were served 
in Fiscal Year 2019--a 21 percent increase over Fiscal Year 2016, when 
VA served about 285,500 veterans. DAV urges VA to continue this trend 
and Congress must continue its oversight of the Department's LTSS 
system, which makes up 11 percent of its proposed budget authority for 
Fiscal Year 2021.
    Today, VA's menu of LTSS includes institutional facility-based care 
such as VA Community Living Centers; Community Nursing Homes; State 
Veterans Homes (nursing homes and domiciliaries); Inpatient Hospice; 
and Inpatient Respite. VA is also authorized to provide a set of home-
and community-based services through non-institutional care programs 
such as Home-Based Primary Care; Home Telehealth; Purchased Skilled 
Home Care; Home Hospice; VA Adult Day Health Care; Community 
Residential Care, and Medical Foster Homes. Other home-and community-
based services VA is authorized to purchase from community providers 
include Homemaker and Home-Health Aide; Veteran-Directed Care; 
Purchased Skilled Home Care; Community Adult Day Health Care; and In-
Home Respite Care.
    With about 9 million veterans 65 years of age or older, 
representing about 47 percent of the total veterans' population, demand 
for these critical programs will continue.\4\ While the total number of 
senior veterans is projected to decline into the foreseeable future, 
this population remains the largest age cohort peaking as a percentage 
of the veterans' population at 48 percent in about 2030. About 3.2 
million veterans 65 years of age or older use VA health care services 
and about half of these veterans (1.6 million) are service connected. 
In 2019, 425,478 veterans received LTSS from VA. Of these veterans, 
27.8 percent were 85 or older. LTSS is not just for aging veterans--
16.7 percent of VA's LTSS were provided to veterans less than 65 years 
of age. Most LTSS users have a high burden of service-connected 
disability (priority 1 for health care enrollment), catastrophic 
disability (priority 4) or are low-income (priority 5). About a third 
(33.2 percent) live in rural areas. \5\
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    \4\ Department of Veterans Affairs. VETPOP2016: Table 1L, accessed 
from va.gov Feb. 18, 2020.
    \5\ Department of Veterans Affairs. Fiscal Year 2021 Budget 
Submission. Vol. II: Medical Programs and Information Technology 
Programs. P. 81-92.
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    DAV, along with our partners in The Independent Budget,\6\ called 
for Congress to conduct an oversight hearing into VA's use of home-and 
community-based services so we are particularly pleased to have this 
opportunity. As a group, we had also called on Congress to request the 
Government Accountability Office (GAO) to update its report on 
veterans' access to home-and community-based services. We are pleased 
that GAO has made its report available for this hearing and will 
discuss the findings from its new report below. The last GAO report 
dedicated to long-term care in VA was published more than a decade ago 
and recommended improvements in VA's planning and budgeting for non-
institutional long-term care that have yet to be addressed.\7\
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    \6\ http://www.independentbudget.org/
    \7\ GAO. ``VA Health Care: Long-Term Care Strategic Planning and 
Budgeting Need Improvement.'' GAO-09-145. Publicly released: Jan. 23, 
2009.
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    Before the Gulf Wars began, the VA was increasingly becoming the 
refuge of older veterans from the World War II era--many were aging 
with significant disabilities and chronic conditions that required 
long-term care. VA had begun a major transformation from almost total 
reliance on inpatient care to one that provided more care on an 
outpatient basis and in the community. VA and most other long-term care 
providers long ago shifted the focus of institutional care from serving 
as a place veterans would go to die to a more transitional and often 
more intensive role. Many of VA's community living centers (skilled 
nursing facilities) now offer only subacute and rehabilitative care or 
specialized respite and end of life care (hospice) for most veterans. 
Congress mandated that VA allow the highest priority veterans--those 
with service-connected conditions rated 70 percent or more (priority 
1A)--who enter its community living centers to remain as long as they 
and their families deem necessary.\8\ It should be noted, however, that 
VA only keeps these Priority 1A veterans an average of 10 days longer 
than those with nonservice-connected disabilities.
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    \8\ Title I, Subtitle A, Sect. 101, Veterans Millennium Health and 
Benefits Act (Public Law 106-117).
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    About 80 percent of veterans in VA's CLCs are considered ``short-
stay'' and only 20 percent ``long-stay'' patients. VA returns veterans 
with shorter stays to home or transitions them to State or community 
programs as soon as it deems they have received the maximum benefit 
from treatment in the CLC. CLCs are generally the most expensive 
institutional care venue because VA pays the full cost of care for 
veterans in these homes compared to the other settings and VA CLCs are 
able to provide acute care that requires higher staffing levels and 
more specialized equipment. The higher cost also include the overhead 
costs of being associated with a VA medical center.
    VA CLCs cost $1,184 per day compared to $328 per day in CNH and 
$160 per day in SVH.\9\ While the least cost to VA for institutional 
care is SVHs, 80 percent of veterans receive VA's partial daily rate 
that covers only about a quarter of their care costs. For the remaining 
20 percent of veterans who have a service-connected disability residing 
in SVHs, VA pays the full cost of their care. VA also pays the full 
cost of care for CNH but 30 percent of these veterans receive lower 
cost long-term care and about 70 percent receive the short-term care 
that many veterans receive in CLC. Considering the cost and quality of 
the SVH and the unique role they play in long-term care, Congress 
should consider funding additional construction grants that propose to 
build out the capacity of these programs.
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    \9\ Department of Veterans Affairs. Fiscal Year 2021 Budget 
Submission. Vol. II: Medical Programs and Information Technology 
Programs. P. 81-92.
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    As younger veterans with acute disabilities and differing needs 
began to flood the VA in the wake of the Gulf Wars, VA's priorities 
shifted and long-term care lost out to responding to post-traumatic 
care needs of a younger population. Creating or revitalizing its 
programs to respond to these needs shifted resources from LTSS 
programs. Instituting new community-care programs has lately also 
consumed VA's resources and focus. VA had begun important end of life 
care initiatives and important innovations of its non-institutional 
long-term care portfolio that now continue to languish. This shift in 
priorities and other reforms have kept VA from revisiting development 
of a robust strategic plan for meeting veterans' long-term care 
needs.\10\
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    \10\ GAO 20-284, VA Long Term Care, p. 21.
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    VA's CLCs continue to offer high quality care, but they are not 
without their challenges--GAO reported that about 80 percent had 
vacancies for nurse assistants and home health aides. These shortages 
are rampant throughout the long-term care industry and often impair 
program capacity, including for non-institutional options. Innovative 
solutions for training additional nurse assistants and home health 
aides are in short supply. VA should aim to be part of the solution to 
this national problem. Whether this involves reevaluating pay grades, 
development of tuition support or reimbursement for education, in-house 
training programs or creation of other incentives, VA can help address 
this need for these scarce professionals. In addition, it can look at 
means of incentivizing the reallocation of staff and other resources in 
more rural locations and offering special training for the specialized 
care many aging veterans require such as dementia care, behavioral 
supported care or ventilator dependent care.
    Local VA Geriatrics and Extended Care (GEC) programs often 
prioritize staffing institutional settings rather than home-and 
community-care programs through the same budget. GAO reports that in 
2017, VA spent 63 percent of its obligations for LTSS on institutional 
care and 37 percent on non-institutional care. By 2037, VA projects 
spending about 53 percent of its funding on institutional care and 47 
percent on home and community programs.\11\ Whether that split is the 
``right'' balance is unclear. DAV supports GAO's recommendation that VA 
build a timeframe for a standardized means of determining veterans' 
needs for non-institutional care options at each VA medical center.
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    \11\ GAO 20-284, VA Long Term Care, p. 18.
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    VA has created some specialized care for aging veterans it serves 
such as those with spinal cord injury and disease. VA, like other 
health care systems, is having difficulty meeting the needs of veterans 
with dementia and behavioral issues and those who require 
ventilators.\12\
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    \12\ GAO 20-284, VA Long Term Care, p. 21.
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    Most veterans with family or friends who can play some role in 
assisting them are eager to return home. Congress made this goal more 
attainable by enabling family caregivers of veterans of eras on or 
after September 11, 2001 to assist veterans with service-connected 
disabilities under the Caregivers and Veterans Omnibus Health Services 
Act of 2010 (P.L. 111-163). The VA MISSION Act of 2018 (P.L. 115-182) 
expanded the VA's Family Caregiver Assistance Program to caregivers of 
service-disabled veterans from eras before September 11, 2001.
    DAV developed the Unsung Heroes Initiative to advocate for the 
expansion of VA's Family Caregiver program to not just veterans with 
service-connected disabilities who were injured on or after September 
11, 2001, but those of later eras aging with disabilities and those who 
have service-connected illnesses such as ALS, Parkinson's disease or 
cancers. There is precedence in DoD's Special Compensation for 
Assistance with Activities of Daily Living program, which covers both 
injury and disease. Both severe injury and disease can create 
significant needs for personal assistance and tasks of independent 
living.
    DAV's 2017 report, America's Unsung Heroes, includes a survey of 
over 1,800 respondents, of whom more than 1,000 were family caregivers, 
which found that about three-quarters believe that their loved one 
would require institutional care without their assistance--now (about 
25 percent) or in the future (50 percent).\13\ As they age, caregivers 
worry that without additional support they will be unable to continue 
in their caregiving role. Most found that caregiving has taken a toll 
on their financial stability, friendships, family life, physical health 
or fitness, mental health and job or career.\14\ These family members 
stated stipends, health insurance, medical training and other supports 
would be important or very important to them.\15\ Other surveys 
including the 2015 RAND study and the 2010 National Alliance of 
Caregiving (NAC) study have similar findings about caregiver 
burdens.\16\ \17\
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    \13\ DAV. America's Unsung Heroes: Challenges and inequities facing 
veteran caregivers. 2017, p. 10
    \14\ DAV. America's Unsung Heroes: Challenges and inequities facing 
veteran caregivers. 2017, p. 9
    \15\ DAV. America's Unsung Heroes: Challenges and inequities facing 
veteran caregivers. 2017, p. 17
    \16\ RAND Military Caregivers Study. 2014
    \17\ National Alliance of Caregiving and United Health Foundation 
Study. 2010
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    VA's Comprehensive Caregiver Support Program (CCSP) has gone a long 
way toward addressing the problems of caregivers of post-9/11 veterans. 
While the legislation has been passed to include caregivers of disabled 
veterans pre-9/11,\18\ the implementation of this legislation has been 
stalled by technological barriers. The clock is ticking for many of the 
family caregivers who would be affected by this law--as they age, and 
the years of caregiving they have already provided continue to take a 
toll, they may no longer be able to provide the same levels of 
assistance. Congress required VA to improve its information technology 
administrative support systems before moving forward with this 
expansion and significant delays are now impeding thousands of veterans 
and their families from receiving this support. DAV hopes that this 
Committee will continue to closely monitor this initiative to ensure 
the thousands of veterans it would serve can remain in their homes or 
return there--often at far less cost to the Federal Government.
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    \18\ VA MISSION Act of 2018 (P.L. 115-182)
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    VA was able to compare a small number of caregivers enrolled and 
not enrolled in CCSP and found that caregivers in this 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. Although things are not perfect in this program, as we 
have already stated, DAV would support the addition of caregivers whose 
loved ones have grave illnesses, such as those Vietnam veterans 
suffering from diseases caused by Agent Orange, veterans suffering from 
Gulf War Illnesses, and the newest generation of veterans exposed to 
burn pits and other toxic and environmental hazards. Therefore, DAV 
endorses Congressman Ruiz's bill, H.R. 4451, the Support Our Services 
for Veterans Caregivers Act, which would make them eligible for the 
program. Equally important, the bill would also require VA to conduct a 
multidimensional assessment to assess the burden and strain caregivers 
experience while participating in the CSSP.
    We also support H.R. 5701, the Care for the Caregiver Act, 
introduced by Representatives Hudson and Rice. We eagerly anticipate 
the introduction in the House of a companion bill to S. 2216, The 
Transparency and Effective Accountability Measures (TEAM) for Veteran 
Caregivers Act, which we endorse. Collectively, these bipartisan bills 
would: Require VA to recognize Primary family caregivers as ``part of 
the clinical team'' so they can more effectively advocate for their 
veteran; standardize clinical evaluation for eligibility; extend 
stipend payments to help the family caregiver transition when the 
veteran is discharged from the program (due to death or functional 
improvement); require a minimum standard of information to be included 
in decision letters so veterans and caregivers understand the basis of 
such decisions; and establish permanent eligibility criteria for the 
most catastrophically injured veteran so they do not have to worry 
about arbitrarily losing caregiver support and services. We urge 
Congress pass these bills--veterans and their family caregivers have 
waited far too long for VA to act on these common sense provisions.
    Because of our hard work to improve and expand the CSSP, we are 
concerned about the long-term viability of this important benefit, 
which is not considered part of the VA's basic care package or among 
its LTSS programs. Demand for the program from post-September 11 
veterans was higher than VA anticipated and taking funds from within 
appropriations requires a significant shift away from other 
programming--including its ``mandatory'' benefits package, which 
includes long-term care. VA must determine how to meet the growing 
demand for this program among other LTSS services.
    In terms of funding, the Administration's Fiscal Year 2021 request 
included approximately $1.2 billion for VA's comprehensive caregiver 
support program. Because this request represents an overall increase of 
$485 million over Fiscal Year 2020, it is noteworthy that $650 million 
is to implement the eligibility expansion required under the VA MISSION 
Act; thus, we are concerned this request assumes a reduction in the 
number of existing program participants--approximately 20,000 approved 
family caregivers. The IB recommends appropriating $779 million for 
Fiscal Year 2021 for the phase-one expansion scheduled toward the end 
of Fiscal Year 2020, with only a small portion of the expansion cost 
absorbed in Fiscal Year 2020. The IB's recommendation is based on the 
Congressional Budget Office's estimate for preparing the program, 
including increased staffing and IT needs, and the beginning of the 
first phase of expansion. To continue the expansion, the IB recommends 
$1.4 billion for Fiscal Year 2022.
    VA has recently rebranded its non-institutional care program under 
its ``Choose Home Initiative'' to expand in-home care options. All 
veterans who are determined to have a clinical need for it, are 
eligible for home and community services including home-based primary 
care, day care, homemaker/health aide services, hospice or respite 
services. Unfortunately, GAO's recent report notes that there are 
waiting lists for VA's Home-Based Primary Care program. Over the time 
studied, about 1,800 veterans were waiting for this care and without 
intervention given the growing demand for this program, the list will 
grow.\19\
---------------------------------------------------------------------------
    \19\ GAO 20-284, VA Long Term Care, p. 22.

    Veteran-Directed Care. If VA determines veterans are in clinical 
need for such services, veterans or their caregivers may choose 
Veteran-Directed Care (formerly, VD-HCBS). The Veteran-Directed Care 
program 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 Veteran-Directed Care, the veteran has the opportunity to 
manage a monthly budget based on functional and clinical need, hire 
family members or friends to provide personal caregiver services in the 
home, and purchase goods and services that will allow him or her to 
remain in the home. Veterans can also decide to receive assistance from 
an Options Counselor to help plan care and services, and the veteran 
can receive financial management support from a Financial Management 
Services (FMS) organization. To fully administer this program, Veteran 
Care Agreements \20\ are used between the local VAMC and its 
surrounding Aging and Disability Network Agencies (ADNAs) including 
State Units on Aging (SUA), Aging & Disability Resource Centers 
(ADRCs), Area Agencies on Aging (AAAs) and Centers for Independent 
Living (CIL).
---------------------------------------------------------------------------
    \20\  Section 102 of the VA MISSION Act of 2018, Public Law 115-182
---------------------------------------------------------------------------
    A recent analysis of Veteran-Directed Care participants' health 
care use in Fiscal Year 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 while honoring 
the veteran's choice to remain in their home rather than in an 
institutional setting. Another example is the program administered at 
the San Diego VA health care System has partnered with the local AAA to 
provide veterans in San Diego county access to this program. Cost 
savings/avoidance for this specific program of $1.6 million over two 
years can be found here: https://nwd.acl.gov/pdf/
SD%20Visa%20Flyer_100215_ 508.pdf. Simply, Veteran-Directed Care is 
capable of serving three veterans for every one residing in a community 
nursing home at VA's expense.
    About 3 years ago, during his confirmation hearing, Secretary 
nominee David Shulkin committed to expand access to the Veteran-
Directed Care program and make it available at every VA medical center 
within the next 3 years. Unfortunately, VA has made significantly 
slower progress in adding the sites that make this program available to 
veterans, adding four new programs in 2019. As of this writing, the 
Veteran-Directed Care program has 145 providers supporting 69 VAMCs 
across 37 states, including D.C. and Puerto Rico.
    This program is an important mechanism for expanding access to 
veterans in rural communities and to service-connected veterans with 
illnesses whose caregivers do not qualify for VA's family caregiver 
program. However, because this is a discretionary program, much like 
all the other home-and community-based services, VA offers as part of 
the veteran medical benefit package, it is up to each VAMC to establish 
this program and to ensure full coverage across its market area.
    Since 1951, the VA's Community Residential Care (CRC) Program has 
provided health care and sheltered supervision to eligible veterans not 
in need of acute hospital care, but who, because of medical and/or 
psychosocial health conditions, are not able to live independently and 
have no suitable family or significant others to aid them.
    The CRC Program is an important component in VA's continuum of 
long-term care services operating under the authority of title 38, 
United States Code, Section 1730. Any veteran who lives in an approved 
CRC residence in the community is under the oversight of the CRC 
Program. This program has evolved through the years to encompass, 
Assisted Living such as VA's Medical Foster Home, Personal Care Home, 
Family Care Home, and Psychiatric CRC Home.
    Assisted living bridges the gap between home care and nursing 
homes. Assisted living is a general term that refers to a wide variety 
of residential settings that provide 24-hour room and board and 
supportive services to residents requiring minimal need for assistance 
to those who require some ongoing assistance with personal care and 
activities of daily living. VA's MFH program is commonly known as adult 
foster care homes in the private sector and some residences that are 
licensed as adult foster care homes may call themselves ``assisted 
living.'' An adult foster care is a residential setting that provides 
24-hour room and board, personal care, protection and supervision for 
adults, including the elderly who require supervision on an ongoing 
basis but do not require continuous nursing care.

    Medical Foster Home. New partnerships between Home-Based Primary 
Care (HBPC) and the MFHs and CRCs have allowed veterans to live 
independently in the community, as a preferred means to receive family 
style living with room, board, and personal care.
    VA must expand the MFH program as an alternative to nursing care 
for some veterans at a much lower cost (about half the cost of other VA 
nursing care venues). MFHs serve no more than three individuals with 
needs for 24-hour care or supervision in private homes. VA makes 
referrals to such care providers, but is currently not authorized to 
cover the full cost of this care for veterans. VA has once again asked 
Congress to authorize it to pay for approved medical foster homes for 
service-connected veterans in its Fiscal Year 2021 budget submission.
    While HVAC is to be commended for passing this legislation out of 
Committee in previous Congresses, it has not passed H.R. 1527, the 
Long-Term Care Veterans Choice Act in this Congress. DAV is hopeful 
that this hearing, along with VA's budget request, will provide the 
impetus for the Committee to reconsider taking action.
    Veterans enrolled in VA who are 70 years and older are projected to 
increase by 30 percent to about 3.9 million. And 15 years from now, the 
veterans of the Afghanistan and Iraq wars will be middle aged and many 
are likely to continue to require support for the same complex co-
morbid conditions of post-traumatic stress, traumatic brain injury, 
chronic pain and orthopedic traumas they struggle with today. Already, 
VA's long-term care patient profile includes almost 30 percent of 
veterans who are younger than 65 years old.
    Clearly, VA's MFH program should be realigned under a more 
appropriate statutory authority. Public Law 106-117 authorized an 
Assisted Living Pilot Program (ALPP) carried out in VA's VISN 20. 
Conducted from January 29, 2003, through June 23, 2004, and involving 
634 veterans who were placed in assisted living facilities, the pilot 
project yielded an overall assessment report submitted to Congress 
stating, ``the ALPP could fill an important niche in the continuum of 
long-term care services at a time when VA is facing a steep increase in 
the number of chronically ill elderly who will need increasing amounts 
of long-term care.''\21\ Unfortunately, VA's transmittal letter that 
conveyed the ALPP report to Congress stated that VA was not seeking 
authority at that time to provide assisted living services, because VA 
considered assisted living to be primarily a housing function.
---------------------------------------------------------------------------
    \21\ Susan H, Marylou G, et al., Evaluation of Assisted Living 
Pilot Program. Report to Congress. Washington, DC, Office of Geriatrics 
and Extended Care, VHA, July 2004.
---------------------------------------------------------------------------
    Despite VA's reticence, the 2004 ALPP report seemed most favorable, 
and assisted living appears to be an unqualified success. In fact, 
Title XVII, Section 1705, of the National Defense Authorization Act for 
Fiscal Year 2008, Public Law 110-181, authorizes VA to provide assisted 
living services.

    Assisted Living for Veterans with Traumatic Brain Injury. Veterans 
with severe traumatic Brian Injury (TBI) suffer from short-term and 
long-term changes, including difficulty with attention and 
concentration, memory, organizational skills, perception, expressing 
feelings, inappropriate behaviors, and physical impairments.
    The Assisted Living for Veterans with Traumatic Brain Injury (AL-
TBI) pilot program ran from 2009 through 2017. It provided specialized 
residential care and rehabilitation to eligible veterans with TBI to 
enhance their rehabilitation, quality of life, and community 
integration. Veterans meeting eligibility criteria are placed in 
private sector TBI residential care facilities specializing in neuro-
rehabilitation or neurobehavioral rehabilitation.
    The pilot has not been extended and without an assisted living 
program, families and caregivers do not have a fully supported 
comprehensive plan for long-term services and supports for veterans 
with severe TBI.
    Demands for all types of long-term care will continue to grow into 
the foreseeable future. DAV agrees with GAO that VA must create 
measureable goals for its LTSS programs to ensure it is making optimal 
choices allocating resources to veterans. It must look to less 
expensive means to provide meaningful care and support. Congress must 
authorize VA to reimburse care in medical foster homes. VA should more 
quickly move toward providing more access to home-and community-based 
services through every VA medical center. It should allocate additional 
resources in home telehealth and home-based primary care to allow more 
veterans to recover and be monitored for chronic conditions at home. It 
should more quickly bring adult day care, respite and hospice programs 
online. Most importantly, VA must enable as many family caregivers to 
assist as possible. These options will not only improve the quality of 
care for our veterans, they are likely to be more satisfactory to 
veterans and their families and cost less.
    Madam Chair, DAV is pleased to have had the opportunity to revisit 
the topic of VA's Long-Term Service and Supports system for veterans. 
We look forward to working with this Subcommittee to ensure veteran 
continue to have access to a full array of LTSS.
                                 ______
                                 

                   Prepared Statement of Mark Bowman

    Chairwoman Brownley, Ranking Member Dr. Dunn and Members of the 
Subcommittee:
    Thank you for inviting the National Association of State Veterans 
Homes (NASVH) to testify on the future of the State Veterans Home 
program and veterans long term care in general. I currently serve as 
President of NASVH, an all-volunteer organization dedicated to 
promoting and enhancing the quality of care and life of veterans and 
families in State Veterans Homes through education, networking, and 
advocacy. However, my full time job is Executive Director of the Office 
of Kentucky Veteran Centers, which oversees the operation of four State 
Veterans Homes among other responsibilities. I am pleased to join you 
today on behalf of NASVH to discuss the State Veterans Home program, 
the current challenges we face and future opportunities to better meet 
the long term care needs of America's aging and ill veterans and their 
families.
    The State Veterans Home program dates back to the post-Civil War 
period, when there were a large number of indigent and disabled 
veterans unable to earn their own livelihood who needed care. While the 
Federal Government already operated national homes for disabled union 
volunteer soldiers, the total number of veterans needing care was 
overwhelming. In recognition of this need, and the debt that a grateful 
nation owed its defenders, a number of states independently established 
State Veterans Homes to help care for those who had borne the battle.
    The first State Veterans Home was established in 1864 at Rocky 
Hill, Connecticut. In 1888, Congress enacted legislation to provide 
Federal aid ($100/year) to help alleviate the burden placed upon 
states. With the establishment of the Veterans Administration in 1930 
to care for an ever-increasing number of veterans, the State Veterans 
Home program was expanded to include additional levels of care as well 
as a Federal grant program to support the construction of State 
Veterans Homes.
    Madame Chairwoman, as the title of the hearing implies, and the 
Government Accountability Office (GAO) confirms, the number of aging 
Vietnam Veterans seeking long term care options from VA will continue 
increasing over the next decade. In order to address the `coming 
tsunami,' VA is going to need all its resources and creativity to 
provide veterans the long term services and supports they desire and 
have earned.
    The State Veterans Home program offers two distinct advantages as 
Congress and VA seek innovative solutions. First, by partnering with 
states, VA can leverage its long term care dollars to serve more 
veterans through the State Veterans Home program than by directly 
providing the services or paying for private sector care. Second, the 
structure of the State Veterans Home program allows each State to 
tailor long term care solutions to the unique characteristics and 
preferences of its veterans. As I have heard many NASVH members say: 
``If you have seen one State Veterans Home you have seen one State 
Veterans Home.'' States can serve as the laboratories of innovation, 
and then allow VA and other states to take advantage of their best 
practices, which NASVH strongly encourages.
    Today, there are 157 State Veteran Homes located in all 50 states 
and the Commonwealth of Puerto Rico, with over 30,000 authorized beds 
available, making the State Veterans Home program the largest provider 
of long term care for our Nation's veterans. As the recent GAO report 
confirms, ``State Veterans Homes had the highest average daily census 
and provided over half of all institutional care based on the average 
number of veterans for which VA funded nursing home care on any given 
day during the year.''
[GRAPHIC] [TIFF OMITTED] T1635.013


    However, as VA's Fiscal Year 2021 budget submission makes clear, 
State Veterans Homes will account for less than one quarter of VA's 
Fiscal Year 2020 total obligations for long term institutional care.

[GRAPHIC] [TIFF OMITTED] T1635.014


    Furthermore, VA's calculation of the institutional per diem for 
State Veterans Homes for veterans' nursing home care is 40 percent 
lower than for private sector community nursing homes and less than 
one-sixth the cost of VA's own community living centers (CLCs).
[GRAPHIC] [TIFF OMITTED] T1635.015


    As both GAO and VA's budget make clear, investing in State Veterans 
Homes is the most cost-effective way to maximize VA's Federal dollars 
to provide convenient, high-quality institutional care for those sick 
and elderly veterans who have no home-based care options.

Skilled Nursing Care Program

    The primary program offered by most State Veterans Homes is skilled 
nursing care, which provides nursing home care for aging and ill 
veterans; in some states, widows, spouses, and Gold Star Parents may 
also be eligible for admission. To support this program, VA provides a 
per diem payment for each eligible veteran, as well as grants for the 
construction, expansion, renovation and repair of the Homes.
    The basic VA per diem rate for nursing home care is currently 
$112.36, which covers approximately 30 percent of the total cost of 
care, although VA is authorized to provide up to 50 percent. State 
Veterans Homes make up the balance differently in each State, using a 
variety of other funding sources, including State support, Medicare and 
the veterans themselves who share in the cost. As a result of Public 
Law 112-154, VA also pays a higher prevailing rate for veterans who 
needs nursing home care due to a service connected disability or for 
veterans with service-connected disabilities rated at 70 percent or 
higher. This prevailing rate per diem varies among the states and is 
considered payment in full by VA.

Insufficient Construction Grant Funding

    VA also provides Grants for State Extended Care Facilities, 
commonly known as State Home Construction Grants, which provide states 
with up to 65 percent of the cost to build, renovate and maintain 
Homes, with states required to provide at least 35 percent in matching 
funds. As a condition of receiving these grants, states must continue 
to operate the program for at least 20 years or be subject to recapture 
provisions in Federal law.
    State Home Construction Grant requests are categorized into 8 
groups, as well as additional subgroups, reflecting statutory 
priorities. The highest priorities are accorded to life-safety projects 
as well as the construction of new Homes in states with an insufficient 
number of beds according to Federal statute. Once a grant request 
secures its matching State funding it is placed into Priority Group 1 
in the order of sub-priority groups and by the date the grant request 
moved onto the Priority Group 1 List.
    Although VA has not yet released the Fiscal Year 2020 Priority 
Group List, as a result of more States providing new matching funding 
over the past year, the new Priority Group 1 List is expected to grow 
to almost $500 million or more. With an estimated $700 million worth of 
grant requests in Priority Groups 2 to 8 awaiting State matching funds, 
the total Federal share to fulfill all of the pending construction 
grant requests is estimated to be approximately $1.2 billion.
    Unfortunately, for Fiscal Year 2020, the Construction Grant Program 
was only appropriated $90 million, which would allow VA to fund just 
the first 14 projects on the Priority Group 1 List, leaving a growing 
backlog for future years. And with further State matching funding 
expected to move even more grant requests into Priority Group 1 next 
year, it is imperative that Congress provide sufficient funding to 
address the growing backlog. NASVH recommends that Congress appropriate 
$250 million for the State Home Construction Grant Program to fund at 
least half of the pending Priority Group 1 grant requests. We urge this 
Subcommittee and the full Committee on Veterans' Affairs to include 
this recommendation in its Views and Estimates to be provided to the 
Budget Committee this year.

Duplicative External Inspection Surveys

    As a condition of receiving Federal funding, VA certifies and 
closely monitors the care and treatment of veterans in State Veterans 
Homes. As required by law, VA performs a comprehensive inspection 
survey of each State Veterans Home annually to assure resident safety, 
high-quality clinical care and sound financial operations. This 
inspection survey is typically a week-long top-to-bottom review of the 
Home's facilities, services, clinical care, safety protocols and 
financial operations. VA also performs inspection surveys of states 
include Domiciliary Care and Adult Day Health Care programs. If 
deficiencies are found at a State Veterans Home, it is required to 
rectify the deficiency as a condition of keeping its certification.
    In addition, about 60 percent of State Veterans Homes are also 
certified to receive Medicare support for their residents. Just like 
VA, the Department of Health and Human Services, through the Centers 
for Medicare and Medicaid (CMS), requires an annual inspection survey 
for the same purposes of assuring safety and quality care. In fact, the 
CMS survey is more than 90 percent identical to the clinical life and 
safety sections of the VA inspection survey. It too is typically a 
week-long inspection that is not announced in advance. Because these 
two Federal agencies do not coordinate their inspections, many State 
Homes have had these two virtually identical inspections occur over 
consecutive weeks; some have even occurred simultaneously, seriously 
disrupting the State Veteran Home and its veteran residents. In our 
view, requiring State Homes to undergo two separate and duplicative 
Federal inspections surveys - when the Federal standard is one annual 
survey - is not only disruptive to State Homes, but also financially 
inefficient for the Federal Government and taxpayers.
    To address this problem, NASVH worked with Congressman Tom Suozzi 
(NY) who introduced legislation in the House to require CMS to use the 
results of the VA survey to satisfy their annual inspection survey 
requirements, similar to how CMS uses and accepts the results of 
certifications by the Joint Commission for hospital accreditation. H.R. 
4138, the State Veterans Home Inspection Simplification Act, has 
growing bipartisan support in the House; companion bipartisan 
legislation, S. 3350, was recently introduced in the Senate by Senators 
Mike Crapo (ID) and Jon Tester (MT). These bills would not prevent CMS 
from investigating any complaints in State Veterans Homes, but would 
simply prevent unnecessary duplication of annual Federal inspections. 
Furthermore, the legislation contemplates CMS working out an agreement 
with VA to add any inspection items or questions to the VA inspection 
survey that CMS determines necessary. NASVH strongly supports passage 
of the State Veterans Home Inspection Simplification Act and asks for 
the support of all members of the Subcommittee.
    It is important to understand that in addition to the VA and CMS 
inspections, State Veterans Homes are also subject to both regular and 
periodic inspections and audits from State agencies, the Inspector 
General of the Department of Veterans Affairs, and the Civil Rights 
Division of the Department of Justice, among other inspectors. 
Moreover, they are held accountable to the general public through 
oversight by Congress, veterans service organizations and the media.
    Each State is also accountable for ensuring veterans in its State 
Veterans Homes receive quality long term and other health care 
services, and are focused on achieving high patient satisfaction in 
comfortable and safe conditions. State Veterans Homes generally 
function within a state's department or division of veterans' affairs, 
public health, or other accountable agency, and typically operate under 
the governance and oversight of a board of trustees, a board of 
visitors, or other similar accountable public bodies. Finally, State 
Veterans Homes hold themselves accountable for the quality of care 
through myriad internal management controls, State and Federal long 
term care regulations, and integration of model policies, practices and 
standards advocated by the NASVH and other standards bodies, for the 
continuous quality improvement of their programs of care for sick, 
elderly and disabled veterans.

Mental Health and Behavioral Issues

    The VA nursing home per diem provided to State Veterans Homes 
covers, among other items, basic primary care for veteran residents; 
specialty care is not considered part of the per diem. However, VA has 
been treating all mental health care as an obligation of the Homes, 
despite the fact that mental health care is a form of specialty care. 
Psychiatrists and psychologists are medical specialties, not part of 
basic primary care. Yet, VA has taken the position that State Veterans 
Homes must bear the full cost of providing mental health care to their 
resident veterans. Given the high costs for psychiatrists and 
psychologists, many State Veterans Homes may not be able to continue 
admitting veterans with significant mental health issues, leaving these 
veterans with fewer options at a time when veteran suicide is a 
national crisis and top VA and congressional priority. NASVH believes 
VA should be responsible for providing eligible veterans with their 
mental health care, in the same manner as VA provides enrolled veterans 
all other necessary specialty care, and asks for support from the 
Subcommittee for this position.
    In fact, a number of State Veterans Homes have indicated that they 
would be willing and capable of providing care for veterans with severe 
behavioral issues or serious mental illness if a higher per diem or 
other cost subsidization were made available, since such veterans 
require intensive supervision , often one-to-one, as well as more 
direct care that is significantly more costly. NASVH is interested in 
exploring potential programs or similar models of care that State 
Veterans Homes might be able to offer for this very challenging 
veterans population.

Domiciliary Care Program

    State Home Domiciliary Care programs provide alternative long term 
support for veterans who are not in need of skilled nursing care, but 
who need shelter and supportive services. There are approximately 6,000 
Domiciliary Care beds in 50 State Veterans Homes in 30 states, 
including California, Florida, Illinois, Michigan, Pennsylvania, Ohio, 
Illinois and Virginia. The State Home Domiciliary Care program can play 
an integral role in VA's mission of helping the homeless and providing 
a safety net for veterans in their communities. The level of care in 
Domiciliaries varies from State to State, with some providing only 
basic food and shelter, and others offering more enhanced levels of 
support that may include social, vocational and employment services.
    Based on a recent NASVH survey, the average age of Domiciliary 
residents is about 75 and the average length of stay is 3.5 years. The 
average daily total cost per Domiciliary resident was reported by State 
Homes as $187; however that cost will rise as the financial burden of 
the new regulations takes full effect. VA provides a Domiciliary per 
diem of $48.50, which is roughly 25 percent of the total daily cost 
reported by State Homes.
    In November 2018, a decade after first initiating a rulemaking 
process for State Veterans Homes Domiciliary and Adult Day Health Care 
programs, VA finally promulgated new regulations (RIN-2900-AO88) 
governing these programs; full enforcement of the new regulations began 
in May 2019. Unfortunately, the decade-long delay in finalizing the 
Domiciliary regulation resulted in a number of unintended problems for 
States who currently operate such programs. The most significant change 
is unexpected increases to the minimum staffing requirements and other 
care changes that have significantly increased the costs to State 
Veterans Homes, without increasing the VA per diem. As a result, many 
states are considering closing the programs, leaving hundreds, perhaps 
thousands, of veterans at greater risk of becoming homeless. NASVH 
calls on Congress to work with VA to provide relief to these 
Domiciliary Care programs either by increasing the VA per diem rate to 
a more realistic amount or by making significant corrections to the 
regulations in consultation with State Veterans Homes.
    Another negative impact of the new regulations has been VA's 
inconsistent enforcement of eligibility requirements. Previously, VA 
had not strictly enforced Domiciliary eligibility requirements, 
allowing veterans who had some challenges in performing all the 
activities of daily living (ADLs) to qualify for a Domiciliary per 
diem, if the State Veteran Home was providing adequate support using 
non-VA resources. However, since promulgation of the new regulations, 
local VA facilities who oversee the Homes began precluding a number of 
current Domiciliary residents from being eligible for VA per diem 
because they were unable to perform all ADLs independently, without 
even minor assistance. VA also began enforcing a work requirement for 
Domiciliary residents, even though such requirements are not allowed in 
many states. In addition, some State Homes - with the full knowledge 
and support of VA - have been operating higher levels of Domiciliary 
Care programs for veterans, such as for dementia care or assisted 
living, and could be forced to shut down if the new enforcement 
continues. It is important to make clear that the Domiciliary programs 
referenced above are providing a higher level of care than what the 
Domiciliary per diem covers, all at the state's expense.
    Recognizing the problems created by the recent Domiciliary 
regulation, VA encouraged State Veterans Homes who had current 
residents excluded from the Domiciliary per diem program to apply for 
equitable relief. This past December Secretary Wilkie granted equitable 
relief for 190 current Domiciliary residents, allowing them to continue 
receiving the VA per diem support. However, a renewed request for these 
veterans will have to be made annually and - most importantly - these 
Domiciliary programs will not be able to admit similarly situated 
veterans in the future, further threatening the sustainability of 
Domiciliary Care programs.
    To address the known problems with the recent Domiciliary 
regulations, VA has indicated it intends to initiative a new rulemaking 
process, however NASVH is concerned that this could take years to be 
finalized, just as it took over a decade for the current regulation. 
Furthermore, there is no certainty that the new regulations will 
actually fix the current problems or strengthen the program. NASVH 
calls on Congress to work with VA to address the known problems and 
explore possible legislative remedies. For example, Congress could 
authorize enhanced levels of Domiciliary care, such as care for 
dementia, which would better address the current and future needs of 
veterans who need less than Skilled Nursing Care. Such a program could 
start initially as a pilot program to test different models of enhanced 
domiciliary care.

Adult Day Health Care (ADHC) Program

    Adult Day Health Care is a non-institutional alternative to a 
skilled nursing facility for aging veterans who have sufficient family 
support to remain in their own homes, but who need or will benefit from 
a day program at a State Veterans Home to promote wellness, health 
maintenance, and socialization. In addition, ADHC can help to maximize 
the participant's independence and enhance their quality of life, as 
well as provide much-needed respite for family caregivers. A higher 
level of ADHC, known as medical supervision model Adult Day Health 
Care, also provides comprehensive medical, nursing and personal care 
services combined with social activities for physically or cognitively 
impaired adults. The medical supervision model ADHC program is staffed 
by caring and compassionate teams of multi-disciplinary healthcare 
professionals who evaluate each participant and customize an 
individualized plan of care specific to their health and social needs. 
A medical supervision model ADHC program can help veterans remain in 
their own homes for additional months or years, thereby improving their 
quality of life. It can also lower the cost and burden on VA by 
deferring or delaying their use of more expensive skilled nursing care 
and can help frail, elderly veterans avoid unnecessary emergency room 
admissions and hospitalizations as well.
    Over the past several years there have only been three State 
Veterans Homes operating ADHC programs - New York, Minnesota and Hawaii 
- in large part due to an inadequate per diem rate for most states to 
make it financially viable. Fortunately, in March 2018, Congress passed 
and the President signed the State Veterans Home Adult Day Health Care 
Improvement Act (P.L. 115-159) which established a higher per diem for 
medical supervision model ADHC for veterans who have a service-
connected disability rated at 70 percent or more, or who needs medical 
supervision model ADHC care for a service-connected disability. The law 
requires VA to enter into agreements with State Veterans Homes to, 
``...adequately reimburse the State home for the care provided by the 
State home, including necessary transportation expenses.'' In 
fulfillment of this requirement, VA has recently consulted with several 
members of NASVH who operate or are considering operating medical 
supervision model ADHC programs. We are hopeful that VA will offer a 
path forward that allows other states who have shown interest to open 
their own programs in the coming years. We encourage the Subcommittee 
to remain engaged with VA as it finalizes these new ADHC per diem rates 
so that more veterans - and their family caregivers - can benefit from 
the higher level of assistance offered by medical supervision model 
ADHC.
    To further encourage State Veterans Homes to operate ADHC programs, 
VA and Congress should modify the Construction Grant program so that 
funding can be used to support the construction of new, or modification 
or expansion of existing facilities for ADHC programs. Given the small 
size of some of these programs, the Construction Grant program should 
also support State Homes seeking to establish satellite ADHC programs 
within existing medical space that is more conveniently located in 
areas with higher concentrations of veterans.

Future Opportunities for State Veterans Homes

    Madame Chairwoman, State Veterans Homes are a trusted and valuable 
partner for VA to help meet the evolving needs of aging and ill 
veterans, through both existing and potentially new institutional and 
non-institutional programs. State Veterans Homes already have an 
existing infrastructure as well as knowledge and experience operating 
safe, high-quality long term care programs. Give the flexibility and 
financial benefits to VA from partnering with State Veterans Homes, 
there are myriad possibilities for better addressing the changing 
demographics, needs and preferences of veterans today and in the 
future. As previously discussed above, many State Veterans Homes would 
have interest in providing additional levels of care that are higher 
than allowed under Domiciliary Care, but lower than required for 
Skilled Nursing Care. Such ``enhanced' Domiciliary Care could help to 
fill gaps between these two programs and better meet the needs of 
veterans and their families.
    State Veterans Homes could also be used to expand non-institutional 
care by encouraging greater usage of Adult Day Health Care, as well as 
additional home-based programs. For example, a State Veteran Home that 
provides medical supervision model ADHC might also be able to operate a 
Home Based Primary Care program that would be able to fulfill all of 
the needs of a veteran to allow him or her to remain in their home. 
Such an integrated non-institutional program could begin as a pilot 
program, with different states customize its pilots to meet local 
circumstances. NASVH recommends that the Subcommittee consider 
establishing such pilot programs to explore new arrangements for 
providing integrated non-institutional care programs through and in 
partnership with State Veterans Homes.

Creating a True Partnership with VA

    Finally, in order to fully maximize State Veterans Homes' resources 
and capabilities. VA must commit itself to a true partnership. Too 
often, State Veterans Homes are an afterthought in VA's planning and 
budgeting processes. For example, the GAO report presented today relies 
on incomplete VA data projections for State Veterans Homes. The report 
notes that in looking at VA's future long term care utilization, ``VA 
projection data... do not include projections for State Veterans Homes 
or State Adult Day Health Care programs...'' because State Veterans 
Homes are not incorporated into VA's Enrolled Health Care Projection 
Model. By contrast, private sector community nursing homes are included 
in VA's projections.
    Another example is the lack of representation by State Veterans 
Homes on VA's Geriatrics and Gerontology Advisory Committee (GGAC), 
despite NAVSH nominating three highly qualified State Veteran Home 
administrators. By contrast, the GAO report notes that the, 
`...committee members included a member from a nursing home industry 
group...'' despite the fact that the State Veterans Home program being 
larger and more cost effective. State Veterans Homes need a seat on the 
GGAC and at the table whenever VA is engaged in long term care 
planning.
    Finally, to be a true partner with VA, the State Veterans Homes 
need to have a single responsible office inside VA which oversees all 
aspects of the program. Currently, State Veterans Homes are overseen by 
at least three major program offices: Geriatrics and Extended Care; 
Central Business Office; and the Construction Grant Program Office. 
While VA has designated a lead point of contact, the lack of true 
programmatic leadership has resulted in a lack of visibility and lack 
of advocacy within VA for the State Veterans Home program. With a VA 
budget for State Veterans Homes per diem topping $1.5 billion, it is 
time for VA and Congress to consider establishing an Office for State 
Veterans Homes within VA.
    Chairwoman Brownley, while there has been rebalancing inside VA 
between institutional and non-institutional care in recent years, a 
trend that is projected to continue in the future, we must remind the 
Subcommittee that the need for traditional nursing home care is neither 
diminishing nor will it ever go away. The total average daily census 
for all VA-supported nursing home, both long stay and short stay, is 
about 40,000 total; this is just a fraction of a percent of the total 
number of veterans over the age of 65, a population that is expected 
rise in the coming decade. NASVH and our member State Veterans Homes 
will continue to seek new and innovative ways of delivering long term 
services and supports to aging and ill veterans, however it would be a 
grave mistake to neglect the existing infrastructure provided by State 
Veterans Homes. That concludes my statement and I would be happy to 
respond to any questions you may have.

                       Statements for the Record

                              ----------                              


          Prepared Statement of Paralyzed Veterans of America

    Chairwoman Brownley, Ranking Member Dunn, and members of the 
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank 
you for this opportunity to provide input as you examine the Department 
of Veterans Affairs' (VA) readiness to handle rapidly growing numbers 
of aging veterans who are relying on VA for their health care.
    PVA continues to be concerned about the lack of VA long-term care 
(LTS) services for veterans with spinal cord injury or disorder (SCI/
D). Approximately 8,650 of our members are now over 65 years of age and 
more than 4,000 are currently between 55 and 64. These aging veterans 
are experiencing an increasing need for VA's home and community-based 
services and VA's specialized SCI/D nursing home care. Unfortunately, 
we believe that VA is not requesting, and Congress is not providing, 
sufficient resources to meet the demand.
    In 2012, VA's own research \1\ warned that a wave of elderly 
veterans with SCI was coming and the department should prepare for 
them. At the time, aging veterans, new cases of SCI from recent 
conflicts, and increasing numbers of women veterans were dramatically 
changing the profile of the Veterans Health Administration's (VHA) SCI/
D population. Sadly, little preparation has taken place since that 
time. VA's SCI footprint is relatively the same and the wave is peaking 
and ready to crest.
---------------------------------------------------------------------------
    \1\ ``Who are the women and men in Veterans Health Administration's 
current spinal cord injury population?'' https://
www.rehab.research.va.gov/jour/2012/493/pdf/page351.pdf.
---------------------------------------------------------------------------
    Like the general VHA population, veterans with SCI/D are aging in 
large numbers. Growing older imposes additional physical and medical 
challenges on all veterans, but especially for those with an SCI/D. 
Having an SCI/D can exacerbate physical and physiologic declines--
including in the musculoskeletal, cardiovascular, gastrointestinal, 
pulmonary, and integumentary systems--brought on by the aging process. 
Furthermore, veterans with SCI/D are also more likely than the general 
population to experience chronic pain, bone loss, pressure injury 
(pressure sores), kidney and bladder stones. As a general rule, the 
need for direct, hands on care increases exponentially as veterans with 
SCI/Ds age.
    A small but distinct subpopulation among veterans approaching the 
silver tsunami, are women veterans with SCI/D. Women are one of the 
fastest growing groups of veterans. Women veterans with an SCI/D are 
less likely to be married; have a higher burden of disease, and greater 
reliance on outside assistance; are diagnosed with more health 
conditions than men; and have higher diagnosis rates of lifetime 
depression.
    PVA believes that the most pressing concerns for addressing the 
needs of aging veterans with catastrophic disabilities include 
preserving access to VA's specialty care services, increased access to 
VA's caregiver supports, and improved access to VA's long-term services 
and supports. We will discuss each of these issues below.

Preserve Access to Specialty Care Services

    Catastrophically disabled veterans are among the most vulnerable 
individuals VA serves. It is essential that VA preserves its capacity 
to provide specialty care services. PVA consistently testifies that VHA 
is the best health care provider for veterans. The VA's SCI/D System of 
Care, comprised of 25 SCI Centers and six LTC facilities, provides a 
coordinated life-long continuum of services for veterans with an SCI/D 
that has led to increased lifespans of these veterans by decades. VA's 
specialized systems of care follow higher clinical standards than those 
required in the private sector. Preserving and strengthening VA's 
specialized systems of care--such as SCI/D care, blinded 
rehabilitation, amputee care, polytrauma care, and mental health care--
remains the highest priority for PVA. However, if VA continues to 
woefully understaff facilities, their capacity to treat veterans will 
be diminished, which could lead to the closure of facilities, halt 
improvements in the lives of those with SCI/D, and reduce the services 
available to them.
    Nearly 49,000 VA staffing positions went unfilled last year. In 
September 2019, VA's Office of the Inspector General \2\ reported that 
131 of the 140 VA medical facilities had severe shortages for medical 
officers and 102 of the 140 facilities had severe nurse shortages. 
Additional shortages in Human Resources Management positions compounded 
this problem department-wide. In 2015, SCI/D nurses worked more than 
105,000 combined hours of overtime due to understaffing. A system that 
relies upon floating nurses, not properly trained to handle SCI 
patients, overworks existing SCI/D nursing staff. This leads to burn 
out, injury, and loss of work time or staff departure and is 
unacceptable. In some circumstances, it even jeopardizes the health 
care of veterans.
---------------------------------------------------------------------------
    \2\ Veterans Health Administration, OIG Determination of Veterans 
Health Administration's Occupational Staffing Shortages, September 30, 
2019, https://www.va.gov/oig/pubs/VAOIG-19-00346-241.pdf.
---------------------------------------------------------------------------
    VA's ability to meet the highest standard of care to our veterans 
relies on more than just having the right number of physicians and 
nurses. They also need qualified and well-trained housekeepers. Last 
year, at some VA medical facilities, staffing levels for environmental 
(custodial) employees dipped below 50 percent, which heightens the 
health risks to veteran patients, particularly those with compromised 
immune systems, such as those with serious illnesses or catastrophic 
injuries. Low pay, a cumbersome hiring process, and a lack of qualified 
applicants are often cited as major contributing factors to the VA 
staffing problem.
    Staffing problems have a direct, adverse impact on the SCI system. 
Lengthy, cumbersome hiring processes make it difficult to hire and 
retain staff, which prohibits SCI/D Centers from meeting adequate 
staffing levels necessary to care for this specialized population. PVA 
estimates there is a shortage of 600 nurses in the SCI/D System of 
Care. Considering SCI/D veterans are a vulnerable patient population, 
the reluctance to meet legally mandated staffing levels is tantamount 
to willful dereliction of duty. SCI/D Centers with nursing shortages 
limit bed availability for admission to an SCI/D Center, reducing 
access for specialized care delivery. Veterans are often admitted to a 
VA non-SCI/D ward and treated by untrained SCI/D clinicians for days or 
weeks until an SCI/D bed becomes available. As SCI/D LTC facilities are 
exceptionally limited, veterans with SCI/D who have chronic medical 
issues are being treated in community institutions, by providers not 
trained in SCI/D. This results in compromised quality of care and poor 
outcomes. Given the magnitude of this situation, PVA strongly advocates 
for Congress to provide enough funding for VA to reform its hiring 
practices and hire additional medical professionals, particularly 
physicians, nurses, psychologists, social workers, and rehabilitation 
therapists, to meet demand for services in the SCI/D System of Care and 
ensure the positions, pay, and other incentives they offer are 
competitive with the private sector.

Increase Access to VA Caregiver Supports

    The VA MISSION Act requires VA to expand access to the 
Comprehensive Family Caregiver program to include veterans who incurred 
a serious injury on or before May 7, 1975; and two years later, to 
those who incurred or aggravated a serious injury in the line of duty 
after May 7, 1975, through September 10, 2001. The law further required 
the Secretary to implement an information technology system that fully 
supports the program and allows for data assessment and comprehensive 
monitoring of the program on or before October 1, 2018. VA has failed, 
however, to meet any of the deadlines to expand this benefit. 
Consequently, thousands of eligible veterans and their caregivers will 
have to wait longer than Congress intended.
    VA continues to provide shifting goals for its rollout of the 
expansion of the caregiver program. Without accountability and follow 
through, these goals mean nothing and weaken the belief in the VA's 
ability to fulfill their obligations to those most in need. At the 
February 27, 2020, House Veterans' Affairs Committee hearing on VA's 
Fiscal Year 2021 budget, Secretary Wilkie stated VA's current goal for 
expansion of the caregiver program is June 2020. PVA calls on Congress 
to perform effective oversight to press VA to implement the expansion 
of caregiver benefits to eligible veterans and caregivers by June. 
Also, since Congress intended the final phase of the expansion to 
service-connected injured veterans be initiated on October 1, 2021, we 
call on Congress to hold the department to that date so these veterans 
will not experience further delays.
    There is, however, another deserving group of veterans who were not 
included under the original program or the expansion: veterans with 
service-connected illnesses such as amyotrophic lateral sclerosis (ALS) 
or the hundreds of other illnesses included in the VA's Presumptive 
Disease List. This too is unjust. For this program to be genuinely 
inclusive of all our Nation's veterans and their caregivers, it must 
not exclude those with service-connected illnesses. Therefore, PVA 
urges the Committee to approve H.R. 4451, the ``Support Our Services to 
Veterans Caregivers Act'' by Representatives Ruiz and Higgins which 
would expand the program to veterans with service-connected 
catastrophic illnesses, not just injuries, from all eras of service.

Improve Access to VA's Long-Term Services and Supports

    PVA continues to be concerned about the lack of VA LTC beds and 
services for veterans with SCI/D. Many aging veterans with an SCI/D are 
currently in need of VA LTC services. Unfortunately, VA is not 
requesting and Congress is not providing sufficient resources to meet 
the current demand. In turn, as a result of insufficient resources, VA 
is moving toward purchasing care in the community instead of 
maintaining in-house LTC for these veterans, even though it is very 
difficult to find placement for veterans who are ventilator dependent.
    VA designated six specialized LTC facilities because of the unique, 
comprehensive medical needs of veterans with SCI/D, which are usually 
not appropriately met in community nursing homes and non-SCI/Designated 
facilities. These veterans require more nursing care than the average 
patient. Additionally, in SCI/D LTC units, the distribution of severely 
ill veterans is even more pronounced as a sizable portion require 
chronic pressure ulcer, ventilator, and bowel and bladder care due to 
secondary complications of SCI/D issues.
    The Long Beach VA Medical Center is the department's newest LTC 
facility and it is also the only SCI/D LTC Center located west of the 
Mississippi to serve 11 acute SCI/D Centers. It has a capacity of 12 
inpatient beds and because it is always full, it has a long wait list 
to receive admissions. A recent GAO report \3\ stated that veterans 
needing LTC have moved from the Northeast to the South, and that VA now 
has too many LTC beds in the Northeast and too few in the South. While 
the GAO report focused on veterans in general, the same finding likely 
holds true for those with SCI/D. Unfortunately, the woefully inadequate 
number of beds available barely addresses the high demand. In these 
instances, the only option is to place the veteran into the local 
community where they receive suboptimal care by untrained SCI/D-health 
professionals.
---------------------------------------------------------------------------
    \3\ GAO-19-478, Estimating Resources Needed to Provide Community 
Care: https://www.gao.gov/products/GAO-19-478
---------------------------------------------------------------------------
    Four of the six SCI/D LTC Centers have sufficient staffing. Of the 
other two facilities, one has some staffing needs and the other is in 
dire need of personnel. Thus, some facilities are operating at or near 
capacity, while others only achieve a fraction of theirs. The VA claims 
they face challenges hiring staff needed for LTC facilities and this 
problem will grow as the Nation's health care provider shortage 
worsens.
    Although VA has identified the need to provide additional SCI/D LTC 
facilities and has included these additional centers in ongoing 
facility renovations, such plans have been languishing for years.
    Currently VA has 18 SCI/D-related construction projects in various 
states of priority and design. Some are partially funded but need more 
money assigned against the project in order for it to proceed. The 
Administration is requesting funding for two major projects in its 
Fiscal Year 2021 budget proposal to Congress; \4\ a new SCI/D Center 
with 30 (replacement) acute beds and 20 (new) LTC beds in San Diego, 
California, as well as a new 30 bed LTC Center with space for an 
additional future 30 beds in Dallas, Texas. PVA encourages Congress to 
fulfill their funding request for this pair of desperately needed 
facilities, but also urges you to increase funding for the Dallas LTC 
Center to complete all 60 beds at the same time. Last, in accordance 
with the recommendations of ``The Independent Budget Policy Agenda for 
the 116th Congress,'' PVA recommends that VA SCI/D leadership design an 
SCI/D LTC strategic plan that addresses the need for increased LTC beds 
in VA SCI/D Centers.
---------------------------------------------------------------------------
    \4\ FY 2021 Budget Submission for the Department of Veterans 
Affairs, Construction and Long-Range Plan, https:// www.va.gov/ budget/ 
docs/ summary/ fy2021 VAbudget VolumeIV construction And LongRange 
Plan.pdf.
---------------------------------------------------------------------------
    VA also offers a number of specialized long-term services and 
supports to include Spinal Cord Injury-Home Care, Medical Foster Homes, 
Veterans Directed Care, and Respite Care. All of these programs are 
covered by VA, with the exception of the Medical Foster Home program. 
In accordance with VA Policy, VHA Directive 1141.02(1), Medical Foster 
Home Procedures, VA may refer veterans to a VA approved Medical Foster 
Home, but VA does not have the authority to cover the cost of services 
provided.
    Medical Foster Homes serve as an alternative to nursing homes for 
selected veterans who are no longer able to live independently due to 
functional, cognitive, or psychosocial impairment, at about half of the 
cost of nursing home care and are intended to serve veterans who are 
unable to live independently due to functional, cognitive, or 
psychosocial impairment resulting from conditions such as complex 
chronic disease, psychological disorder, SCI/D or Polytrauma. Medical 
Foster Homes are private residences where the caregiver and relief 
caregivers provide care and supervision 24 hours a day, 7 days a week. 
Based on a veteran's income and the level of care they need, the 
monthly charge for a Medical Foster Home is about $1,500 to $3,000.
    We urge the Committee to approve H.R. 1527, the ``Long-Term Care 
Veterans Choice Act,'' which would authorize VA to enter into contracts 
with Medical Foster Homes that meet VA's standards and to cover the 
cost of care. Medical Foster Homes allow veterans to remain in a more 
home-like environment and receive adequate care and services at a 
fraction of the cost of living in a nursing home or LTC facility. It's 
a win-win for the veteran and the taxpayer.
    Chairwoman Brownley, Ranking Member Dunn, PVA appreciates this 
opportunity to express our views on VA's current readiness to address 
the needs of aging veterans with catastrophic disabilities. We look 
forward to working with the Subcommittee on increasing VA's capacity.

  Information Required by Rule XI 2(g) of the House of Representatives

    Pursuant to Rule XI 2(g) of the House of Representatives, the 
following information is provided regarding Federal grants and 
contracts.

                            Fiscal Year 2020

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events--Grant to support rehabilitation sports 
activities--$253,337.

                            Fiscal Year 2019

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events--Grant to support rehabilitation sports 
activities--$193,247.

                            Fiscal Year 2018

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events--Grant to support rehabilitation sports 
activities--$181,000.

                     Disclosure of Foreign Payments

    Paralyzed Veterans of America is largely supported by donations 
from the general public. However, in some very rare cases we receive 
direct donations from foreign nationals. In addition, we receive 
funding from corporations and foundations which in some cases are U.S. 
subsidiaries of non-U.S. companies.
                                 ______
                                 

          Prepared Statement of The Elizabeth Dole Foundation

    Chairwoman Brownley, Ranking Member Dunn, and Members of the 
Subcommittee, the Elizabeth Dole Foundation is pleased to provide our 
comments in advance of the Subcommittee's hearing, ``The Silver 
Tsunami: is VA ready?'' We applaud the Subcommittee for focusing its 
attention on VA's readiness to meet the needs of the largest cohort of 
Veterans, baby boomers, as they enter old age.
    We thank the Subcommittee for its continued support of the 
estimated 5.5 million military and Veteran caregivers nationwide, many 
of whom are caring for an aging Veteran population. According to the 
2012 U.S. Census brief, there are over 12.4 million Veterans who are 65 
years old or older, mostly consisting of those who served in World War 
II, Korea, Vietnam, and even the Persian Gulf. Every conflict or 
military engagement comes with its own unique set of health challenges 
for active duty service members, and as Veterans age, the long term 
effects of their injuries or illnesses are only compounded by the 
natural effects of aging.
    A recent GAO report found that more than half a million Veterans 
received long-term care from the VA in 2018, either in a nursing home 
or through elder care and home support programs. Demand for long-term 
care increased 14 percent from 2014 to 2018, alone. Over the next 
decade, pre-9/11 Veterans will increasingly require long-term care. The 
VA projects that their spending on long-term care will double by 2037. 
However, increasingly, aging seniors and baby boomers are seeking to 
age-in-place and remain in their homes for as long as possible before 
seeking institutional care. In fact, a 2016 AARP study found that more 
than 90 percent of adults over the age of 65 report they would prefer 
to stay in their current residence as they age. Home-based geriatrics 
care is an attractive option for patients and the VA alike, potentially 
representing millions of dollars in savings each year. However, a home-
based solution is often dependent on family caregivers, who support 
everything from medication assistance and wound care to food 
preparation and mobility assistance.
    In 2014, the Elizabeth Dole Foundation commissioned a study by the 
RAND Corporation to better understand the needs of our Nation's Hidden 
Heroes, the spouses, parents, siblings, and other loved ones providing 
care for our Nation's wounded warriors. Beyond quantifying the number 
of military caregivers as 5.5 million individuals nationwide, the 
report provided us with insights regarding the demographics of this 
population and specific challenges these military families were facing. 
Key findings from this study include:

      Seventeen percent of civilian caregivers reported 
spending more than 40 hours per week providing care (8 percent reported 
spending more than 80 hours per week)

      Military caregivers consistently experience worse health 
outcomes, greater strains in family relationships, and more workplace 
problems than non-caregivers, and post-9/11 military caregivers fare 
worst in these areas.

    The Elizabeth Dole Foundation commends VA's Geriatrics and Extended 
Care Program and their new Choose Home Initiative which seeks to 
establish partnerships to support aging Veterans with home aids and 
support within their homes. However, evidence is mounting that more 
support is needed to help the millions of military and veteran 
caregivers who will increasingly be called upon for support as Veterans 
age over the next decade.

    A cornerstone of this additional support is expansion of the VA 
Program of Comprehensive Assistance for Family Caregivers (PCAFC) that 
was authorized in the VA MISSION Act of 2018. To date, PCAFC has been 
restricted to post-9/11 Veteran caregivers, effectively shutting out 
the estimated 4.4 million veterans caregivers who support pre-9/11 
Veterans. With the MISSION Act, VA was authorized to use a phased 
approach to expand PCAFC to eligible Veterans from all eras. However, 
despite passage of the MISSION Act in 2018, expansion of the program 
has been met with frequent delays by the VA, with the Department 
struggling to get new technology and processes in place to be able to 
process new applicants to the program. We ask that the Subcommittee 
continue to pressure VA officials for updates regarding the PCAFC 
expansion effort, so that we are supporting the millions of Hidden 
Heroes nationwide who are providing countless hours of support to our 
wounded warriors each day.

    Beyond the PCAFC, there are a number of other VA programs that 
provide support for aging Veterans and their caregivers. These include:

      The VA Fiduciary Program

      Veteran Directed Home & Community-Based Care

      Aid & Attendance Pension Benefit

      Housebound Pension Benefit

      Respite Care

    We have provided a short summary on each of these programs below 
for your reference.

VA Fiduciary Program

    The VA Fiduciary Program was established to protect Veterans who, 
due to an injury, disease or aging issues, are unable to manage their 
financial affairs. In these instances, VA will appoint a fiduciary to 
oversee financial management of VA benefit payments. Often time, family 
caregivers or other family members serve as fiduciaries for 
beneficiaries, however if family or friends are not able to serve, the 
VA can also work with qualified individuals or organizations to serve 
this role.
    The Elizabeth Dole Foundation notes that the Fiduciary Program is 
an important resource for caregivers of aging Veterans. Often, these 
Veterans are receiving a number of different benefits that must be 
managed--VA benefits, social security payments, retirement benefits, 
etc. While becoming a fiduciary comes with a number of important 
responsibilities, the program allows for the caregiver to be an active 
member of the Veteran's team and ensure that the financial well-being 
of the veteran is in order.

Veteran Directed Home & Community Based Care

    In partnership with the VA, the Department of Health and Human 
Services established the Veteran Directed Home & Community Based Care 
program (formerly known as VD-HCBS). Veteran Directed Home care is a 
consumer directed service that allows for Veterans to choose what kind 
of care they need and deserve. Since the program's launch, the 
Elizabeth Dole Foundation has heard from countless Veterans and 
caregivers participating in the program that the flexibility of the 
care model has increased their family's quality of life substantially. 
However, a challenge with the program is that it is only offered in 37 
states and individual VA Medical Centers are responsible for 
establishing a Veteran Directed Home Program at their facility. We ask 
that the Subcommittee pressure the VA to push for full expansion of the 
program to all 50 states.

VA Aid & Attendance Benefit

    Under this Veteran Benefits Administration benefit, eligible 
Veterans may receive a VA Aid and Attendance monthly benefit added to 
their monthly VA pension to help with activities of daily living. A 
Veteran may use these funds to pay an informal caregiver to provide the 
care and support they may need. This informal caregiver can be an adult 
child, grandchild, or other family member; however paying a spouse to 
provide that in-home care is not viable through this option. Like many 
of these options, the eligibility for this benefit is a challenge. In 
order to be eligible, the veteran must first qualify for the basic VA 
pension.

Housebound Pension Benefit

    Similar to the Aid & Attendance pension, the Housebound Pension 
Benefit allows Veterans who is permanently disabled to pay a non-
spousal relative to be their caregiver. In order to qualify for this 
pension benefit, the veteran must qualify for a basic VA pension and 
prove that they are unable to leave the home due to disability.

Respite

    No matter the benefits that a veteran and their caregiver may 
qualify for, respite may be the most important benefit that is 
available to a caregiver. Respite allows for a caregiver to take a 
short-term break to recharge. While the VA does offer respite, not all 
caregivers qualify. Respite care is also offered through a myriad of 
local and State resources through grants from the Department of Health 
and Human Services and the LIFESPAN Respite Care Act. The challenge of 
having respite care offered through many different venues and different 
eligibility requirements, means that caregivers may feel too exhausted 
to explore their options because it is too much work to navigate the 
systems on their own. The Elizabeth Dole Foundation has long advocated 
for accessibility to quality respite care for veteran caregivers. If a 
caregiver is not able to provide the care their veteran needs due to 
caregiver burnout, the family may have to explore the options of 
institutional care.
    Often Veteran caregivers give up their lives to serve their 
Veterans and ensure that they receive the quality of life they deserve 
after making the ultimate sacrifice in service to our Nation. As the 
American health care system prepares for the largest population subset 
to enter retirement, the Veterans Health Administration and the 
Veterans Benefits Administration must also prepare to support the 
Veteran caregivers that will be taking care of these aging veterans. 
With statistics showing that many pre-9/11 Veteran caregivers are often 
the children of Veterans, this may mean they are part of the ``sandwich 
generation,'' providing simultaneous care for their parents and their 
children. This will bring about its own set of challenges that the DoD, 
VA, and HHS must be prepared to address.
    A challenge that will need to be addressed is the eligibility and 
criteria for these benefits and programs. The Elizabeth Dole Foundation 
urges Congress, the VA, DoD, and HHS to listen to the caregivers who 
are performing these tasks for this population of Veterans to better 
understand their needs so the systems can be better prepared for the 
``silver tsunami.''
    Thank you again for this opportunity to provide a written testimony 
to the House Veteran's Affairs Subcommittee on Health for the ``Silver 
Tsunami: is the VA ready?'' hearing. We look forward to our continued 
work together to support our Nation's military and veteran caregivers.

                                 [all]