    [Senate Hearing 117-583]
    [From the U.S. Government Publishing Office]

                                                          S. Hrg. 117-583

                            HONORING OUR COMMITMENT:
                    IMPROVING VA'S PROGRAM OF COMPREHENSIVE
                        ASSISTANCE FOR FAMILY CAREGIVERS

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 MARCH 23, 2022

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                                  __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    50-935 PDF                  WASHINGTON : 2023

    -----------------------------------------------------------------------------------

                         COMMITTEE ON VETERANS' AFFAIRS

                         Jon Tester, Montana, Chairman
    Patty Murray, Washington             Jerry Moran, Kansas, Ranking
    Bernard Sanders, Vermont                 Member
    Sherrod Brown, Ohio                  John Boozman, Arkansas
    Richard Blumenthal, Connecticut      Bill Cassidy, Louisiana
    Mazie K. Hirono, Hawaii              Mike Rounds, South Dakota
    Joe Manchin III, West Virginia       Thom Tillis, North Carolina
    Kyrsten Sinema, Arizona              Dan Sullivan, Alaska
    Margaret Wood Hassan, New Hampshire  Marsha Blackburn, Tennessee
                                         Kevin Cramer, North Dakota
                                         Tommy Tuberville, Alabama
                          Tony McClain, Staff Director
                     Jon Towers, Republican Staff Director

                                C O N T E N T S

                                  ----------

                                 MARCH 23, 2022

                                    SENATORS

                                                                       Page
    Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
    Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......     2
    Murray, Hon. Patty, U.S. Senator from Washington.................    21
    Boozman, Hon. John, U.S. Senator from Arkansas...................    23
    Brown, Hon. Sherrod, U.S. Senator from Ohio......................    24
    Sinema, Hon. Kyrsten, U.S. Senator from Arizona..................    28

                                   WITNESSES
                                    Panel I

    Beth Taylor, DHA, Assistant Under Secretary for Health, Patient
      Care Services and Chief Nursing Office, Veterans Health
      Administration, Department of Veterans Affairs; accompanied by
      Colleen Richardson, PhD, Executive Director, Caregiver Support
      Program........................................................     4

                                    Panel II

    Steve Schwab, Chief Executive Officer, Elizabeth Dole Foundation.    10
    Caira Benson, Caregiver of Post-9/11 Army Veteran................    11
    Jim Marszalek, National Service Director, Disabled American
      Veterans.......................................................    12
    Andrea Sawyer, Advocacy Navigator, Quality of Life Foundation....    14
    Sarah Verardo, Chief Executive Officer, The Independence Fund....    15

                                    APPENDIX
                              Prepared Statements

    Beth Taylor, M.D., Assistant Under Secretary for Health, Patient
      Care Services and Chief Nursing Office, Veterans Health
      Administration, Department of Veterans Affairs.................    37
    Steve Schwab, Chief Executive Officer, Elizabeth Dole Foundation.    41
    Caira Benson, Caregiver of Post-9/11 Army Veteran................    46
    Jim Marszalek, National Service Director, Disabled American
      Veterans.......................................................    51
    Andrea Sawyer, Advocacy Navigator, Quality of Life Foundation....    63
    Sarah Verardo, Chief Executive Officer, The Independence Fund....    88

                            Questions for the Record

    Department of Veterans Affairs response to questions submitted
      by:
      Hon. Jon Tester................................................   123
      Hon. Margaret Wood Hassan......................................   128
      Hon. Patty Murray..............................................   133
      Hon. Tommy Tuberville..........................................   135

                           Statements for the Record

    Statement of Michelle Flatoff, Caregiver for Michael Flatoff.....   139
      Attachment--Letter from Jason Thilges, Director, Madison Vet
        Center; Therapist for Michael Flatoff........................   141
    Statement of Shawn Moore, LMSW, Veteran Caregiver and Advocate,
      Elizabeth Dole Foundation......................................   142
    Alzheimer's Association and Alzheimer's Impact Movement (AIM)....   145
    Paralyzed Veterans of America (PVA)..............................   147
    Veteran Warriors.................................................   151
    Vietnam Veterans of America......................................   161

                       HONORING OUR COMMITMENT: IMPROVING
                         VA'S PROGRAM OF COMPREHENSIVE
                        ASSISTANCE FOR FAMILY CAREGIVERS

                                  ----------

                           WEDNESDAY, MARCH 23, 2022

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 3:01 p.m., via
    Webex and in Room SR-418, Russell Senate Office Building, Hon.
    Jon Tester, Chairman of the Committee, presiding.
        Present: Senators Tester, Murray, Brown, Sinema, Hassan,
    Moran, and Boozman.

                  OPENING STATEMENT OF CHAIRMAN TESTER

        Chairman Tester. I am going to call this hearing to order.
        Senator Moran will be here shortly and hopefully before I
    get done with my opening statement, but I want to wish
    everybody a good afternoon, and I want to thank you all for
    being here today to discuss VA's Program of Comprehensive
    Assistance for Family Caregivers.
        Congress required VA to establish support for caregivers
    after seeing the need for at-home assistance for Iraq and
    Afghanistan veterans coming home with serious injuries. The
    success on life-changing assistance it provided led Congress to
    remove the disparity between pre- and post-9/11 caregivers by
    expanding the program to veterans of all eras in the VA MISSION
    Act.
        However, under the Trump administration, VA implemented new
    regulations narrowing eligibility much more than Congress ever
    intended to do. VA narrowed eligibility to veterans with a 70
    percent or higher service-connected disability rating and those
    with an inability to perform an activity of daily living
    without assistance each and every time the activity occurs.
    That resulted in a mere 14 percent acceptance rate into the
    program and thousands of legacy post-9/11 participants no
    longer qualified for the benefits that they need, that they
    have earned, and that they deserve. The veterans in my State
    and every State represented on this Committee received letters
    kicking them out of the program.
        I expressed this concern to the Trump administration, and
    more recently to Secretary McDonough, that too many veterans
    and caregivers would be left without the critical assistance
    they needed because of VA's overly restrictive regulations, and
    I pressed them to reconsider. Many of these folks up here
    joined me in that effort.
        Today, I am pleased that the Biden administration and
    Secretary McDonough have listened to the concerns raised by the
    people on this Committee and to the veterans and caregivers
    across our great country. Just yesterday, VA announced that it
    will be taking steps to change the restrictive Trump
    regulations that have been harmful to so many veterans and
    their caregivers. VA will immediately halt the discharge of
    legacy participants from the program, meaning that no
    caregivers who are already in the program will be removed in
    October. VA will also reevaluate the program's eligibility
    requirements to ensure they meet the intent of Congress.
        I appreciate Secretary McDonough and Deputy Secretary Remy
    making this information public before the hearing so members of
    this Committee could have the latest of information.
        We understand the VA witnesses here today will not be able
    to speak with great detail about some of these proposals, but I
    appreciate them being here to discuss the issue with this
    Committee. And we will hear from our second panel about their
    concerns with the program and how it is critically to veterans
    and caregivers nationwide.
        I want to say a few things about our friend, Garry
    Augustine. I want to take a moment to recognize his life, a
    decorated veteran, a fierce advocate, and former Executive
    Director of the DAV, who passed away last week. As a member of
    this Committee for the last 15 years, I have had the honor of
    working closely with Garry on a host of issues critical to
    veterans and their families. One issue particularly close to
    his heart was the caregivers program that we are going to be
    talking about today, and he helped lead the fight to expand the
    program to veterans of all generations, including his fellow
    Vietnam veterans.
        As we work to improve this program, we also should do this
    with Garry in mind and do our best to honor his lifetime of
    service as a soldier, as a veteran, and as a leader in the
    veterans advocacy community. His work for veterans and their
    families will certainly be felt for years to come, and he is
    somebody that I can tell you on a personal note I have missed
    since his retirement and continue to miss him.
        We will give Senator Moran a minute or two, and then if he
    does not show we will go to the panel one.
        [Pause.]
        Chairman Tester. I will now turn it over to Senator Moran
    for his opening statement.

                   OPENING STATEMENT OF SENATOR MORAN

        Senator Moran. Chairman, thank you for your delay. When my
    former colleague, Senator Roberts, announced his retirement
    from the Senate, people started congratulating me on being a
    senior Senator, and I did not know what it meant.
        Chairman Tester. It means you are a lot older.
        Senator Moran. That is not what I thought it meant. It
    meant I talk a lot more.
        Chairman Tester. Okay.
        Senator Moran. And I got caught.
        Mr. Chairman, thank you, and I thank our witnesses for
    joining us today. This is a really important topic, and I am
    glad we are having this hearing.
        The VA is expected to see a significant increase of
    veterans with long-term care needs within the near future. To
    prepare for this increasing trend, the Department has routinely
    told Congress and veterans that it is shifting the focus of its
    long-term care from institutional care settings to home- and
    community-based settings. And I applaud the Department's
    efforts to empower veterans by supporting their desires to stay
    at home and to remain in their communities as long as possible,
    surrounded by family and loved ones.
        To that end, family caregivers play an integral role in
    making certain our veterans can remain at home and are central
    to the success of VA's efforts to shift care to home- and
    community-based settings. It is important to make certain that
    these frontline heroes are adequately supported in their work
    caring for our Nation's veterans.
        This week, I was pleased to introduce, with Senator Hassan
    and Senator Tester of this Committee, the Elizabeth Dole Home
    and Community Based Services for Veterans and Caregivers Act to
    expand home-and community-based services for aging and
    homebound veterans. The Elizabeth Dole Act will empower
    veterans and caregivers by increasing the spending cap for
    alternative care programs and expanding access to alternative
    care programs to veterans living in U.S. Territories and Native
    veterans enrolled in IHS or Tribal Health programs.
        As we work toward enabling veterans to delay the need for
    institutional care through legislation like the Elizabeth Dole
    Act, it is important that we do not lose sight of making
    certain related laws we previously enacted are implemented
    properly. In recognition of the vital work that caregivers
    perform, Congress expanded the Program of Comprehensive
    Assistance for Family Caregivers in the VA MISSION Act to make
    certain that family caregivers of veterans from any era receive
    the support and resources necessary to keep the veteran at
    home.
        The VA, however, is failing at implementing this expansion.
    From the two-year initial delay in implementing phase one to
    the inexcusably high denial rates, we continue to hear from
    advocates and caregivers alike about the real fear of being
    unfairly denied or discharged from the program because of how
    the VA runs it.
        Today's hearing is both timely and necessary as we work to
    make certain the laws we pass are implemented in ways that work
    as Congress intended. We have a duty to see to it that the VA
    is faithfully executing these laws and investing resources as
    intended into family caregivers.
        Thank you again, and I look forward to today's testimony.
        Chairman Tester. Thank you, Senator Moran.
        Now we will start with the panelists on panel one. I would
    like to welcome Dr. Beth Taylor, who is the VA's Assistant
    Under Secretary for Health for Patient Care Services and the
    Chief Nursing Office, to our first panel.
        You have got a big job, Dr. Taylor.
        She is accompanied and supported by Dr. Colleen Richardson,
    Executive Director of the Caregiver Support Program.
        You, too, have a big job.
        I want to thank you both for being here, and Dr. Taylor,
    you may begin. We are going to give you five minutes.
    Hopefully, you can keep it to that, but please know that your
    entire written statement will be a part of the record.

                                PANEL I

                                  ----------

                        STATEMENT OF BETH TAYLOR

                   ACCOMPANIED BY COLLEEN RICHARDSON

        Dr. Taylor. Thank you. Good afternoon, Chairman Tester,
    Ranking Member Moran, and members of the Committee. I
    appreciate your interest in the VA Caregiver Support Program
    and the opportunity to answer your questions today. I am
    accompanied by Dr. Colleen Richardson, Executive Director of
    our Caregiver Support Program.
        The contributions of caregiving has an important impact in
    the lives of family members and an increasingly valuable role
    in our health care system today. Through our combined 37 years
    of VA clinical experience, Dr. Richardson and I have witnessed
    and recognized the impact of caregiving on the health and well-
    being of our veterans. The role of caregiving is not only time
    and energy intensive; it has an impact on one's physical,
    psychological, and financial health.
        The VA Caregiver Support Program's mission is to provide
    resources, training, tools, and support services to the
    caregivers of our Nation's veterans. The VA Caregiver Support
    Program is breaking new ground and setting the standard on
    caregiving and the health care industry. By being a
    trailblazer, the program is in a dynamic state of evolution,
    and to evolve we must require a consistent feedback and
    partnership with all of you, our partners who are with us
    today, our veterans, our caregivers, and our many stakeholders
    that make our work possible. We are proud to be leading the
    country in providing a program which offers unmatched benefits,
    services, and support to caregivers of veterans to enable them
    to achieve their optimal level of independence and well-being.
        In 2010, the VA established the Caregiver Support Program
    to administer the Program of Comprehensive Assistance for
    Family Caregivers, PCAFC, and the Program of General Caregiver
    Support Services, PGCSS, two programs which support caregivers
    of veterans in need of personal care services.
        Initially, PCAFC was targeted toward caregivers of eligible
    veterans who incurred or aggravated a serious injury in the
    line of duty on or after September 11th, 2001.
        Through the MISSION Act of 2018, VA was authorized to
    expand eligibility to veterans who incurred or aggravated a
    serious injury or illness in the line of duty for all eras in a
    phased approach: phase one, which occurred October 1st of 2020,
    and phase two, which will go live this October 1st. The
    adoption of the new MISSION Act regulations was to address
    issues in the lack of standardization, consistency, and
    equitability identified in PCAFC while expanding the program
    and making it more inclusive for veterans and caregivers of all
    service eras.
        We have doubled the size of the program in the 16 months
    since expansion, quite an accomplishment, and credit is due to
    our CSP staff throughout the enterprise. Their work is
    particularly notable during the COVID era, where many
    clinicians also stepped forward to help with first and fourth
    mission assignments to ensure we could meet the care demands of
    our system and of our Nation and where the challenges of the
    new normal work environment required them to accomplish the
    expansion in new and untested ways. We recognize the hard work
    of our staff, yet we acknowledge there is so much more to be
    done.
        To be clear, we were not able to fully anticipate the
    challenges COVID would present nor the impact the regulation
    would have on different eras of veterans. Through the
    evaluation of feedback from internal quality assessments,
    veterans, caregivers, and VSOs, along with other partners, we
    recognized the need to take a step back and assess. We have
    heard and understand the issues that have been raised about the
    rate of acceptance in PCAFC as well as the concerns regarding
    our legacy participants and the eligibility criteria. The
    Caregiver Support Program has taken efforts to closely examine
    program data, and as we gain increasing granularity with our
    data systems, we can better identify and define trends that
    help us and others understand the true performance of the
    program.
        Now more than ever, veterans and caregivers have options
    available to appeal a PCAFC decision with which they disagree.
    A ruling by the U.S. Court of Appeals for Veterans Claims made
    available PCAFC decisions to be appealed to the Board of
    Veterans' Appeals. The Caregiver Support Program is actively
    implementing the necessary infrastructure and processes to
    offer the full spectrum of options available under the Appeals
    Modernization Act, which includes supplemental claims, higher
    level reviews, and appeals to the board.
        As a VA nurse, a daughter, granddaughter and great
    granddaughter of veterans, and in partnership with Dr.
    Richardson, a psychologist, a combat veteran, and a former
    member of the Navy Medical Service Corps, you have our
    commitment to guide the Caregiver Support Program to be the
    preeminent program in the industry on caregiving. We welcome
    and invite you, this Committee, our partners, and our
    stakeholders to help us in achieving this mission.
        I thank you for the opportunity to discuss the
    accomplishments and opportunities of our program, and we stand
    ready to respond to your questions.

        [The prepared statement of Dr. Taylor appears on page 37 of
    the Appendix.]

        Chairman Tester. To the second. Good job. I will tell you
    that I do not know who is going to show up to this hearing.
    This is a very, very busy time right now. Do not make an
    assessment because Senator Moran and I are the only ones at
    this Committee that this is not an important issue. This is a
    very important issue. And like I say, they may all show up;
    none may show up. Nonetheless, this is really important.
        And by the way, I will just ask a question. Whoever wants
    to answer them can answer them. But the truth is I do look
    forward to working with you to develop new regulations to
    administer this program in a much more fair and much more
    efficient way.
        I understand VA will be changing the current regulations
    for the caregivers program through its rulemaking process. So
    the question is: What is the process and timeline to get the
    proposed regulations so that we can get these restrictive
    criteria off the books?
        Dr. Taylor. Thank you, Chairman, for that question. I
    think, most importantly, the process is going to involve our
    stakeholders; it is going to involve partnership with members
    of this Committee; it is going to involve our veterans and our
    caregivers. We need to look at the process holistically, and we
    need to anticipate what the impact of any changes in
    eligibility might be, especially as we have learned in the
    phase one rollout that different eras of veterans have
    different needs. So we must not only think about the veterans
    that we are serving now, but we must anticipate our phase two
    expansion and anticipate what needs that that cohort of
    veterans may have that we have not seen yet to date.
        So in terms of the timeline, sir, we do not have that
    established, but I can tell you that tomorrow at 8:00 Dr.
    Richardson and myself have a meeting with the Acting Under
    Secretary and we will be initiating our efforts relative to the
    announcements that the Deputy Secretary had in the press
    conference yesterday.
        Chairman Tester. Okay. Very, very good. I think that it is
    going to be critically important that as you go through that
    process and announce that timeline that you set up that, as you
    said, in the process, the VSOs need to know where you are so
    that they know what to do within that timeline.
        The number of post-9/11 veterans who were poised to be
    dropped from this program in October, not to mention all the
    veterans denied entry into the program in the first place, is
    concerning to all of us. For those notified that they would be
    removed from the program in October, is there anything that
    they need to do now?
        Dr. Taylor. No, sir. There will be additional
    communications coming out to the veterans and caregivers,
    notifying them of the announcement yesterday and the impact
    that that will have. I am sure that our veterans and caregivers
    have many questions related to the announcement yesterday, and
    those details will be coming out imminently.
        Chairman Tester. For those that were denied access to the
    program under the current regulations, will they need to apply
    again?
        Dr. Taylor. Dr. Richardson, can you take that one, please?
        Dr. Richardson. Sure. Good afternoon, Mr. Tester. So to
    answer that question, sir, I think there is still more to come
    on that. We have not figured out exactly the path that we want
    to go given yesterday's announcement, but rest assured that
    between Dr. Taylor and myself we will make sure that it is
    equitable and fair to all veterans as we move forward in this
    process. So, more to come, sir.
        Chairman Tester. I appreciate that. Look, I think that
    making it as user friendly as possible for the veterans is
    really important, especially as to what has happened now. So
    communication is going to be very, very important directly with
    the veterans, with the VSOs, so they can help you with
    communication is really important.
        Now look, I have heard from caregivers around the country
    that the consistent reassessments of veterans and their
    caregivers take a mental and physical toll. And by the way, I
    would agree with that as you take a look at the challenges
    these folks have. Will these assessments continue even as the
    VA works to improve this program?
        Dr. Taylor. Yes, sir, our current plan is for those
    assessments to continue and really for a couple reasons. One,
    we want to have a complete data set on the needs of our
    veterans in the different cohorts, and so we feel it is
    important to continue those assessments. However, we also feel
    it is important to be clear about the actions that we will not
    be taking as a result of those assessments as we have in the
    past.
        And I want to--I think we want to ensure that we are very
    clear about our communications with those caregivers and
    families. We know historically that we have not done the best
    job in communicating. I think Dr. Richardson would agree. And
    we want to be very clear about our communications and what the
    purpose of the reassessments are and how we might use that
    information to better the program going forward.
        Chairman Tester. Yes. Look, in the end you guys have to
    make this program. And I do not work in the Agency, but it
    seems to me if the VA is reevaluating criteria right now I
    would just say make sure the evaluations you are doing are
    going to actually do you some good in the end with the criteria
    changing.
        And then the other question is: How does the program
    support mental health needs of caregivers, or does it?
        Dr. Taylor. Yes, an excellent, excellent question, sir, and
    one that we are particularly concerned about as recognizing
    that there is, as you just said, stressors associated with the
    assessments, the potential denials of the program, and so we
    are very cognizant of that. We want to make sure that our
    caregivers and our veterans have the support services that they
    need, and we partner very closely with the Office of Mental
    Health Services to ensure that we have wraparound support for
    our veterans who may need mental health support.
        Chairman Tester. Thank you.
        Senator Moran.
        Senator Moran. Chairman, thank you. Again, thank you both
    for being here. It is a little bit more of a difficult hearing,
    maybe for you and us, with the announcement from yesterday.
        Dr. Taylor. Yes, sir.
        Senator Moran. I mean, I think the correct answer will
    often be we do not yet know. But what do you expect, or what do
    you think, the changes in regulations will accomplish? And
    maybe your answer is that that is going to be determined by all
    those consultations that we think you should make. But what is
    the problem that is being solved, that is being attempted to be
    solved?
        Dr. Taylor. Yes, excellent question, Senator. Thank you. I
    think what we do know by the experience with the phase one
    expansion is, as I said a few minutes ago, that different eras
    of veterans have different needs. We have also found that some
    veterans, while they need support services, may need them
    intermittently and not as narrowly as was originally described
    in the regulation.
        So for example, there may be a veteran that is receiving
    radiology or oncologic chemotherapy procedures and may have
    periods of time where they need a caregiver over a long period
    while they are in that, whenever they are receiving that
    treatment. Or, there may be a veteran who has had a very
    significant surgery and for a period of time they may need
    caregiver support but it is not indefinite. It is not for their
    lifetime. So I think those are two examples that give us an
    opportunity to reflect on what we have written in our
    regulations and what clarifications, or what minor shifts, we
    might be able to make to capture men and women like I just
    described and others who may have intermittent or periodic
    needs.
        Senator Moran. I was not sure when you answered Senator
    Tester's question about timeframe. So is the Department
    proposing new regulations that will be written and then
    submitting them for comments or commentary by the groups that
    you described?
        Dr. Taylor. Yes, sir.
        Senator Moran. As compared to getting the input first and
    then drafting the regulations. The regulations will be
    something we can see soon?
        Dr. Taylor. We are certainly hoping that. I think we are
    planning a summit in the month of April, so coming up obviously
    very soon. And we really want to get input. You know, our
    thought is we will help--we will need that help in co-creating
    the way forward and ensuring that we have it right because we
    recognize that as the Chairman suggested, that the original
    intent--the first regulation we missed the mark on that, and so
    we want to get it right. But we also recognize that we can only
    do that through partnerships with our VSOs, our stakeholders.
        Senator Moran. So regulations drafted and then submitted
    for commentary.
        Dr. Taylor. Yes, sir.
        Senator Moran. At what point in time did you realize the
    mark had been missed?
        Dr. Taylor. I think as we gathered data, especially with
    the expansion of caregiver support. You know, with the phase
    one expansion. I think as we got additional information about
    what the era, that particular era, of veterans needed and also
    thinking that the experience with legacy and applying the new
    criteria against men and women who had been in this program for
    many years, that is how we came to the conclusion internally
    that we have missed the mark.
        Senator Moran. Dr. Richardson, the centralized teams, team
    reviews and the final eligibility determination for all legacy
    participant reassessments, I want to spend a minute on that.
    These teams make the determination based on an assessment done
    by the local VA medical center and through telehealth visits.
    Have I got that right?
        Dr. Richardson. Yes, sir, that is accurate.
        Senator Moran. That is my premise. And my question is: Does
    the VA think that this centralized process ensures consistent,
    appropriate application of the eligibility criteria, including
    mental health determinations?
        Dr. Richardson. Sir, that is an excellent question. I think
    we had the opportunity to remove decision-making from the
    medical facilities. There is over 140 medical facilities. So
    that is 140, at least 140, different decisions.
        So we have these specialized, Centralized Eligibility and
    Appeals Teams which are specifically trained to look at the
    assessments that the medical facility staff have completed and
    objectively, as a team, look at the holistic picture of the
    veteran and render a decision based on those assessments. We
    feel like having it removed from the medical facilities offers
    a more objective perspective on the chart.
        As far as consistency goes, we are seeing consistency
    amongst decision-making within the CEA Teams. However, I think,
    as Dr. Taylor has alluded to, we are seeing some gaps with the
    ability to expand regulations further to capture more veterans
    as we move forward. But as far as consistency in decision-
    making, we are seeing that across the teams.
        Senator Moran. So the result to date would be different,
    broadly different, from one hospital to another?
        Dr. Richardson. They should not be, sir.
        Senator Moran. But they are?
        Dr. Richardson. So we have done consistency and
    standardization exercises, and we are only seeing that there
    are about three facilities or three visits----
        Senator Moran. Three outliers.
        Dr. Richardson. Three outliers, yes, sir.
        Senator Moran. Any of them in Kansas?
        Dr. Richardson. No, sir.
        Senator Moran. Of course, an outlier could be, in my mind,
    a good thing or a bad thing. I do not know which way that cuts.
        Dr. Richardson. That is right.
        Senator Moran. How is information from the VA provider or
    other providers taken into account during the reassessment
    process? And most importantly, well equally important, is in
    mental health providers in particular, was--their commentary,
    their notes, their description of their patient, how was it
    considered?
        Dr. Richardson. Great question, sir. So it is taken into
    consideration. I do think that is another opportunity for
    training and education and another opportunity to partner with
    our primary care physicians. We have heard concerns about that
    as well, that those things are not being taken into
    consideration. So I think that is another opportunity to expand
    upon and do better on.
        Senator Moran. Let me conclude with kind of a series of
    questions. What percentage of the decisions were overturned
    through the appeals process?
        Dr. Richardson. Great question, sir. It is 13 percent.
        Senator Moran. And what is at least an estimate of how long
    the process takes through the VHA clinical appeals process,
    through the Board of Veterans' Appeals for supplemental claims
    and higher level reviews? What is the extent of all that?
        Dr. Richardson. Sure. So the median days for decision with
    VHA, the VHA clinical appeals process, is around 17 days for a
    decision. It is yet to be determined what that will be with the
    Board as we continue to work through those processes?
        Senator Moran. What resources has the VA dedicated to
    processing the appeals that have been generated by the legacy
    participant reassessment process and the program expansion?
        Dr. Richardson. Sure. So we have dedicated resources
    already getting ready to hire for phase two expansion. We are
    getting ready to hire an additional 362 staff. We had 80
    percent of that hired to date. So we have roughly about 2,200
    staff within the Caregiver Support Program across the country;
    80 percent of that is currently hired.
        In regards to the appeals to the Board of Veterans'
    Appeals, we have staff detailed into the program office with an
    org chart of an additional 70-plus staff getting ready to come
    on board as well.
        Senator Moran. Quite a team.
        Dr. Richardson. Yes, sir.
        Senator Moran. While Senator Tester sneezes, I will ask one
    more question. What VA resources have been dedicated to making
    certain that they are appropriately adjudicated? So in addition
    to personnel, any other thing that I should know about what the
    VA is doing to make certain they get it right?
        Dr. Richardson. That is a great question, sir. So we are
    working closely with the VBA and BVA as we move forward. VBA
    has the expertise in this area. So we are leveraging some of
    their automated processing, and they are teaching and educating
    us along the way. It has been a process, and we are thankful
    for their partnership as we move forward.
        Senator Moran. Thank you both.
        Chairman Tester. Yes, thank you very much, Senator Moran.
        And I want to thank you also both for your testimony today
    and the answers to the questions, very concise, and I
    appreciate that very much. We will release you. You are welcome
    to stay and hear the second panel if you would like, and we
    will go to our second panel.
        And I will introduce the second panel as we are getting set
    up. We have multiple veterans service and advocacy
    organizations who represent and assist veterans and caregivers
    across our country. Our second panel will include Steve Schwab,
    who is Chief Executive Officer of the Elizabeth Dole
    Foundation; Caira Benson, a caregiver for a husband who is a
    post-9/11 Army veteran. We have Jim Marszalek, the National
    Service Director for the Disabled American Veterans; Andrea
    Sawyer, Advocacy Navigator for the Quality of Life Foundation.
    And even though this is not a virtual hearing for the members,
    it is virtual hearing for one of our folks that are testifying.
    This is Sarah Verardo, Chief Executive Officer of the
    Independence Fund, and as I said, she will be joining us
    virtually.
        Steve, Mr. Schwab, we will start with your opening
    statement.

                                PANEL II

                                  ----------

                       STATEMENT OF STEVE SCHWAB

        Mr. Schwab. Thank you so much, Mr. Chairman. Chairman
    Tester, Ranking Member Moran, and members of the Committee, the
    Elizabeth Dole Foundation is pleased to testify today on the
    VA's Program of Comprehensive Assistance for Family Caregivers.
    We are also deeply appreciative to you, Senator Moran, Chairman
    Tester, and others who have offered bipartisan support to the
    Elizabeth Dole Foundation Act.
        As you might suspect, I had a very different testimony
    planned until yesterday's announcement from the VA, but I am
    very pleased to be with the Committee today to ensure that we
    do right by our veterans and their caregivers. The Dole
    Foundation applauds Secretary McDonough and Deputy Secretary
    Remy and the program staff for announcing a reversal of all
    legacy caregiver dismissals and for planning to reevaluate the
    program. This was a vitally important decision, and we thank VA
    leadership for listening to our community and taking this very
    necessary step.
        As a result, we now need to shift our focus to building a
    new, inclusive, and realistic eligibility formula and
    regulations and a customer serviced-focused evaluation process.
    Yesterday's decision proves that the voices of our MSOs and
    VSOs and our caregivers and veterans are vital in shaping the
    destiny of VA's support for our community, but there is still
    more that needs to be done.
        While we are looking forward to engaging in a process to
    formulate new regulations, there is one aspect I want to ensure
    is discussed today, and I believe you both referenced this, the
    outsized emphasis on the activities of daily living, which
    stacks the deck against those caring for veterans with TBI or
    PTSD. Many of these veterans require 24-hour care due to
    violent flashbacks, mood swings, confusion, and the inability
    to use their phone or even to prepare a meal. However, because
    they are capable of performing ADLs, they were less likely to
    be eligible for PCAFC under the previous regulations. We must
    ensure this inequity, among others, is addressed in the new
    regulations.
        Recognizing that my time is limited, I am honored to turn
    it over to one of our caregiver fellows, Caira Benson, whose
    story illustrates why yesterday's announcement was so important
    and the path forward to getting this right is so vital.
        Thank you, Mr. Chairman.

        [The prepared statement of Mr. Schwab appears on page 41 of
    the Appendix.]

        Chairman Tester. Caira.

                       STATEMENT OF CAIRA BENSON

        Ms. Benson. Thank you, Steve.
        Chairman Tester, Ranking Member Moran, and members of the
    Committee, thank you for inviting me to share my story.
        I am a full-time caregiver to my husband, Eric, an Army
    combat veteran who lives with traumatic brain injury, chronic
    pain, and a degenerative neurological condition. I have been a
    wife staring at their comatose spouse, being told it is time to
    say goodbye, only to feel relief when he defied all
    expectations.
        Today, Eric is considered permanently and totally disabled
    and unable to work. He is wheelchair-dependent, struggles
    cognitively, suffers migraines and blackouts, and is losing his
    vision. He is 41.
        Congress created the Program of Comprehensive Assistance
    for Family Caregivers to assist caregivers like me, whose
    spouse needs substantial care. The program should have been a
    blessing. However, the program has become unpredictable,
    stressful, and frankly, dehumanizing. My husband grows more
    dependent on my care every day. Yet, I was accepted to the
    caregiver program in 2017, dropped in 2018, denied in 2019, and
    readmitted in 2020 but only after 2 hard-fought appeals.
        The assessments are demoralizing. My husband is only
    capable of 30 minutes of sustained cognitive activity. I had to
    watch him answer questions until he was doubled over and
    drooling on himself in exhaustion because the assessor would
    not allow me to help him respond. There is no reason to ignore
    medical accommodations and cause medical distress to prove what
    was already well documented.
        Despite all of Eric's care needs, we were only approved for
    level one. His need for supervision, protection, and
    instruction, even though clearly documented in both his
    assessment and medical records, was never even taken into
    consideration by the CEAT.
        Before I was a caregiver, I was a nonprofit executive and a
    college professor. We are a one-income household, not by choice
    but by forced circumstance. The cost of caregiving is crushing,
    and my family should not have to fear that an annual assessment
    or a policy change will threaten our financial stability.
        To the members of this Committee, please know that I speak
    for every caregiver when I say our ability to provide holistic
    care for our veterans is hampered by frequent and intrusive
    assessments which are not properly reflective of clinical
    records or weighed accurately in CEAT decisions. Congress must
    ensure that any new regulations require a veteran's needs to be
    documented accurately, evaluated thoroughly, so that our Nation
    can better serve our veterans and their caregivers.
        Thank you. I look forward to your questions.

        [The prepared statement of Ms. Benson appears on page 46 of
    the Appendix.]

        Chairman Tester. Appreciate your testimony.
        Jim, please proceed.

                       STATEMENT OF JIM MARSZALEK

        Mr. Marszalek. Chairman Tester, Ranking Member Moran, thank
    you for inviting DAV to testify on ways to fix and strengthen
    VA's comprehensive caregiver program.
        Mr. Chairman, six years ago, DAV launched the Unsung Heroes
    Initiative to honor family caregivers, to extend the program to
    veterans of all eras, and to include veterans disabled due to
    illnesses, not just injuries. In 2018, we were pleased when
    Congress passed the VA MISSION Act, which expanded the
    caregiver program to veterans of all eras. And in 2020, we
    applauded when VA adopted new rules that extended eligibility
    to cover illnesses. These new regulations also attempted to fix
    longstanding problems with eligibility, reassessments, and
    appeals.
        Unfortunately, almost two years later, it is clear many of
    the same problems remain. For example, the regulations changed
    how VA measures a veteran's need for assistance with activities
    of daily living or ADLs. According to VA's new definition, the
    veteran must require help each time they complete an ADL. Under
    this standard, a paralyzed veteran who finds the strength to
    transfer from their wheelchair just one time in a day would not
    meet this each-time standard for mobility. What is worse, VA
    does not even explain how they determine an ADL meets the each
    time standard. Mr. Chairman, it has become clear that these new
    regulations are not working as the law intended.
        Let me share a story of a veteran and caregiver that
    illustrates problems with the current regulations. In 1969,
    Dennis Joyner was gravely wounded in Vietnam by a landmine,
    resulting in the amputation of both his legs and his left arm.
    He spent months recovering in hospitals and years rebuilding
    his life. But Dennis was blessed to marry Donna, who gave up
    her career and became his full-time caregiver.
        When the program was expanded to include Vietnam veterans,
    they were thrilled to be approved at the highest level of
    support. But just one year later, VA conducted a reassessment
    and notified them that their caregiver benefits would be
    reduced. They, and we, cannot understand how VA could find that
    Dennis needed less caregiver support since his injuries have
    not and will never improve, and the only change was they are
    both a year older.
        Mr. Chairman, VA's caregiver program was created precisely
    for people like Dennis and Donna.
        We were pleased to hear VA yesterday announce a plan to
    review and change the regulations and to protect caregiver
    benefits during the process. Unless VA prioritizes getting
    veterans and caregivers into the program and not out of it, the
    problems will persist.
        Here is a few of DAV's recommendations. First, VA must
    replace the current eligibility regulations, particularly the
    each-time ADL rule, and create new standards that are clear,
    consistent, and equitable.
        Second, VA must provide detailed explanations on how
    standards will be measured and applied in each decision
    notification it sends to veterans and caregivers.
        Third, eligibility decisions for veterans should be shifted
    to VBA, allowing VHA to focus on qualifying, training, and
    supporting family caregivers. VBA already has the experience
    and infrastructure necessary to process these claims.
        Fourth, VA should only require annual reassessments when a
    veteran's disabilities and need for caregiver services are
    likely to have changed. A 70-year-old veteran who is paralyzed
    or missing multiple limbs is extremely unlikely to need less
    caregiver support one year later.
        Finally, the Administration should withdraw its appeal in
    the Beaudette case that provided veterans the right to appeal
    caregiver decisions to the board. Veterans must have all of
    their due process rights protected, including full appeal
    rights.
        Mr. Chairman, that concludes my statement. I am happy to
    answer any questions you may have.

        [The prepared statement of Mr. Marszalek appears on page 51
    of the Appendix.]

        Chairman Tester. Thank you, Jim, and I appreciate your
    recommendations.
        Andrea?

                       STATEMENT OF ANDREA SAWYER

        Ms. Sawyer. Mr. Chairman and Ranking Member Moran, thank
    you for holding this hearing.
        I work for the Quality of Foundation which was created to
    serve the families of seriously wounded veterans. We have
    created educational resources and are one of the few
    organizations that assist with clinical appeals, one of which
    was the Bensons' appeal.
        Over the years, legislation and policy surrounding
    caregivers have evolved. Congress passed the VA MISSION Act
    which expanded eligibility to the program. By broadening
    eligibility, Congress acknowledged caregiver involvement led to
    improved outcomes. Congress included traumatic brain injury,
    psychological trauma, and other mental disorders, and
    identified seriously injured as the level of severity to be
    considered.
        As a result of the new legislation, the VA drafted new
    regulations. We have found that while the legislation created a
    program for seriously injured, VA has created a program for the
    catastrophically injured. Under the new regulation, a veteran
    must now require assistance with an ADL each and every time it
    is completed. Under the new supervision standard, the veteran
    must need continuous daily care.
        Quality of Life has requested information on the decision-
    making process SOPs and training documents to inform our
    efforts, but we have been denied access to that information.
        We would like to applaud the VA for taking steps to pause
    the dropping of caregivers to review the process.
        Now it is even more relevant to highlight the challenges
    faced by families as they navigate the PCAFC. We have noticed
    the following issues.
        Number one, information that should be correct in the VA
    medical records is not. Ratings information, documentation of
    guardianships and fiduciaries are wrong. These documents
    indicate an already established need for assistance or
    supervision.
        Number two, the collaboration with the veteran's primary
    care manager is rarely filled out by the veteran's doctor, and
    that information is limited to very generic information and
    only includes the last 12 months of records. The program is
    supposed to gather outside medical records. This rarely
    happens.
        We do not have any idea if the new assessment has been
    validated against other industry standard validated instruments
    or how it is scored to make decisions on whether a veteran
    qualifies for a caregiver.
        And lastly, during the assessment process, the veteran must
    list his deficits and then the caregiver must describe all
    assistance provided in front of the veteran, repeatedly, taking
    an emotional and mental health toll.
        There is a large denial rate for applicants. Legacy review
    denials are high.
        Given the information presented above, we respectfully ask
    the Committee to work with the VA and nonprofit organizations
    on the following items and additional items in our testimony:
    to realign the program with congressional intent; to increase
    transparency related to the decision-making process, VA needs
    to make the full criteria available; to change the requirements
    so a veteran does not have to be present for the caregiver's
    interview and lengthen the timeframe for check-ins and
    reassessments to lessen the burden on caregivers and veterans;
    and, to require the VA to honor its duty to assist the veterans
    to help collect their records.
        We would like to thank the Secretary for preemptively
    granting our request to place a moratorium on drops and
    reassessments, which was our number one ask.
        To leave you with an appeal from a caregiver on her
    thoughts about this program, one caregiver stated, ``We have
    spent the last 15 years focusing on every improvement our son
    has made. The PCAFC reassessment process wipes that out. I had
    to recount everything he could not do in front of him. My son,
    who was a nuclear engineer, now struggles to put Legos
    together. He wept during the assessment. I asked if he could
    leave and was told, no. As a mother, it broke my heart. When he
    starts to recover mentally, we have to go through it all again
    for the quarterly assessment.'' And we have similar letters to
    offer for the record.

        [The letters referred to appear on pages 139-144 of the
    Appendix.]

        Mr. Chairman, the Quality of Life Foundation thanks you for
    holding this hearing, and we look forward to answering any
    questions you may have.

        [The prepared statement of Ms. Sawyer appears on page 63 of
    the Appendix.]

        Chairman Tester. Thank you, Andrea.
        Next, virtually, we have Sarah Verardo.

                       STATEMENT OF SARAH VERARDO

        Ms. Verardo. Chairman Tester, Senator Moran, thank you for
    inviting me today to testify in front of you.
        I hope you and your staff have had the opportunity to
    review my written testimony submitted on Monday, and I hope you
    see that our organization, along with many other organizations,
    has made every effort possible to warn the VA that this new
    regulation does not honor the commitment Congress set with
    veterans and caregivers through the MISSION Act. It is a
    dramatic step back in the support it provides disabled veterans
    and the caregivers who support them and places every veteran
    and the caregivers in support, that are supporting them, in
    real danger of falling through the cracks of what has turned
    into a senseless, compassionless, bureaucratic nightmare.
        I am a caregiver myself to my catastrophically wounded
    husband, Sergeant Michael Verardo, U.S. Army, Retired. Michael
    was twice wounded in Afghanistan in 2010, imminent death
    status, his arm and leg blown off, and 120 surgeries later. As
    his recent annual reassessment for the caregiver program noted,
    Mike requires constant assistance to complete the basic
    activities of daily living and needs my constant support to
    navigate life and society.
        But just last week, we were notified that Mike will be
    demoted to the lowest tier in the new caregiver ratings. Why?
    Apparently, because someone on the Centralized Evaluation and
    Assessment Team, the CEAT, saw videos from 2016 and 2017 where
    Mike was advocating for reform in VA health care programs.
    While I was with him at every one of those events to provide
    the assistance he needed even then, those five and six-year-old
    videos were apparently enough to determine Mike did not need as
    much support anymore. The rest of his assessment explicitly
    said otherwise, and his VA records note that the declines have
    been devastating and he requires the equivalent of full-time
    nursing home care. But this one statement about an internet
    search, which by the way is nowhere in the regulation, was
    enough to reduce Mike's rating.
        When did Google become a clinical evaluation tool? How is
    this even allowable, ethical, or legal? And most importantly,
    Senators, what are you going to do about it?
        What is even more incredible is that I am relatively one of
    the lucky ones, if you can call it that. Over the last five and
    a half months, we have been inundated with pleas of veterans
    and caregivers being told they will be disenrolled come October
    1st, 2022. After years of being at the highest tier ratings in
    the prior caregiver program, now these catastrophically
    disabled veterans, many of whose cases I have detailed in my
    written testimony, are being told they are somehow miraculously
    cured, can complete their activities of daily living or ADLs,
    and no longer need any supervision.
        The assessment documents in these cases detail how these
    veterans fail their ADLs and need supervision for their own
    safety. But because the regulation requires the assessment
    teams to make the impossible prediction the veteran will
    require continuous moderate to significant levels of personal
    care services for the next six months, the assessment teams
    realize they cannot, that likely no one can, so they say the
    veteran must be disenrolled.
        And The Independence Fund and many of the other
    organizations who have joined in on this crusade have warned
    the VA, Congress, and even this Committee that exactly this
    would happen. We made these warnings during the lead-up to the
    new regulation, during the public comment period on that
    regulation, in our letter to the Committee in 2020, in my
    comments before the Caregiver Advisory Committee in 2021, and
    in a letter that we and 21 other organizations sent to the
    Secretary last November.
        We have detailed in the written testimony how each element
    of the new regulation was unnecessary and counterproductive,
    but the real tragedy is that it was unnecessary. By the law you
    passed, VA could have simply certified the caregiver IT
    tracking system and used the old regulation. But as you said,
    Chairman Tester, it appears the VA took the opportunity of the
    congressionally mandated expansion of the caregiver program to
    pre-9/11 veterans to also make it tougher to get into the
    program.
        We are cautiously optimistic with VA's announcement
    yesterday regarding the suspension of disenrollments and
    demotions for legacy caregivers. But, Senators, this is the
    third time since 2017 the VA has been forced to pause these
    actions because of the systemic lack of consistency in these
    evaluations. This time it is because the regulation is so
    poorly written.
        And we will fully engage in the stakeholder summit we hope
    that VA holds as soon as possible. We will support such changes
    like the one we recommended in our petition for rulemaking and
    letters, and we ask Congress to make the necessary legislative
    changes.

        [The letter and petition referred to appear on pages 105-
    120 of the Appendix.]

        But, Senators, we have been down this road before, and it
    has failed before. Bureaucratic delays to protect the systems
    and processes has consistently proven stronger than the desire
    to help veterans and caregivers.
        So, Senators, we ask you if we are not all here together by
    the end of April or May at the very latest then we ask you to
    please take action to fix this legislatively. Thousands of
    caregivers across this country are counting on you.
        We have stepped up to take on the unimaginable. We have
    fought longer and harder than any one person is meant to fight.
    And we live lives without margin while fighting against the
    very institution and the very program meant to help us all
    while navigating heartbreaking declines and loss in our own
    homes. So we are counting on you, and we need your help.
        Thank you.

        [The prepared statement of Ms. Verardo appears on page 88
    of the Appendix.]

        Chairman Tester. Sarah, thank you for your testimony. I
    want to thank everybody for their testimony.
        And please know that I do not think there is anybody on
    this Committee that is happy with what has happened. I remember
    talking to Assistant Secretary Remy while he was being
    confirmed and said we have got, I believe, an 86 percent denial
    rate in this program. I do not think that is what Congress
    intended.
        And then when I hear the stories of assessment and
    reassessment, it is something that makes you wonder why. That
    is all. Just, why.
        And I am going to focus most of my questions with you,
    Caira. I could focus it with anybody who testified today, but--
    I think you have talked about the fact that your husband is a
    triple amputee, correct?
        Ms. Benson. No. My husband has all his limbs.
        Chairman Tester. He has what?
        Ms. Benson. He has all his limbs.
        Chairman Tester. He has all his limbs. And so the injury
    that he has is with TBI and PTSD?
        Ms. Benson. No. He has a TBI, and the TBI was significant
    enough that he has toxic encephalopathy as well. So his brain,
    for lack of a better term, is dying.
        Chairman Tester. Gotcha. And so when you first got accepted
    into the program and then you were reevaluated, did the person
    who did the assessment--as was pointed out I think by Jim, that
    you know, he was a year older. Did they give you any reason
    why?
        Ms. Benson. No. So our first entry into the program was
    '17. We were dropped in '18 because we wintered in the South
    and they considered us nonpermanent address. By '19, we had
    won----
        Chairman Tester. So, stop for a second.
        Ms. Benson. Yes.
        Chairman Tester. You were dropped from the program because
    you had a different address in the winter than you did in the
    summer?
        Ms. Benson. Correct.
        Chairman Tester. I assume that must be part of the regs?
        Ms. Benson. No.
        Chairman Tester. I mean, you lived in this country, right?
        Ms. Benson. Correct.
        Chairman Tester. You fought for this country, right?
        Ms. Benson. He did.
        Chairman Tester. That is an interesting twist. Keep going.
        Ms. Benson. So in '19, we applied again, but because we had
    finally won a correct diagnosis of traumatic brain injury--my
    husband was injured in 2000 and 2003. He was not diagnosed with
    TBI and encephalopathy until 2018. Because he had that on
    board, we were considered ineligible for the program because it
    was not service-connected. And the filing in VBA to get that
    service-connected has been active since 2016.
        When the regulations changed in 2020, it no longer had to
    be service-connected, and we were ecstatic. My husband was home
    based primary care at that point. They encouraged us to apply
    yet again, and we did. We were accepted in at level one. At
    that point in time, he had one ADL and he was given
    intermittent supervision, protection, and instruction.
        We reassessed in 2020, January of this year. He had just
    been released from the hospital for COVID. He had five ADLs
    that were hands-on and needed continuous daily care, as is
    evidenced by three doctors saying he could not be left alone.
    We still attained level one.
        The VA only counted--or the CEAT, I should say, counted two
    of the ADLs because the other three ADLs, even though he needed
    anywhere from 25 to 75 percent help during those ADLs, were not
    entirely dependent. We were told in order for an ADL to count
    it had to be 100 percent caregiver effort. They did not include
    supervision, protection, and instruction even though three of
    his doctors had asked us never to leave him alone. And we were
    issued level one.
        We decided not to appeal at that point. We were exhausted.
        Chairman Tester. I have got you. Just curious, did the TBI
    happen in service to the country?
        Ms. Benson. It did.
        Chairman Tester. Was he in theater?
        Ms. Benson. He was in--his first TBI was a parachute
    malfunction during basic airborne course.
        Chairman Tester. Yep.
        Ms. Benson. His second was a double car bomb in Baqubah.
        Chairman Tester. And did the Department of Defense--did
    they diagnose him as having traumatic brain injury?
        Ms. Benson. No. He was never screened under the DOD. The VA
    diagnosed him.
        Chairman Tester. Okay. I will kick it over to you, Senator
    Moran.
        Senator Moran. I do not how to respond. I mean, I
    appreciate your circumstance, the stories that you tell. I do
    not know how you are capable of doing what you are doing, and I
    do not understand why the process that is designed to help you
    ends up harming you. And I apologize for that, and we continue
    to work to try to care of veterans, in the process, make the VA
    perform its duties as it should.
        And it is true for all of our witnesses and advocates here
    today. Thank you for what you do to care for those who have
    been harmed so greatly.
        I do not know who to ask this question to, but--how do you
    explain what Caira just described? Steve, you brought Caira to
    us. Obviously, Caira has the capability of telling a story that
    is so compelling, and it sounds like there is just so many
    other circumstances in which there is a compelling reason to
    get this right.
        How did it--why did it go so wrong? What went on that
    precipitates this kind of circumstance?
        Mr. Schwab. Well, Senator Moran, thanks for that question.
    And you can see why we wanted to bring Caira here to bear
    witness to what she has been going through. Andrea mentioned
    that she has got letters from countless other caregivers who
    have experienced similar circumstances. You heard compellingly
    from Sarah what she and Michael have faced in their own
    situation. And unfortunately, that is happening too much and
    too often.
        And, Senator Tester, I believe you asked a really important
    question to the VA earlier around consistency. I think it was
    you that asked that question. And it was suggested, and perhaps
    it is true, that the VA said that there are three hospitals
    that they deem outside of the consistency that they have seen
    across other institutions in executing evaluations. We have not
    seen that.
        The inconsistency on the experience that caregivers have
    faced across the country is unbelievable, and going into these
    evaluations it seems that the standard all too often is how do
    we get to ``no'' versus how do we get to ``yes.'' And if we
    cannot get to ``yes'' or we have got to get somewhere in the
    middle, there is not a clear path given to that caregiver and
    that veteran. There is not a warm handoff.
        I do not want to say that happens in every situation. There
    are certainly great people at the VA at every level doing good
    work. But there is far too many stories like Caira's and
    Sarah's and Andrea's that are happening, and that points to
    some real root issues. And we think it is because there is 160
    facilities that are executing this program in different ways.
        As hard as--and Colleen has been a great new leader for the
    program, but as hard as we put forward new issues around
    consistency it does not seem to be changing what we have been
    experiencing.
        Senator Moran. Mr. Schwab, I mean, that suggests that in a
    sense that is luck of the draw or where you live, just
    circumstances, not that the program is--the program may be
    fine, but it is implemented differently in different places.
        Mr. Schwab. That is correct.
        Senator Moran. So some people have an appropriate response,
    and others have a tragic response.
        Mr. Schwab. That is correct.
        Senator Moran. What was announced yesterday by the Deputy
    Secretary, I think as I looked at what was said, it is enacting
    a moratorium on discharging legacy participants from the
    program, reviewing eligibility requirements to ensure they meet
    congressional intent, and explore shifting some responsibility
    to VBA. Could you each, or any of you who feel that this is a
    question that you could answer well, tell me what you think
    this means for veterans and caregivers? Did you hear what you
    wanted to hear even though it is now not in the beginning?
        Jim, you look like you were ready to speak.
        Mr. Marszalek. Sure. Thank you, Senator. I am optimistic. I
    was glad to hear, VA say that there is going to be a summit in
    April because that is news to me. But I think that is what
    needs to happen, to get people together to talk about these
    different issues. And I was glad to hear they are working with
    VBA already because they have been through these processes
    before.
        The transparency is the biggest issue here. Every caregiver
    we have talked to--and I am sure everybody at the table can
    attest it. You are not getting any information as to how they
    made their decision. They are not sharing any of it, and we do
    not know how they have made the decision and how they have come
    to the conclusion.
        The case I talked about, about Denny, he got a year older.
    Nothing has changed. His level of caregiver support that his
    wife provided has never changed at all in the past year
    although he was reduced and not told why. The letter just said,
    you are being reduced to the lower level effective this date.
    That is all the letter says.
        So I think you have to go back to the drawing board and
    figure out what should the regulations be, but I think you have
    to do it with everybody. And I will refer back to the appeals
    modernization. That took everybody in a room months to figure
    out a good appeal process for VBA. We are in the same situation
    right here. We have tried. The process is broken. It is not
    working. It is not how anybody intended it to be.
        So we have got to go back to the drawing board and figure
    out how do we do this together, and you have got to have
    everybody at the table. And I think caregiver families at the
    table, talking about what their experiencing is very, very
    important.
        The reassessments, going through those so frequently, and
    requiring the veteran to be part of some of these quarterly
    calls as well is damaging to the veteran. It is doing more harm
    than good. I mean, we are hearing that across the board.
        Senator Moran. Thank you.
        Chairman Tester. Go ahead.
        Ms. Sawyer. Thank you. I would like to say I am optimistic
    that the VA is willing to look at this regulation and
    assessment. One of the things that we have found as we are
    reviewing the clinical decisions that we can find in the record
    is that there are issues surrounding the fact that outside
    medical records are very often not included. They (veterans and
    caregivers) are not given time to gather outside medical
    records and have them included.
        In a lot of cases, and the Bensons' case was one, from the
    time she was notified that she was being reassessed until the
    time she had a CEAT decision was like three weeks. So she did
    not have time to gather a lot of the outside medical records.
    And then there is a whole process to get the records scanned
    into the VA, and a decision had already been made.
        In addition, the PCM is not asked very specific questions.
    They are basically asked: Does the veteran understand the
    treatment plan? Does the caregiver understand the treatment
    plan? Can the care be provided in the home? And, has the
    veteran ever been considered for institutionalization?
        Well, why not ask them whether or not the veteran can
    perform the ADLs, or whether or not they can meet the standard,
    whether or not they think the veteran is able to meet the
    standards for supervision, protection, and instruction, rather
    than relying on a self-report from the veteran and caregiver
    that then they (the VA) can disregard as a self-report.
        The third thing in that decision is that there is a
    question that CEAT considers, or the decision-making body
    considers, that is worded in a very strange way. The question
    is: Is the individual unable to self-sustain in the community?
    And the answer to that single question determines whether or
    not a veteran is tiered at a tier one or a tier two.
        The question itself is worded in a backward manner. So if
    you answer, is the individual unable to self-sustain in the
    community and you say ``no,'' that means the veteran is able to
    self-sustain in the community. If they would simply change the
    question, is the individual able to self-sustain in the
    community, that would overturn about 75 percent of the tiering
    errors between level one and level two that we see.
        Thank you.
        Chairman Tester. Great point.
        Senator Moran. Thank you, Ms. Sawyer.
        Chairman Tester. Senator Murray.

                          SENATOR PATTY MURRAY

        Senator Murray. Well, thank you so much to all of you.
    Thank you for being here. Thank you for continuing to stay on
    this. And I certainly think when we first passed this, Senator
    Tester and others know who worked on this, we never expected
    these kinds of challenges this far into this.
        So you know, I am glad the VA made some announcements
    yesterday. We are going to be following up on this. Your
    testimony today is extremely important. And I know I am not
    going to give up, and I know Senator Tester is not going to
    give up, Senator Brown, Senator Moran. We want this to work.
        Senator Boozman. What about me?
        Senator Murray. Well, I did not see you over there. All of
    us. I do not know anybody that wants this program to work like
    this. I think we are in this, and we want you to know that, and
    we are going to continue to work to make sure that this program
    is instituted the way we envisioned it when we first passed it.
    So thank you all very much for being here and I appreciate the
    responses so far.
        I do want to ask Ms. Sawyer a question a little bit
    differently. And it is great to see you again. Thank you for
    your steadfast leadership advocating for veterans and their
    caregivers.
        As you know, we made changes in the last caregiver bill to
    make VA better account for the invisible wounds of war for
    which a veteran may need a caregiver. Tell me, has the VA done
    a better job with invisible wounds, and what would you like to
    see them do as part of this new look at regulations?
        Ms. Sawyer. So I do believe they have expanded the areas of
    criteria that they look for in adding self-protection, self-
    direction, self-neglect, safety inside and outside the home,
    delusions, hallucinations.
        Unfortunately--and I think some of this has to do with
    COVID and how they (VA) have changed things with COVID--it
    becomes a self-report. They ask the veterans and caregivers
    about these things themselves.
        They do not ask for the input of any specialist. The input
    of any specialist is not required--only five questions from the
    PCM, those very generic questions that I listed, which do not
    really get to the heart of the matter and whether or not anyone
    feels that this veteran has a mental health need or a
    psychological need or a traumatic brain injury for supervision.
        Senator Murray. I think that is what Caira was referring to
    when you said you had three doctors that said he needed
    somebody with him.
        Ms. Benson. Correct.
        Ms. Sawyer. Yes.
        Senator Murray. But that did not count.
        Ms. Sawyer. Yes. They (specialists) are not even asked
    for--they are not required to be asked for their input. Only
    the PCM is required to be asked for his input. And then like I
    said, those questions are very generic.
        Why wouldn't you ask the specialist for their input? What
    is the purpose of not allowing them to weigh in?
        Our organization, in working with appeals, has taken those
    areas of supervision, protection, and instruction and actually
    asked the specialist to weigh in on those. And in some cases,
    we have actually received notes back that say they (the
    specialists) are not allowed to answer those questions because
    it would give too much information on the needs of the veteran.
    Well, isn't that the entire purpose of this evaluation, to
    inform the decision-making body about the needs of the veteran?
        The other thing that I think misses the mark is in the
    development of these assessments and in their administration.
    These are 90-minute to 120-minute assessments, where the
    veteran has to sit and list on multiple occasions all of the
    things he or she can no longer do. And then he has to sit there
    while the caregiver then recounts everything the veteran cannot
    do for himself or herself and everything that they (the
    caregiver) then have to do as a result either to provide the
    veteran assistance or just do because the veteran is no longer
    able to do that. What we hear repeatedly is that takes an
    emotional toll. For some of these folks who have very severe
    brain injuries, sometimes they forget that they have these
    deficits.
        We have been told for the last several years: ``Build up
    your veteran; focus on their independence.'' And then we have
    an exam that does nothing but tears them down. And as soon as
    you get them built back up, it is time for a quarterly
    assessment that goes over the same thing.
        And so there is really no other disability program that you
    qualify for that you have to requalify for or have a check-in
    on such a frequent basis, and we are wondering why VA does
    that.
        And then we hear VA say that there is a lot of wraparound
    VA mental health services, but I do not see that in practice.
    And I especially do not see anyone checking in after these
    reassessments, when basically the home is in mental and
    emotional tatters. I mean, what we hear about this assessment
    is it takes weeks to get people back to their standard and even
    with the quarterly assessments.
        I mean, I can tell you from my own household. After a
    quarterly assessment, it would take two to three days to get
    him to be able to say, gosh, I feel like I am worthless.
        And so I think they attempted to expand the areas they were
    looking at, but I do not think that it has been implemented as
    they intended for it to be implemented.
        Senator Murray. Okay. Well, my time is out. But I really
    appreciate all the work, all you are doing, and your testimony
    really means a lot to all of us. Thank you.
        Ms. Sawyer. Thank you.
        Chairman Tester. Senator Boozman.

                          SENATOR JOHN BOOZMAN

        Senator Boozman. Well, thank you all for being here, and
    you really are making a big difference. This is a mess, and I
    know that we are all committed to helping get it straightened
    out.
        We say these things all the time, but the answers need to
    come from the ground-up. Okay? And you all are certainly on the
    front lines and doing a tremendous job, and we really do
    appreciate that. And like you say, you are making a difference.
        So, Steve, we can agree on the transparency thing. You
    know? What else do we agree on that we need to--what other
    changes? I mean, these real-life--you know, all of the--you
    know, why we do not have the specialists involved and this and
    that. I mean, none of that makes any sense. Where do we start?
        You mentioned a--you know, that we are going to have a
    summit. Who needs to be at the summit? You know?
        Mr. Schwab. Senator Boozman, thank you for that question. I
    think we need to start over. I think that VA, Congress, the
    major stakeholder groups need to be put in a room for as many
    days as it takes us to bring these stories forward, to bring
    these experiences forward, to bring the advocacy and the
    regulatory experience that the VSOs and MSOs have, alongside
    our friends and partners at the VA.
        I will say, Senator, you know, there are good folks. These
    are good folks in the VA----
        Senator Boozman. No, no. For sure.
        Mr. Schwab [continuing]. Who want to get this right. But to
    Sarah's point in her testimony, we have now paused the program
    three or four times, and we have made temporary solutions. It
    is time to go back to the fundamentals----
        Senator Boozman. Right.
        Mr. Schwab [continuing]. And redraw the lines.
        Senator Boozman. Right. Very good. Anybody else comment
    on--again, like you say, you have given us a lot of really good
    information.
        And it is just something we are going to have to figure
    out, Mr. Chairman, and you are going to have a lot of support
    in doing it. But it is going to be something that we are going
    to have to--you know, we--one of the things that Congress does
    not do a very good job of--we are so blessed, you know, in the
    sense that for the last several years we have been able to do a
    lot for veterans. And that is our veterans service
    organizations, that is you all, pressing things forward.
        Sometimes we do not do as good a job on the oversight as
    we--and that is nobody's fault. I mean, it is our fault. You
    know, in the sense that we have got to do a better job. But
    this is one of the things I think we are all committed to, to
    rolling up our sleeves and getting the stakeholders involved,
    getting you all involved, and see how we can come up with some
    policies that are, you know, user friendly.
        And as you point out, Steve, these are not bad people.
    These are people that are trying to do the right thing. They
    are handicapped by the bureaucracy, and sometimes you are not
    able to even use good common sense.
        So thank you all for being here. We do appreciate it. And I
    know it is hard to talk about these things, but you have done a
    tremendous job expressing the problems you go through and your
    loved ones. So that is really what it is all about.
        Thank you.
        Chairman Tester. Senator Brown.

                         SENATOR SHERROD BROWN

        Senator Brown. Thanks, Mr. Chairman. And thank you all for
    your testimony and the pain that you have gone through and the
    advocacy that you do for others, including your loved ones but
    people you do not know, too.
        Before talking about specifically AIR Commission, I want to
    just raise concerns, and I will do this--I am doing this
    personally with the Secretary, but want to raise concerns about
    his recommendation to the AIR Commission to close down the
    Chillicothe. It is a veterans hospital center south of Columbus
    and serving Appalachia. And the plans that VA has announced to
    close it down, it is a long process. We will have other
    opportunities to weigh in.
        But I know already veterans are scared. The hundreds of
    workers there are scared. It is in Appalachia. It is a poor
    part of Ohio. They will have to drive to either--some will
    drive to West Virginia. Some will drive to Dayton. Some will
    drive to Cincinnati. There are long drives to get the kind of
    care that they are used to getting. And so I wanted to put that
    just so my colleagues would hear that, about Chillicothe. I
    know that Senator Tester, in his State, has a lot of those same
    concerns.
        I want to concur with what Senator Murray. I thought she
    said it really well, as you all did, about the caregivers
    program, that we did not intend to change how VA decided who
    would be let into the program or have people removed. We voted,
    and we wanted to expand it.
        I had a roundtable with caregivers and hearing the same
    kinds of stories you told. I know that Senators Boozman and
    Moran and Tester have had the same kinds of discussions. My
    staff has reached out to a number of caregivers, too, and heard
    directly about what happens if they are kicked off of the
    caregiver program in September. They told me, without this
    program, they expect even more veterans suicides. The
    hopelessness you could see in their eyes, speaking for the
    person whom they are caring for, their husband, their sister,
    their whomever it is in each case.
        I applaud the steps VA took this week to ensure those in
    the program could remain, but it does not solve the problem.
        So I want to start with you, Mr. Schwab, and thanks for
    what the Dole Foundation is doing. You have been so important
    in this process.
        Yesterday, the VA announced, as you know, convening an
    external stakeholder event to get input for its new regulation.
    Many of us raised concerns. All of us up here raised concerns,
    specifically that veterans needed to have a 70 percent service
    connected disability rating or the inability to perform an
    activity of daily living without assistance.
        What recommendations would you give to VA, Mr. Schwab, when
    drafting the new regulations? How many caregivers are going
    through the appeals process that you know of?
        Mr. Schwab. Thanks, Senator. That is a great question. The
    appeals side, I will tell you that way too many caregivers are
    so frustrated. And this is a big concern of ours by the way.
    The appeals processes exist for a reason. Gives folks their
    right to appeal a decision to our government. In droves, folks
    are not appealing because they are exhausted and they feel
    like----
        Senator Brown. What Ms. Benson said, yes.
        Mr. Schwab. Yes. They feel like--and I think Andrea is
    seeing this. I think our friends at DAV are seeing this. We are
    certainly seeing this at EDF. The Independence Fund, I know is
    as well. With a 13 percent, you know, ``yes'' rate on appeals
    is a pretty low yield, which discourages appeals altogether. So
    I think there is a lot of work we have to do around appeals.
        Senator Brown. So they are exhausted. I am sorry to
    interrupt. They are exhausted because they have gone through so
    much already. They are also not very hopeful that their
    appeal--that they will win their appeal.
        Mr. Schwab. That is right, Senator.
        Senator Brown. Okay.
        Mr. Schwab. And their exhaustion comes from the arduous
    evaluative process that you have heard a lot about today.
        Senator Brown. Okay. So what is your most important
    recommendation when drafting the new regulations? Ms. Benson,
    do you want to? Yes.
        Ms. Benson. If that is allowed, thank you. I think some of
    the exhaustion--these assessments are six to eight hours over
    four assessments. Some of them are in the home. We are
    exhausted just to get through the process.
        And for like my husband, we are dealing with some of the
    most catastrophically worst of the worst. These are exhausting
    for them. It can take us weeks and days to get back on track
    and into a normal rhythm. And they are non-accommodative. We
    are dealing with veterans with severe disabilities and not able
    to accommodate those disabilities in assessment. It seems
    entirely backward.
        Senator Brown. Give me an example.
        Ms. Benson. My husband----
        Senator Brown. Either with your husband or somebody else,
    yes. Sure.
        Ms. Benson. A prime example, my husband has a 30-minute
    cognitive--sustained cognitive task limit set by his provision
    team, by his HBPC team. After 30 minutes of sustained cognitive
    activity, my husband's brain gets tired. His left side of his
    face starts to droop. He has trouble with aphasia or finding
    words. He gets to the point where he cannot swallow. And it is
    all due to exhaustion. Yet, he has to be there for an hour and
    a half of questioning.
        Mr. Schwab. Senator, if I could just address your really
    important question, just piggybacking on Caira's compelling
    comments there, our biggest concern to get right on the
    eligibility front, excuse me, on the formula front is parity
    between physical and mental and emotional conditions. President
    Biden, in the State of the Union, said we need to call for
    parity on mental health across this country. That needs to
    translate down into our agencies. And we are seeing huge
    disparities between caregivers who are caring for veterans with
    physical wounds and those that are caring for veterans with
    invisible wounds. That needs to change.
        Senator Brown. So I am sorry, Mr. Chair, if I could do one
    more quick question.
        Mr. Schwab, if you would, here is my request. Just because
    you are so well connected and do this so well and you know so
    many people, directly or indirectly, like Ms. Benson's husband,
    would you sort of collect for the Committee what your--I assume
    you are doing this--what recommendations you would give to the
    VA?
        Mr. Schwab. Yes.
        Senator Brown. Because we are--all of us--we are all
    singing off the same page, and we all want to fix this. We have
    all talked to caregivers who are struggling in the hardest
    times in their lives, forgetting even the pandemic, but
    struggling in the hardest times of their lives. And we need to
    know specifically how we guide them to do the right thing.
        Mr. Schwab. We are happy to do that, Senator Brown. We work
    really closely with DAV and Quality of Life and The
    Independence Fund, Wounded Warrior Project. We will work
    together on that, and we will bring that back to the Committee.
        Senator Brown. Okay. Thanks.
        Chairman Tester. Thank you.
        Sarah, are you still online?
        Ms. Verardo. Yes, sir, I am. Hello.
        Chairman Tester. Well, I did not want to leave you out of
    this. I will tell you all your testimony was, by the way,
    outstanding. Sarah, you did something that normally would make
    somebody like me angry, but I think it absolutely was the right
    thing to do, and that is you put it on me as much as you put it
    on the VA. You put it on this Committee and Congress as much as
    you put it on the VA. And I want to thank you for that because
    the truth is this is everybody's problem that we need to work
    together to solve. And if we do not do it this way, it will not
    get solved.
        You heard the previous panel, I assume. If you did not,
    this is an unfair--no, it is not either. You can answer this
    question. They talked about the process they were going
    through. The timeline was not definite at this moment in time.
    So I get to ask you, if we were going to have a timeline for
    this, to fix this program, what do you think a reasonable
    timeline would be?
        Ms. Verardo. Thank you so much and for your support and I
    know your advocacy for veterans and caregivers across the
    country.
        This program needs to be fixed immediately. We are all--
    what Steve just said about people are not appealing because
    they are exhausted, I could not--I was here silently saying,
    yes, agree, co-sign, because I am an advocate and I am used to
    being an advocate. When my husband just got dropped a level, my
    first thought was I do not have the fight in me anymore. I just
    cannot do it. I have been fighting to keep him alive going
    forward and to advocate for more than a decade. The fight, they
    won; VA won. And this needs to be fixed immediately from a
    morale standpoint for the veterans and caregivers that are in
    this program and relying on it.
        And also, as everyone has said today, what we go through in
    our households with the veterans for whom we provide care, our
    loved ones, after these assessments, during the assessments, it
    is dehumanizing. It is demoralizing. It is embarrassing.
        My husband--and for a long time, I did not want to say this
    part out loud, and now I have widely shared this. But my
    husband does not control bowel or bladder function. My husband
    had his arm and leg blown off. He is burned over more than 30
    percent of his body. He has had 120 surgeries.
        Many of you have been so amazing to us in this 10-year-plus
    long journey, and VA is forcing us to relive why he cannot--now
    he is on catheter care, bowel and bladder care, through VA. He
    is on a home-based oxygen program. I keep 100 percent of his
    care at the VA because I believe in the VA system and having a
    cohesive system where the right and left hands speak to each
    other, but clearly, that is not happening.
        As we are going through these assessments--and this is true
    for thousands of caregivers. I have outlined 15 in my written
    testimony. As we are going through this process and having to
    relive all these things, and then in front of my husband I am
    having to explain: Well, yes, he does have a shower chair. But,
    no, his bottom is actually very burnt. And because, you know,
    of all the bladder issues, he has a recurring diaper rash. But,
    oh, sir, examiner, could you please check his VA medical files
    that actually detail all of this so that, at 37 years old, my
    husband is sitting next to me hearing about this.
        And so that is why I am here begging you to help fight for
    all of us because we have been fighting for each other and for
    our veterans for a long time and we are exhausted.
        So I hope that right now, immediately in fact, we are going
    to hear news that we are going to reverse the poor decisions.
    We are going to ensure national consistency. And I already feel
    encouraged knowing that you all are taking this issue and
    continuing to look at it so seriously, as all of our partner
    organizations are that are there today. So thank you.
        Chairman Tester. Thank you.
        Senator Sinema.

                         SENATOR KYRSTEN SINEMA

        Senator Sinema. Thank you, Chairman Tester. I want to thank
    our panelists for being here and for the service that your
    organizations do for our veterans.
        I know some of you, like us, are still reviewing the VA's
    announcement yesterday that they are halting discharge of
    legacy participants in the family caregivers program. I am
    encouraged to see that the VA is changing course after feedback
    from veterans, caregivers, and members of Congress for over a
    decade.
        The caregivers program has been a critical lifeline for
    those seriously wounded in the Global War on Terror. The
    caregivers program was designed to support veterans and does so
    by providing flexibility to their loved ones who provide hours
    of daily care. For many of the Arizonans I hear from,
    caregiving has become a full-time job, a job that despite the
    VA's announcement yesterday now feels like it has little job
    security.
        My first question is for any on the panel who would like to
    answer. My office has been hearing from Arizona veterans and
    caregivers with concerns about how they will get by if they are
    removed from the program. What can we do to ease this
    transition if caregivers are removed from the program in the
    future and need to reenter the workforce?
        Mr. Schwab?
        Mr. Schwab. Senator, thanks for that question. It is an
    important one. And thanks for your support of your Arizona
    caregivers. We know that you are a big advocate for those
    families.
        I will say the first thing we ought to do when we relook at
    the program and start over, which we are all discussing is
    necessary, is we have got to move VA towards a warm handoff. If
    someone is decreased in services or dropped from a program,
    they need to be walked through what other services and supports
    are available for them right now at VA.
        And beyond VA, a lot of our organizations provide support
    that fills in the gap for these families when they are not
    eligible for a certain program. And many of us have been
    challenged and struggle to work with VA, to help them
    facilitate a warm handoff to our organizations so that we can
    step in and provide community support to the great families in
    Arizona and elsewhere.
        I think those two things are really, really important when
    we all come together and talk about what are the program goals.
    And I am sure my colleagues have other thoughts.
        Ms. Sawyer. Hi, Senator. So when we get a family that has
    received a denial, before we start the clinical appeal, one of
    the first things we do is to have them reach out to their PCM
    for a referral to HHA and, if necessary, to skilled nursing
    also because by doing that, we actually document the care need
    that VA says the veteran has. By dismissing the family from the
    PCAFC program and then doing the HHA evaluation, we are
    actually documenting the need that the veteran actually does
    need that care according to the--according to another VA
    program.
        And by doing that, we have started the process of getting a
    support in place for a caregiver to begin looking for work,
    whether or not they choose to appeal or whether or not they
    choose to accept those services and move back into the
    workplace.
        We then talk about, you know, if those services are
    offered, then you need to start taking advantage of those
    services. Even if what you are doing it for that falls outside
    of the respite hours, you need to start using those hours, that
    as a caregiver you should not do the VA's job for free because
    we feel like VA is relying upon caregivers to do is that they
    (VA) are going to take the caregiving supports away from
    caregivers and yet no caregiver will leave their post of
    caregiving. So basically, the VA is getting us to do our job
    for free.
        I was an original 2009 caregiver that was put on the Hill
    by an organization to come and advocate for the original
    legislation, and what Congress--what many of the members that
    we met with--said that they wanted to do was to help us, help
    support us so we could stay home, which meant that we gave up
    our jobs and our skills. We gave up our retirement. We gave up
    our contributions to Social Security because as a caregiver, if
    there is no earned income in the home, you cannot contribute to
    Social Security. And the safeguard was that we would have this
    stipend with which we could have at least a little spending
    money that was our money for us to figure out what to do with.
        Basically, we feel like we have been in a reversal. So we
    are having to tell caregivers to find job training that, by the
    way, since you are receiving your caregiver pay, you need to be
    able to do in the home while you are still doing this, while
    you are still receiving the caregiver stipend, but have it
    completed so you can return to work when the caregiver stipend
    runs out. And, go ahead and get your supports in place so that
    when the day you do need to return to work they are already set
    up.
        Senator Sinema. Mr. Chairman, I know my time is expired.
    Are there others who wanted to respond, and might I have . . .
        Mr. Marszalek. Thank you, Senator. I think they put it
    elegantly that, the warm handoff is so important because there
    are other resources out there that are available to folks so if
    they are getting, disenrolled from the program, that they are
    aware of those other resources and they are able to seek those
    out very easily and then we are able to connect them with them
    very easily.
        Senator Sinema. Thanks. Mr. Chairman, if I might, thank
    you. The caregivers program is supposed to include financial
    planning services, and I wanted to ask about the effectiveness
    of the benefit. Are caregivers and their veterans prepared
    financially for the long term, including major changes to the
    program?
        And, Ms. Benson, if you have anything from a personal
    experience to share, I would love to hear that.
        Ms. Benson. Thank you, Senator. That is a far more recent
    addition. In the VISN we are in, to my knowledge, they do not
    have that support in place yet. We are asked if we would like a
    referral. That is something that many of us do not step into. I
    know there are several with fiduciaries who already have some
    planning in place.
        For me, especially when I advocate with other caregivers, I
    talk a lot about making sure you have a secondary plan in
    place. If you have Chapter 35 benefits, make sure you use them
    before they expire. Talking about something as simple as health
    insurance and making sure that you understand the process for
    DIC and that it takes a while. All of those things are things
    we talk about in caregiver advocacy, but I have not heard
    personally that anyone is hearing that from VA or the VISN I am
    in.
        Senator Sinema. Has anyone else heard?
        Ms. Sawyer?
        Ms. Sawyer. I have not actually heard whether or not those
    programs are functional as of yet. But in bringing that up with
    health insurance, one of my concerns about the changes in this
    program and the drops that we have is this program provides
    health insurance for some of our caregivers. And one of the
    concerns that I have is how are we transitioning these
    caregivers who are going to be removed from the program and
    rely on this program for their health insurance. How are we
    transitioning them to health insurance in other ways?
        Senator Sinema. Ms. Sawyer, if I might, that was actually
    my last question.
        Ms. Sawyer. Okay.
        Senator Sinema. My question for all of you is: What, if
    anything, should Congress do to help caregivers who have relied
    on the program for so long and may need to provide for their
    own health care insurance if they are disenrolled?
        Mr. Schwab. Senator, I think that is one of the most
    important questions that has not been asked yet. And your
    colleague, Senator Brown, asked if the Elizabeth Dole
    Foundation would work with our partners to come up with some
    solutions to recast the program. I think at the same time we
    need to come back to the Committee with some recommendations
    for support for families that are eligible, to your question,
    Senator. And I think that is some work that we can do together
    as organizations and report back to the Committee because it is
    an essential question.
        Senator Sinema. Mr. Chairman, if I might, I would like to
    request that we ask for that information back and get it as
    quickly as possible to figure out what, if anything, can
    Congress do, what action can we take, to help people prepare
    for the fact that they may be disenrolled and losing their
    health insurance.
        Chairman Tester. Absolutely, we will get that information,
    and then we will also distribute it not only to everybody on
    this Committee but back to the VA. I think that is part of the
    process conversation that we have had, and that is that in the
    end we have the oversight responsibility, but the bottom line
    is the VA needs to step up. And so any recommendations we
    appreciate so we can take a look and see, if implementable, how
    quickly we can get them done.
        Senator Sinema. Thank you. Thank you, Mr. Chairman.
        Chairman Tester. Thank you. Look, we have a lot of work to
    do. It is pretty obvious by the testimony here today. I have
    been on this Committee for 15 years, and I do not know that we
    have ever had a committee hearing that is as gut-wrenching as
    this hearing is.
        As Ranking Member Moran and I were talking, we passed a
    caregivers component that we thought was going to make it
    better, and obviously, it has made it worse. That was not the
    congressional intent, but it is pretty obvious what has
    transpired here.
        And I think it is really important that we continue with
    more oversight than we began in this program in the past and
    make sure that the changes that the Administration makes
    actually benefit the veterans because that was the
    congressional intent from the beginning. It was not to make it
    more bureaucratic. It was not to kick people off the program.
    It was not to put veterans through hell in assessments. It was
    about making sure that we were doing right by the people who
    served our country and gave a lot to this country with their
    service to this country.
        And so I look forward to continuing to work with the folks
    that are here today and the other VSOs out there that are
    listening and the other veterans that are out there listening
    and the caregivers that are out there listening, to make sure
    that we make the right improvements to this program so it
    serves our veterans in a way that I think Congress intended for
    it to be all along.
        Once again, I want to express my appreciation for the
    witnesses, for being here today. I want to express my
    appreciation for the folks from the VA, Dr. Taylor and Dr.
    Richardson, for you staying and listening because I think it is
    very, very important that we really roll up our sleeves and we
    do not take a long time doing this. We gather the information,
    as much as we can, and I think it is out there, and go to work
    and solve the problem in a timely manner.
        With that, we will keep the record open for a week, and
    this hearing is adjourned.
        [Whereupon, at 4:35 p.m., the Committee was adjourned.]

                                A P P E N D I X

                              Prepared Statements

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                            Questions for the Record

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                           Statements for the Record

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                      [all]