[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]