[Congressional Record Volume 169, Number 199 (Monday, December 4, 2023)]
[House]
[Pages H6097-H6103]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




  ELIZABETH DOLE HOME- AND COMMUNITY-BASED SERVICES FOR VETERANS AND 
                         CAREGIVERS ACT OF 2023

  Mr. BERGMAN. Mr. Speaker, I move to suspend the rules and pass the 
bill (H.R. 542) to amend title 38, United States Code, to improve 
certain programs of the Department of Veterans Affairs for home- and 
community-based services for veterans, and for other purposes, as 
amended.
  The Clerk read the title of the bill.
  The text of the bill is as follows:

                                H.R. 542

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Elizabeth 
     Dole Home- and Community-Based Services for Veterans and 
     Caregivers Act of 2023'' or the ``Elizabeth Dole Home Care 
     Act of 2023''.
       (b) Table of Contents.--The table of contents for this Act 
     is as follows:

Sec. 1. Short title; table of contents.
Sec. 2. Increase of expenditure cap for noninstitutional care 
              alternatives to nursing home care.
Sec. 3. Coordination with Program of All-Inclusive Care for the 
              Elderly.
Sec. 4. Home- and community-based services: programs.
Sec. 5. Coordination with assistance and support services for 
              caregivers.
Sec. 6. Development of centralized website for program information.
Sec. 7. Improvements relating to Homemaker and Home Health Aide 
              program.
Sec. 8. Reviews and other improvements relating to home- and community-
              based services.
Sec. 9. Modification of certain housing loan fees.
Sec. 10. Definitions.

     SEC. 2. INCREASE OF EXPENDITURE CAP FOR NONINSTITUTIONAL CARE 
                   ALTERNATIVES TO NURSING HOME CARE.

       (a) Increase of Expenditure Cap.--Section 1720C(d) of title 
     38, United States Code, is amended--
       (1) by striking ``The total cost'' and inserting ``(1) 
     Except as provided in paragraph (2), the total cost'';
       (2) by striking ``65 percent'' and inserting ``100 
     percent''; and
       (3) by adding at the end the following new paragraph:
       ``(2)(A) The total cost of providing services or in-kind 
     assistance in the case of any veteran described in 
     subparagraph (B) for any fiscal year under the program may 
     exceed 100 percent of the cost that would otherwise have been 
     incurred as specified in paragraph (1) if the Secretary 
     determines, based on a consideration of clinical need, 
     geographic market factors, and such other matters as the 
     Secretary may prescribe through regulation, that such higher 
     total cost is in the best interest of the veteran.
       ``(B) A veteran described in this subparagraph is a veteran 
     with amyotrophic lateral sclerosis, a spinal cord injury, or 
     a condition the Secretary determines to be similar to such 
     conditions.''.
       (b) Applicability.--The amendments made by subsection (a) 
     shall apply with respect to fiscal years beginning on or 
     after the date of the enactment of this Act.

     SEC. 3. COORDINATION WITH PROGRAM OF ALL-INCLUSIVE CARE FOR 
                   THE ELDERLY.

       Section 1720C of title 38, United States Code, as amended 
     by section 2, is further amended by adding at the end the 
     following new subsection:
       ``(f) In furnishing services to a veteran under the program 
     conducted pursuant to subsection (a), if a medical center of 
     the Department through which such program is administered is 
     located in a geographic area in which services are available 
     to the veteran under a PACE program (as such term is defined 
     in sections 1894(a)(2) and 1934(a)(2) of the Social Security 
     Act (42 U.S.C. 1395eee(a)(2); 1396u-4(a)(2))), the Secretary 
     shall seek to enter into an agreement with the PACE program 
     operating in that area for the furnishing of such 
     services.''.

     SEC. 4. HOME- AND COMMUNITY-BASED SERVICES: PROGRAMS.

       (a) Programs.--Chapter 17 of title 38, United States Code, 
     is amended by inserting after section 1720J the following new 
     section (and conforming the table of sections at the 
     beginning of such chapter accordingly):

     ``Sec. 1720K. Home- and community-based services: programs

       ``(a) In General.--In furnishing noninstitutional 
     alternatives to nursing home care pursuant to the authority 
     of section 1720C of this title (or any other authority under 
     this chapter or other provision of law administered by the 
     Secretary of Veterans Affairs), the Secretary shall carry out 
     each of the programs specified in this section in accordance 
     with such relevant authorities except as otherwise provided 
     in this section.
       ``(b) Veteran-Directed Care Program.--(1) The Secretary of 
     Veterans Affairs, in collaboration with the Secretary of 
     Health and Human Services, shall carry out a program to be 
     known as the `Veteran-Directed Care program'. Under such 
     program, the Secretary of Veterans Affairs may enter into 
     agreements with the providers described in paragraph (2) to 
     provide to eligible veterans funds, to the extent 
     practicable, to obtain such in-home care services and related 
     items as may be determined appropriate by the Secretary of 
     Veterans Affairs and selected by the veteran, including 
     through the veteran hiring individuals to provide such 
     services and items or directly purchasing such services and 
     items.
       ``(2) The providers described in this paragraph are the 
     following:
       ``(A) An Aging and Disability Resource Center, an area 
     agency on aging, or a State agency.
       ``(B) A center for independent living.
       ``(C) An Indian tribe or tribal organization receiving 
     assistance under title VI of the Older Americans Act of 1965 
     (42 U.S.C. 3057 et seq.).

[[Page H6098]]

       ``(3) In carrying out the Veteran-Directed Care program, 
     the Secretary of Veterans Affairs shall--
       ``(A) administer such program through each medical center 
     of the Department of Veterans Affairs;
       ``(B) seek to ensure the availability of such program in 
     American Samoa, Guam, the Commonwealth of the Northern 
     Mariana Islands, the Commonwealth of Puerto Rico, the Virgin 
     Islands of the United States, and any other territory or 
     possession of the United States, to the extent practicable; 
     and
       ``(C) seek to ensure the availability of such program for 
     eligible veterans who are Native American veterans receiving 
     care and services furnished by the Indian Health Service, a 
     tribal health program, an Urban Indian organization, or (in 
     the case of a Native Hawaiian veteran) a Native Hawaiian 
     health care system, to the extent practicable.
       ``(4) If a veteran participating in the Veteran-Directed 
     Care program is catastrophically disabled, the veteran may 
     continue to use funds under the program during a period of 
     hospitalization in the same manner that the veteran would be 
     authorized to use such funds under the program if the veteran 
     were not hospitalized.
       ``(c) Homemaker and Home Health Aide Program.--(1) The 
     Secretary shall carry out a program to be known as the 
     `Homemaker and Home Health Aide program' under which the 
     Secretary may enter into agreements with home health agencies 
     to provide to eligible veterans such home health aide 
     services as may be determined appropriate by the Secretary.
       ``(2) In carrying out the Homemaker and Home Health Aide 
     program, the Secretary shall, to the extent practicable, 
     ensure the availability of such program--
       ``(A) in the locations specified in subparagraph (B) of 
     subsection (b)(3); and
       ``(B) for the veteran populations specified in subparagraph 
     (C) of such subsection.
       ``(d) Home-Based Primary Care Program.--The Secretary shall 
     carry out a program to be known as the `Home-Based Primary 
     Care program' under which the Secretary may furnish to 
     eligible veterans in-home health care, the provision of which 
     is overseen by a provider of the Department.
       ``(e) Purchased Skilled Home Care Program.--The Secretary 
     shall carry out a program to be known as the `Purchased 
     Skilled Home Care program' under which the Secretary may 
     furnish to eligible veterans such in-home care services as 
     may be determined appropriate and selected by the Secretary 
     for the veteran.
       ``(f) Caregiver Support.--(1) With respect to a resident 
     eligible caregiver of a veteran participating in a program 
     under this section, the Secretary shall--
       ``(A) if the veteran meets the requirements of a covered 
     veteran under section 1720G(b) of this title, provide to such 
     caregiver the option of enrolling in the program of general 
     caregiver support services under such section;
       ``(B) provide to such caregiver covered respite care of not 
     less than 30 days annually; and
       ``(C) conduct on an annual basis (and, to the extent 
     practicable, in connection with in-person services provided 
     under the program in which the veteran is participating), a 
     wellness contact of such caregiver.
       ``(2) Covered respite care provided to a resident eligible 
     caregiver of a veteran under paragraph (1) may exceed 30 days 
     annually if such extension is requested by the resident 
     eligible caregiver or veteran and determined medically 
     appropriate by the Secretary.
       ``(g) Rule of Construction.--Nothing in this section shall 
     be construed to limit the authority of the Secretary to carry 
     out programs providing home- and community-based services 
     under any other provision of law.
       ``(h) Definitions.--In this section:
       ``(1) The terms `Aging and Disability Resource Center', 
     `area agency on aging', and `State agency' have the meanings 
     given those terms in section 102 of the Older Americans Act 
     of 1965 (42 U.S.C. 3002).
       ``(2) The terms `caregiver' and `family caregiver', with 
     respect to a veteran, have the meanings given those terms, 
     respectively, under subsection (e) of section 1720G of this 
     title with respect to an eligible veteran under subsection 
     (a) of such section or a covered veteran under subsection (b) 
     of such section, as the case may be.
       ``(3) The term `center for independent living' has the 
     meaning given that term in section 702 of the Rehabilitation 
     Act of 1973 (29 U.S.C. 796a).
       ``(4) The term `covered respite care' has the meaning given 
     such term in section 1720G(d) of this title.
       ``(5) The term `eligible veteran' means any veteran--
       ``(A) for whom the Secretary determines participation in a 
     specific program under this section is medically necessary to 
     promote, preserve, or restore the health of the veteran; and
       ``(B) who absent such participation would be at increased 
     risk for hospitalization, placement in a nursing home, or 
     emergency room care.
       ``(6) The term `home health aide' means an individual 
     employed by a home health agency to provide in-home care 
     services.
       ``(7) The term `in-home care service' means any service, 
     including a personal care service, provided to enable the 
     recipient of such service to live at home.
       ``(8) The terms `Indian tribe' and `tribal organization' 
     have the meanings given those terms in section 4 of the 
     Indian Self-Determination and Education Assistance Act (25 
     U.S.C. 5304).
       ``(9) The terms `Native American' and `Native American 
     veteran' have the meanings given those terms in section 3765 
     of this title.
       ``(10) The terms `Native Hawaiian' and `Native Hawaiian 
     health care system' have the meanings given those terms in 
     section 12 of the Native Hawaiian Health Care Improvement Act 
     (42 U.S.C. 11711).
       ``(11) The terms `tribal health programs' and `Urban Indian 
     organizations' have the meanings given those terms in section 
     4 of the Indian Health Care Improvement Act (25 U.S.C. 1603).
       ``(12) The term `resident eligible caregiver' means an 
     individual who--
       ``(A) is a caregiver, or a family caregiver, of a veteran 
     and resides with that veteran; and
       ``(B) has not entered into a contract, agreement, or other 
     arrangement for such individual to act as a caregiver for 
     that veteran unless such individual is a family member of the 
     veteran or is furnishing caregiver services through a medical 
     foster home.''.
       (b) Deadline for Improved Administration.--The Secretary of 
     Veterans Affairs shall ensure that the Veteran-Directed Care 
     program and the Homemaker and Home Health Aide program are 
     administered through each medical center of the Department of 
     Veterans Affairs in accordance with section 1720K of title 
     38, United States Code (as added by subsection (a)), by not 
     later than two years after the date of the enactment of this 
     Act.

     SEC. 5. COORDINATION WITH ASSISTANCE AND SUPPORT SERVICES FOR 
                   CAREGIVERS.

       (a) Coordination With Program of Comprehensive Assistance 
     for Family Caregivers.--
       (1) Coordination.--Section 1720G(a) of title 38, United 
     States Code, is amended by adding at the end the following 
     new paragraph:
       ``(14)(A) In the case of a veteran or caregiver who seeks 
     services under this subsection and is denied such services, 
     or a veteran or the family caregiver of a veteran who is 
     discharged from the program under this subsection, the 
     Secretary shall--
       ``(i) if the veteran meets the requirements of a covered 
     veteran under subsection (b), provide to such caregiver the 
     option of enrolling in the program of general caregiver 
     support services under such subsection;
       ``(ii) assess the veteran or caregiver for participation in 
     any other available program of the Department for home- and 
     community-based services (including the programs specified in 
     section 1720K of this title) for which the veteran or 
     caregiver may be eligible and, with respect to the veteran, 
     store (and make accessible to the veteran) the results of 
     such assessment in the electronic medical record of the 
     veteran; and
       ``(iii) provide to the veteran or caregiver written 
     information on any such program identified pursuant to the 
     assessment under clause (ii), including information about 
     facilities, eligibility requirements, and relevant contact 
     information for each such program.
       ``(B) For each veteran or family caregiver who is 
     discharged from the program under this subsection, a 
     caregiver support coordinator shall provide for a smooth and 
     personalized transition from such program to an appropriate 
     program of the Department for home- and community-based 
     services (including the programs specified in section 1720K 
     of this title), including by integrating caregiver support 
     across programs.''.
       (2) Applicability.--The amendments made by paragraph (1) 
     shall apply with respect to denials and discharges occurring 
     on or after the date that is 180 days after the date of the 
     enactment of this Act.
       (3) Technical and conforming amendments.--Section 1720G(d) 
     of such title is amended--
       (A) by striking ``or a covered veteran'' each place it 
     appears and inserting ``, a veteran denied or discharged as 
     specified in paragraph (14) of such subsection, or a covered 
     veteran''; and
       (B) by striking ``under subsection (a), means'' each place 
     it appears and inserting ``under subsection (a) or a veteran 
     denied or discharged as specified in paragraph (14) of such 
     subsection, means''.
       (b) Conformity of Respite Care Across Programs.--Section 
     1720G of title 38, United States Code, as amended by 
     subsection (a)(3), is further amended--
       (1) in subsection (a)(3)--
       (A) by amending subparagraph (A)(ii)(III) to read as 
     follows:
       ``(III) covered respite care of not less than 30 days 
     annually;''; and
       (B) by striking subparagraph (B) and redesignating 
     subparagraphs (C) and (D) as subparagraphs (B) through (C), 
     respectively; and
       (2) by amending subsection (b)(3)(A)(iii) to read as 
     follows:
       ``(iii) Covered respite care of not less than 30 days 
     annually.''; and
       (3) in subsection (d)--
       (A) by redesignating paragraphs (2) through (4) as 
     paragraphs (3) through (5), respectively; and
       (B) by inserting after paragraph (1) the following new 
     paragraph:

[[Page H6099]]

       ``(2) The term `covered respite care' means, with respect 
     to a caregiver of a veteran, respite care under section 1720B 
     of this title that--
       ``(A) is medically and age appropriate for the veteran 
     (including 24-hour per day care of the veteran commensurate 
     with the care provided by the caregiver); and
       ``(B) includes in-home care.''.
       (c) Review Relating to Caregiver Contact.--The Secretary 
     shall conduct a review of the capacity of the Department to 
     establish a streamlined system for contacting all caregivers 
     enrolled in the program of general caregiver support services 
     under section 1720G(b) of title 38, United States Code, to 
     provide to such caregivers program updates and alerts 
     relating to emerging services for which such caregivers may 
     be eligible.

     SEC. 6. DEVELOPMENT OF CENTRALIZED WEBSITE FOR PROGRAM 
                   INFORMATION.

       (a) Centralized Website.--The Secretary shall develop and 
     maintain a centralized and publically accessible internet 
     website of the Department as a clearinghouse for information 
     and resources relating to covered programs.
       (b) Contents.--The website under subsection (a) shall 
     contain the following:
       (1) A description of each covered program.
       (2) An informational assessment tool that--
       (A) explains the administrative eligibility, if applicable, 
     of a veteran, or a caregiver of a veteran, for any covered 
     program; and
       (B) provides information, as a result of such explanation, 
     on any covered program for which the veteran or caregiver (as 
     the case may be) may be eligible.
       (3) A list of required procedures for the directors of the 
     medical facilities of the Department to follow in determining 
     the eligibility and suitability of veterans for participation 
     in a covered program, including procedures applicable to 
     instances in which the resource constraints of a facility (or 
     of a community in which a facility is located) may result in 
     the inability to address the health needs of a veteran under 
     a covered program in a timely manner.
       (c) Updates.--The Secretary shall ensure the website under 
     subsection (a) is updated on a periodic basis.

     SEC. 7. IMPROVEMENTS RELATING TO HOMEMAKER AND HOME HEALTH 
                   AIDE PROGRAM.

       (a) Pilot Program for Communities With Shortage of Home 
     Health Aides.--
       (1) Program.--Beginning not later than 18 months after the 
     date of the enactment of this Act, the Secretary shall carry 
     out a three-year pilot program under which the Secretary 
     shall provide homemaker and home health aide services to 
     veterans who reside in communities with a shortage of home 
     health aides.
       (2) Locations.--The Secretary shall select not fewer than 
     five geographic locations in which the Secretary determines 
     there is a shortage of home health aides at which to carry 
     out the pilot program under paragraph (1).
       (3) Nursing assistants.--
       (A) In general.--In carrying out the pilot program under 
     paragraph (1), the Secretary may hire nursing assistants as 
     new employees of the Department of Veterans Affairs, or 
     reassign nursing assistants who are existing employees of the 
     Department, to provide to veterans in-home care services 
     (including basic tasks authorized by the State certification 
     of the nursing assistant) under the pilot program, in lieu of 
     or in addition to the provision of such services through non-
     Department home health aides.
       (B) Relationship to home-based primary care program.--
     Nursing assistants hired or reassigned under subparagraph (A) 
     may provide services to a veteran under the pilot program 
     under paragraph (1) while serving as part of a health care 
     team for the veteran under the Home-Based Primary Care 
     program.
       (4) Report to congress.--Not later than one year after the 
     date on which the Secretary determines the pilot program 
     under paragraph (1) has terminated, the Secretary shall 
     submit to the Committees on Veterans' Affairs of the House of 
     Representatives and the Senate a report on the result of the 
     pilot program.
       (b) Report on Use of Funds.--Not later than one year after 
     the date of the enactment of this Act, the Secretary of 
     Veterans Affairs shall submit to the Committees on Veterans' 
     Affairs of the House of Representatives and the Senate a 
     report containing, with respect to the period beginning in 
     fiscal year 2012 and ending in fiscal year 2023, the 
     following:
       (1) An identification of the amount of funds that were 
     included in a budget of the Department of Veterans Affairs 
     during such period for the provision of in-home care to 
     veterans under the Homemaker and Home Health Aide program but 
     were not expended for such provision, disaggregated by 
     medical center of the Department for which such unexpended 
     funds were budgeted (if such disaggregation is possible).
       (2) To the extent practicable, an identification of the 
     number of veterans for whom, during such period, the hours 
     during which a home health aide was authorized to provide 
     services to the veteran under the Homemaker and Home Health 
     Aide program were reduced for a reason other than a change in 
     the health care needs of the veteran, and a detailed 
     description of the reasons why any such reductions may have 
     occurred.
       (c) Updated Guidance on Program.--Not later than one year 
     after the date of the enactment of this Act, the Secretary 
     shall issue updated guidance for the Homemaker and Home 
     Health Aide program. Such updated guidance shall include the 
     following:
       (1) A process for the transition of veterans from the 
     Homemaker and Home Health Aide program to other covered 
     programs.
       (2) A requirement for the directors of the medical 
     facilities of the Department to complete such process 
     whenever a veteran with care needs has been denied services 
     from home health agencies under the Homemaker and Home Health 
     Aide program as a result of the clinical needs or behavioral 
     issues of the veteran.

     SEC. 8. REVIEWS AND OTHER IMPROVEMENTS RELATING TO HOME- AND 
                   COMMUNITY-BASED SERVICES.

       (a) Office of Geriatric and Extended Care.--
       (1) Review of programs.--The Under Secretary for Health of 
     the Department of Veterans Affairs shall conduct a review of 
     each program administered through the Office of Geriatric and 
     Extended Care of the Department, or successor office, to--
       (A) ensure consistency in program management;
       (B) eliminate service gaps at the medical center level; and
       (C) ensure the availability of, and the access by veterans 
     to, home- and community-based services.
       (2) Assessment of staffing needs.--The Secretary of 
     Veterans Affairs shall conduct an assessment of the staffing 
     needs of the Office of Geriatric and Extended Care of the 
     Department of Veterans Affairs, or successor office.
       (3) Goals for geographic alignment of care.--
       (A) Establishment of goals.--The Director of the Office of 
     Geriatric and Extended Care, or successor office, shall 
     establish quantitative goals to enable aging or disabled 
     veterans who are not located near medical centers of the 
     Department to access extended care services (including by 
     improving access to home- and community-based services for 
     such veterans).
       (B) Implementation timeline.--Each goal established under 
     subparagraph (A) shall include a timeline for the 
     implementation of the goal at each medical center of the 
     Department.
       (4) Goals for in-home specialty care.--The Director of the 
     Office of Geriatric and Extended Care, or successor office, 
     shall establish quantitative goals to address the specialty 
     care needs of veterans through in-home care, including by 
     ensuring the education of home health aides and caregivers of 
     veterans in the following areas:
       (A) Dementia care.
       (B) Care for spinal cord injuries and diseases.
       (C) Ventilator care.
       (D) Other speciality care areas as determined by the 
     Secretary.
       (5) Report to congress.--Not later than one year after the 
     date of the enactment of this Act, the Secretary shall submit 
     to the Committees on Veterans' Affairs of the House of 
     Representatives and the Senate a report containing the 
     findings of the review under paragraph (1), the results of 
     the assessment under paragraph (2), and the goals established 
     under paragraphs (3) and (4).
       (b) Review of Incentives and Efforts Relating to Home- and 
     Community-Based Services.--
       (1) Review.--The Secretary of Veterans Affairs shall 
     conduct a review of the following:
       (A) The financial and organizational incentives for the 
     directors of medical centers of the Department to establish 
     or expand covered programs at such medical centers.
       (B) Any incentives for such directors to provide to 
     veterans home- and community-based services in lieu of 
     institutional care.
       (C) The efforts taken by the Secretary to enhance spending 
     of the Department for extended care by shifting the balance 
     of such spending from institutional care to home- and 
     community-based services.
       (D) The plan of the Under Secretary for Health of the 
     Department to accelerate efforts to enhance spending as 
     specified in subparagraph (C), to match the progress of 
     similar efforts taken by the Administrator of the Centers for 
     Medicare & Medicaid Services with respect to spending of the 
     Centers for Medicare & Medicaid Services for extended care.
       (2) Report to congress.--Not later than one year after the 
     date of the enactment of this Act, the Secretary shall submit 
     to the Committees on Veterans' Affairs of the House of 
     Representatives and the Senate a report on the findings of 
     the review under paragraph (1).
       (c) Review of Respite Care Services.--Not later than two 
     years after the date of the enactment of this Act, the 
     Secretary of Veterans Affairs shall conduct a review of the 
     use, availability, and effectiveness, of the respite care 
     services furnished by the Secretary under chapter 17 of title 
     38, United States Code.
       (d) Collaboration To Improve Home- and Community-Based 
     Services.--
       (1) Report on expansion of certain mental health 
     services.--
       (A) Report.--Not later than two years after the date of the 
     enactment of this Act, the Secretary of Veterans Affairs, in 
     collaboration with the Secretary of Health and Human 
     Services, shall submit to the Committees on Veterans' Affairs 
     of the House of Representatives and the Senate a report 
     containing recommendations for the expansion

[[Page H6100]]

     of mental health services and related support to the 
     caregivers of veterans.
       (B) Matters included.--The report under subparagraph (A) 
     shall include an assessment of the feasibility and 
     advisability of authorizing access to Vet Centers by--
       (i) family caregivers enrolled in a program under section 
     1720G of title 38, United States Code; and
       (ii) family caregivers of veterans participating in a 
     program specified in section 1720K of such title, as added by 
     section 4.
       (2) Recommendations.--
       (A) Development.--The Secretary of Veterans Affairs shall 
     develop recommendations as follows:
       (i) With respect to home- and community-based services for 
     veterans, the Secretary of Veterans Affairs shall develop 
     recommendations regarding new services (in addition to those 
     furnished as of the date of the enactment of this Act) in 
     collaboration with the Secretary of Health and Human 
     Services.
       (ii) With respect to the national shortage of home health 
     aides, the Secretary of Veterans Affairs shall develop 
     recommendations regarding methods to address such shortage in 
     collaboration with the Secretary of Health and Human Services 
     and the Secretary of Labor.
       (B) Submission to congress.--The Secretary of Veterans 
     Affairs shall submit to the Committees on Veterans' Affairs 
     of the House of Representatives and the Senate a report 
     containing the recommendations developed under subparagraph 
     (A) and an identification of any changes in existing law or 
     new statutory authority necessary to implement the 
     recommendations, as determined by the Secretary.
       (C) Consultation with secretary of labor.--In carrying out 
     this paragraph, the Secretary of Veterans Affairs shall 
     consult with the Secretary of Labor.
       (3) Feedback and recommendations on caregiver support.--
       (A) Feedback and recommendations.--The Secretary of 
     Veterans Affairs shall solicit from the entities described in 
     subparagraph (B) feedback and recommendations regarding 
     opportunities for the Secretary to enhance home- and 
     community-based services for veterans and the caregivers of 
     veterans, including through the potential provision by the 
     entity of care and respite services to veterans and 
     caregivers who may not be eligible for any program under 
     section 1720G of title 38, United States Code, or section 
     1720K of such title (as added by section 4), but have a need 
     for assistance.
       (B) Covered entities.--The entities described in this 
     subparagraph are veterans service organizations and nonprofit 
     organizations with a focus on caregiver support (as 
     determined by the Secretary).
       (4) Collaboration for native american veterans.--The 
     Secretary of Veterans Affairs shall collaborate with the 
     Director of the Indian Health Service and representatives 
     from tribal health programs and Urban Indian organizations to 
     ensure the availability of home- and community-based services 
     for Native American veterans, including Native American 
     veterans receiving health care and medical services under 
     multiple health care systems.

     SEC. 9. MODIFICATION OF CERTAIN HOUSING LOAN FEES.

       The loan fee table in section 3729(b)(2) of title 38, 
     United States Code, is amended by striking ``November 15, 
     2031'' each place it appears and inserting ``February 4, 
     2032''.

     SEC. 10. DEFINITIONS.

       In this Act:
       (1) The terms ``caregiver'' and ``family caregiver'' have 
     the meanings given those terms under section 1720K(h) of 
     title 38, United States Code (as added by section 4).
       (2) The term ``covered program''--
       (A) means any program of the Department of Veterans Affairs 
     for home- and community-based services; and
       (B) includes the programs specified in section 1720K of 
     title 38, United States Code (as added by section 4).
       (3) The term ``home- and community-based services''--
       (A) means the services referred to in section 1701(6)(E) of 
     title 38, United States Code; and
       (B) includes services furnished under a program specified 
     in section 1720K of such title (as added by section 4).
       (4) The terms ``Home-Based Primary Care program'', 
     ``Homemaker and Home Health Aide program'', and ``Veteran-
     Directed Care program'' mean the programs of the Department 
     of Veterans Affairs specified in subsection (d), (c), and (b) 
     of such section 1720K, respectively.
       (5) The terms ``home health aide'', ``Native American'', 
     ``Native American veteran'', ``tribal health programs'', and 
     ``Urban Indian organizations'' have the meanings given those 
     terms in subsection (h) of such section 1720K.
       (6) The term ``Vet Center'' has the meaning given that term 
     in section 1712A(h) of title 38, United States Code.
       (7) The term ``veterans service organization'' means any 
     organization recognized by the Secretary under section 5902 
     of such title.

  The SPEAKER pro tempore. Pursuant to the rule, the gentleman from 
Michigan (Mr. Bergman) and the gentleman from California (Mr. Takano) 
each will control 20 minutes.
  The Chair recognizes the gentleman from Michigan.


                             General Leave

  Mr. BERGMAN. Mr. Speaker, I ask unanimous consent that all Members 
may have 5 legislative days in which to revise and extend their 
remarks.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Michigan?
  There was no objection.
  Mr. BERGMAN. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, I rise today in support of H.R. 542, the Elizabeth Dole 
Home- and Community-Based Services for Veterans and Caregivers Act of 
2023, or the Elizabeth Dole Home Care Act of 2023, as amended.
  The bill is a pivotal piece of legislation aimed at transforming the 
landscape of long-term care for our Nation's veterans. I commend 
Representative Brownley for her bipartisan work with me on it.
  Veterans, like all Americans, are living longer. This requires the 
Veterans Administration to adapt to this evolving veteran population to 
ensure that eligible veterans entering their later years have access to 
long-term care that meets their needs.
  As of fiscal year 2022, approximately 3.1 million veterans, roughly 
half of VA's active patient population, were 65 years or older. These 
veterans, often older, sicker, and poorer than the general population, 
and often residing in rural areas, demand a tailored approach to 
healthcare.
  Veterans want to remain at home for care, avoiding admission to long-
term care facilities. This preference is not only understandable but 
becomes imperative given the current challenges with long-term care 
facilities and limited admissions nationwide.
  By expanding VA's noninstitutional long-term care services through 
Representative Brownley's and my bill, we would allow aging and 
disabled veterans the option of staying in their homes. Institutional 
care can be reserved for veterans who truly need intensive round-the-
clock care and services.
  While many States have shifted investments from institutional to 
home- and community-based care, VA has not kept pace. The lack of a 
statutory mandate has led to inconsistent availability of home- and 
community-based services, leaving many veterans underserved simply 
based on where they live. That is unacceptable.
  Veterans and veteran service organizations have consistently urged VA 
to focus on expanding access to home- and community-based services to 
allow veterans to age comfortably and safely in place.
  The Veterans' Affairs Committee answered these demands head-on, and 
we held numerous hearings on the issue and focused on equitable long-
term care access. Our bill would also rightfully eliminate the annual 
cap on noninstitutional care to include greater flexibility in meeting 
the needs of veterans living with ALS or spinal cord injuries, for 
example.
  Under current law, these veterans are often forced into institutional 
care simply because funding cannot be provided for home care. This bill 
would ensure availability of all programs, such as veteran-directed 
care, homemaker home health aide, home-based primary care, and 
purchased skilled home care at all VA medical centers.
  In addition to expanding access, the Dole Act urges the VA to take a 
more active role in helping veterans and their caregivers navigate the 
multiple options that may be available to them as they consider long-
term care.
  It is no secret that the Nation is facing a shortage of qualified 
professionals capable of taking on the tasks required by home- or 
community-based care.
  Representative Brownley's and my bill would create a pilot program to 
bring in more professionals to serve veterans through homemaker and 
home health services.
  Finally, I want to emphasize that we are committed to fiscal 
responsibility and have identified an offset to fully fund these 
programs that will ultimately address the pressing needs of America's 
aging veteran population.
  The Elizabeth Dole Home Care Act of 2023 is a pledge to ensure 
veterans receive the care they deserve, preserving their dignity and 
independence, whether they are catastrophically disabled or in the 
twilight of their lives.
  Mr. Speaker, I sincerely thank Representative Brownley for her 
dedication to this issue and her bipartisan work with me on this 
legislation.

[[Page H6101]]

  Mr. Speaker, I ask unanimous consent to include in the Record a 
letter from 46 organizations, including all of the major veterans 
service organizations, the Elizabeth Dole Foundation, and many other 
groups, and I thank them for their dedication to caring for and serving 
veterans.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Michigan?
  There was no objection.

                                                November 30, 2023.
     Hon. Jon Tester,
     Chairman, Senate Committee on Veterans' Affairs, Washington, 
         DC.
     Hon. Jerry Moran,
     Ranking Member, Senate Committee on Veterans' Affairs, 
         Washington, DC.
     Hon. Mike Bost
     Chairman, House Committee on Veterans' Affairs, Washington, 
         DC.
     Hon. Mark Takano,
     Ranking Member, House Committee on Veterans' Affairs, 
         Washington, DC.
       Dear Chairmen and Ranking Members: As national 
     organizations representing service-disabled veterans and 
     their caregivers, we are writing to thank you for your 
     ongoing commitment to the well-being of our nation's most 
     vulnerable heroes. Together, we hope you quickly Consider and 
     pass the Elizabeth Dole Home Care Act either as part of a 
     veteran supported omnibus package or a standalone bill.
       The enactment of this bipartisan legislation will help to 
     ensure that severely injured, ill, and aging veterans and 
     their caregivers have access to a comprehensive suite of VA 
     services necessary to age in place with well-deserved dignity 
     and much-needed support.
       Most importantly, it would help veterans and their 
     caregivers get the care and support they need now while 
     ensuring that the required program infrastructure is 
     available to serve veterans into the future. Disabled 
     veterans and their families cannot wait any longer.
           Sincerely,
       The Elizabeth Dole Foundation; Paralyzed Veterans of 
     America; AARP; ALS Association; Wounded Warrior Project; IAM 
     ALS; Disabled American Veterans; Air Force Sergeants 
     Association; The Retired Enlisted Association; Veterans of 
     Foreign Wars; American Legion; Military Officers Association 
     of America; Blinded Veterans of America; National Military 
     Family Association; Reserve Officers' Association; Blue Star 
     Families.
       America's Warrior Partnership; Tragedy Assistance Program 
     for Survivors; The American Red Cross; TEAM Public Choices; 
     Psycharmor; Psych Hub; Vets' Community Connections; 
     Association of Military Banks; K9s For Warriors; Travis 
     Manion Foundation; Operation Homefront; Project Sanctuary; 
     Modern Military Association of America; US Military Spouse 
     Chamber of Commerce; Military Family Advisory Network.
       Student Veterans of America; Military Child Education 
     Coalition; RallyPoint; Code of Support; Women in Military 
     Service for America Memorial Foundation, Inc.; Easter Seals 
     DC MD VA; Partners in Promise; Maxim Healthcare Services; 
     Hope for the Warriors; Cohen Veterans Network; Armed Services 
     YMCA; SolaMed Solutions; Exceptional Families of the 
     Military; Easterseals, Inc.; Nation's Finest.

  Mr. BERGMAN. Mr. Speaker, while we are considering this bill today, I 
would remind my colleagues that this legislation is also a part of a 
comprehensive veterans package being negotiated between the House and 
Senate Veterans' Affairs Committees.
  Mr. Speaker, I look forward to working with my colleagues in the days 
ahead to collectively advance not only this legislation, but many other 
proposals that support the interests and the well-being of all 
veterans.
  Finally, I thank the numerous veteran service organization partners 
who have worked with us.
  Mr. Speaker, I urge all my colleagues to support H.R. 542, as 
amended, and I reserve the balance of my time.
  Mr. TAKANO. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, I rise to express my support for H.R. 542, as amended, 
the Elizabeth Dole Home Care Act of 2023.
  This bill, introduced by Representative Brownley and Representative 
Bergman and reported out of committee with unanimous support in July, 
is truly landmark legislation.
  It would require VA to provide access to all home-and community-based 
services, such as home health aides, home-based primary care, and 
respite care to all veterans and caregivers who need them.
  Currently, elderly and disabled veterans only have access to 
important home- and community-based services if their VA medical 
centers have chosen to offer these services.
  This bill is named for a person, who in her personal life and in 
public service, has dedicated herself to caring for others: Senator 
Elizabeth Dole. Tomorrow will mark the second anniversary of the 
passing of Senator Bob Dole, an Army veteran who had a dedicated 
caregiver in the other Senator Dole.
  This legislation will enable veterans to remain at home, safely age 
in place, and avoid or delay admission to nursing homes and other 
costly institutional settings of care. It will also help connect 
veterans' caregivers to respite care and other supportive services that 
help them care for veterans at home and improve VA's coordination with 
other Federal long-term care programs that promote aging at home.
  Finally, the Elizabeth Dole Home Care Act of 2023 will require VA to 
create a website where veterans and their families can more easily 
obtain information about VA's home- and community-based services 
programs and assess whether any of these programs may be right for 
them. The research is clear: veterans prefer to remain at home and 
their health outcomes are better when they do. Home care is by far the 
cheaper alternative to institutional settings.
  Nearly every veteran will at some point face the need for additional 
care at home, or if they can't get it, spend their last years in a 
nursing home setting. This legislation is an investment in care for 
millions of veterans and current servicemembers who need this help now 
or in the future.
  The Elizabeth Dole Home Care Act of 2023 has the support of every 
major veteran service organization, including Paralyzed Veterans of 
America, Disabled American Veterans, Veterans of Foreign Wars, the 
American Legion, the Wounded Warrior Project, and the Military Officers 
Association of America.
  It is also supported by AARP, the National Association of Counties, 
the National PACE Association, and the Elizabeth Dole Foundation.
  It has been these groups' number one policy priority. Shouldn't it be 
ours?
  These groups, and dozens of others, have advocated tirelessly for 
passage since its introduction 2 years ago.
  Despite the great need for this bill, it has been an uphill battle to 
get it to the floor. We have worked to get support and get the cost 
down. That showed when it was voted unanimously out of committee in 
July.
  It seems the battle is not over yet because this bill cannot be taken 
up by the Senate as is. Since the bill was reported, we have worked 
with our counterparts in the Senate to ensure the bill was as near to 
perfect as possible. There were a few changes that were agreed upon by 
all four corners of the Committee on Veterans' Affairs.

                              {time}  1645

  Unfortunately, instead of advancing text with full sign-off, the 
majority has gone back to text they know has problems in the Senate, so 
we will have to either await amendment by the Senate or some other 
legislative action before this legislation can move to President 
Biden's desk for signature.
  The programs and services in this bill are life-changing. In the next 
16 years, VA will have doubled its spending on long-term care services, 
nearing $15 billion, to meet these needs. While enrolled veterans have 
a right to institutional care, there are not enough beds or staff in 
institutional settings in the country to meet the projected need.
  Good sense tells us that VA must move quickly to expand home- and 
community-based services to keep veterans safely in their homes. 
Providing home- and community-based services would also ensure that VA 
has the space and staff to care for those who truly do need 
institutional care.
  It is disappointing that we have not gotten this bill on the fast 
track to signing and that disabled and elderly veterans and their 
caregivers will have to wait even longer for the care they deserve. 
This holiday season, we could have given these veterans a gift with 
lasting impact. The House majority instead tells us we must content 
ourselves to wait for the Elizabeth Dole Home Care Act to be included 
in a larger package.
  The majority has committed to moving this legislative package out of 
the House and the Senate with delivery to the President by the end of 
January. I remind everyone that there are some other big items that we 
have to get done in January, and I am worried about whether or not that 
other big item might impede our ability to get this item done.

[[Page H6102]]

  The intention is that the Elizabeth Dole Home Care Act and the HOME 
Act be included as key pillars of the package.
  The majority has also committed in the last week to not abuse these 
bipartisan bills as leverage to include partisan poison pills in that 
package. I intend to hold my Republican colleagues to that agreement, 
and the stakeholders and the VSOs will, as well.
  This agreement includes the fallback that if this package cannot be 
completed in time, then these bills should be advanced as standalone. 
We received a letter on Friday from a broad coalition of national 
organizations representing service-disabled veterans and their 
caregivers memorializing this agreement that said it best: ``Disabled 
veterans and their families cannot wait any longer.''
  It was the same exact letter that was already included in the Record 
by my colleague from Michigan, so I don't have to include it again now.
  Mr. Speaker, I support H.R. 542, as amended, and I ask my colleagues 
to do the same.
  Mr. Speaker, I yield such time as she may consume to the gentlewoman 
from the great State of California (Ms. Brownley), who is the ranking 
member of the Subcommittee on Health and the author of this amazing 
piece of legislation.
  Ms. BROWNLEY. Mr. Speaker, I thank Ranking Member Takano for his 
partnership and his efforts to bring this important bill for our 
Nation's disabled and aging veterans and their caregivers to the floor.
  Mr. Speaker, I rise in support of this bill, Representative Bergman's 
and my bill, H.R. 542, the Elizabeth Dole Home Care Act.
  I am so proud to have authored this legislation, which delivers the 
largest set of reforms to the VA's long-term care programs in decades. 
The bill will significantly expand access to the programs disabled and 
aging veterans need to live their lives at home and with their 
families.
  Specifically, the bill requires the Department of Veterans Affairs to 
provide access to all home- and community-based services, such as home 
health aides, home-based primary care, home skilled nursing, and 
respite care for caregivers to all veterans who need them. Currently, 
elderly and disabled veterans only have access to these programs if 
their VA medical centers choose to offer them.
  My bill would also require VA to improve care coordination between 
the Program of Comprehensive Assistance for Family Caregivers and VA's 
other home-based programs. If a veteran does not meet the enrollment 
criteria for the comprehensive caregiver program, VA would be required 
to proactively assist the veteran and their caregiver in enrolling in 
other home-based programs and ensure there is a warm handoff for those 
who do not qualify for the comprehensive caregiver program.
  Finally, my legislation would require VA to establish a public-facing 
website that will enable veterans and their loved ones to assess their 
eligibility for each of the home- and community-based services VA 
offers and provide information about how to access these services.
  I have served on the Veterans' Affairs Committee since my first term 
in Congress, and over the last 10 years, I have participated in at 
least five oversight hearings related to improving long-term care for 
our veterans. I have also spoken with countless veterans and their 
loved ones, and based on my experience, one thing is very clear: Almost 
every veteran would prefer to age at home rather than in a facility. 
However, for many veterans, doing so requires certain clinical support 
that can be prohibitively expensive if not covered by the VA. This bill 
would help address just that.
  Furthermore, it is important to really underscore this point: Home- 
and community-based care is far and away higher quality and cheaper to 
provide than institutional care. VA's veteran-directed care program can 
serve three veterans for every one who would be in institutionalized 
care at VA's expense. It is important to note that veterans who 
participate in this program are less likely to develop complications or 
to be hospitalized than those who do not.
  Yet, this program is currently not made available to all veterans. 
The Elizabeth Dole Home Care Act changes that.

  Passage of this legislation cannot wait any longer. Like so many 
families across the country, thousands of elderly and catastrophically 
disabled veterans and their families are having critical and often 
difficult conversations about their long-term care. They question 
whether they spend their lifesavings to keep their veterans at home or 
whether it is safer to go to a VA-funded nursing facility.
  H.R. 542 would help relieve this heartache and give families access 
to programs that will help veterans stay in their homes and receive the 
care they need, the care that they have earned, and the care that they 
deserve.
  I will repeat one more time that, most importantly, health outcomes 
prove to be far better at home compared to institutionalized care.
  Last week, 45 veterans service organizations, military service 
organizations, and community-based organizations sent a letter to House 
and Senate leadership, urging the swift passage of this bill and saying 
that, as the ranking member said, disabled veterans and their families 
cannot wait any longer. I could not agree more.
  Mr. Speaker, I would like to try to put a face to the experiences 
that so many disabled or aging veterans often go through and why this 
bill is so necessary.
  This bill is for the 40-year-old veteran who is quadriplegic and who 
may have to move into institutionalized care because VA won't provide 
the skilled nursing services that would help him remain at home.
  This bill is for the 50-year-old veteran with ALS who has three small 
children and wants to spend the remaining time he has with them at 
home. He shouldn't be forced to move into a long-term care facility 
because the cost of his care has gone over an arbitrary spending cap.
  This bill is for the Vietnam-era amputee who needs help getting 
dressed and preparing food but can otherwise live safely at home. He 
should not have to wait for Congress to act to get the care and 
assistance he needs.
  Moreover, this bill is for the Korean war veteran whose aging spouse 
can no longer provide the level of care she once did. They want to stay 
at home together. It is unconscionable this Congress would make them 
wait a moment longer. They need these services and support, and they 
need it now.
  I am, therefore, perplexed that when the majority brought H.R. 542 to 
the House floor, they chose to bring a version of the legislation that 
did not include the minor revisions that had been negotiated with our 
Senate counterparts. This means future House action will be warranted, 
which is truly inexcusable to me and the veterans, their families, and 
their caregivers who are waiting on passage of this bill. We had the 
opportunity to get this done before the end of the year, send it to the 
Senate, and then to the President's desk for enactment.
  When Representative Bergman and I first introduced this legislation, 
we named it after Senator Elizabeth Dole. She has done more for aging 
and disabled veterans and their caregivers in one lifetime than most of 
us could hope to do in several.
  It was introduced in February 2022, just a few months after the 
veteran she cared for, Senator Bob Dole, passed away. Tomorrow, we will 
mark the second anniversary of Senator Bob Dole's passing. It is a 
shame that we could not honor Senator Elizabeth Dole's example and 
life's work on this anniversary by sending a hotline-ready bill to the 
Senate that the President could sign before Christmas. It is shameful, 
and it is disrespectful, really, to play politics with a bill the 
veteran community wants so badly and a bill that is more cost-
effective, provides better outcomes, and is what our Nation's veterans 
need and want.
  I hope we will soon be voting on the final passage of the bill 
language that the House and Senate have already agreed to and that 
veterans and their families so desperately need. All of us will, one 
day, have conversations about what we want our last years to look like. 
Our aging and disabled veterans have more than earned the right to have 
the option of living out these final years at home.
  Of all the things we owe these men and women, a peaceful and 
dignified

[[Page H6103]]

life after their service to our country is the least we can do. I call 
on my colleagues to do right by these veterans. Put politics aside, 
keep families together, and keep veterans healthy and at home.
  Mr. Speaker, I urge my colleagues to join me in voting for the 
Elizabeth Dole Home Care Act, and I thank Ranking Member Takano and 
Representative Bergman for their work on this bill.
  Mr. TAKANO. Mr. Speaker, I have no further speakers. I am prepared to 
close, and I reserve the balance of my time.
  Mr. BERGMAN. Mr. Speaker, once again, I strongly encourage all 
Members to support this legislation, and I yield back the balance of my 
time.
  Mr. TAKANO. Mr. Speaker, I ask all of my colleagues to join me in 
support of this very important, transformational piece of legislation, 
H.R. 542, as amended, and I yield back the balance of my time.
  The SPEAKER pro tempore. The question is on the motion offered by the 
gentleman from Michigan (Mr. Bergman) that the House suspend the rules 
and pass the bill, H.R. 542, as amended.
  The question was taken.
  The SPEAKER pro tempore. In the opinion of the Chair, two-thirds 
being in the affirmative, the ayes have it.
  Mr. TAKANO. Mr. Speaker, on that I demand the yeas and nays.
  The yeas and nays were ordered.
  The SPEAKER pro tempore. Pursuant to clause 8 of rule XX, further 
proceedings on this motion will be postponed.

                          ____________________