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[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]

                IMPLEMENTATION OF CAREGIVER ASSISTANCE:
                        ARE WE GETTING IT RIGHT?

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 11, 2011

                               __________

                            Serial No. 112-4

                               __________

       Printed for the use of the Committee on Veterans' Affairs

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65-870                    WASHINGTON : 2011
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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

GUS M. BILIRAKIS, Florida            BOB FILNER, California, Ranking
CLIFF STEARNS, Florida               CORRINE BROWN, Florida
DOUG LAMBORN, Colorado               SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee              MICHAEL H. MICHAUD, Maine
DAN BENISHEK, Michigan               LINDA T. SANCHEZ, California
ANN MARIE BUERKLE, New York          BRUCE L. BRALEY, Iowa
JEFF DENHAM, California              JERRY McNERNEY, California
BILL FLORES, Texas                   JOE DONNELLY, Indiana
TIM HUELSKAMP, Kansas                TIMOTHY J. WALZ, Minnesota
BILL JOHNSON, Ohio                   JOHN BARROW, Georgia
JON RUNYAN, New Jersey               RUSS CARNAHAN, Missouri
MARLIN A. STUTZMAN, Indiana
Vacancy
Vacancy

            Helen W. Tolar, Staff Director and Chief Counsel

                         Subcommittee on Health

                ANN MARIE BUERKLE, New York, Chairwoman

CLIFF STEARNS, Florida               MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida            CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              SILVESTRE REYES, Texas
DAN BENISHEK, Michigan               RUSS CARNAHAN, Missouri
JEFF DENHAM, California              JOE DONNELLY, Indiana
JON RUNYAN, New Jersey

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                               __________

                             March 11, 2011

                                                                   Page
Implementation of Caregiver Assistance: Are We Getting It Right?.     1

                           OPENING STATEMENTS

Chairwoman Ann Marie Buerkle.....................................     1
    Prepared statement of Chairwoman Buerkle.....................    28
Hon. Michael H. Michaud, Ranking Democratic Member...............     3
    Prepared statement of Congressman Michaud....................    29
Hon. Gus M. Bilirakis, prepared statement of.....................    30
Hon. Silvestre Reyes, prepared statement of......................    30
Hon. Russ Carnahan, prepared statement of........................    31

                               WITNESSES

U.S. Department of Veterans Affairs, Hon. Robert A. Petzel, M.D., 
  Under Secretary for Health, Veterans Health Administration.....    20
    Prepared statement of Mr. Petzel.............................    56

                                 ______

Disabled American Veterans, Adrian Atizado, Assistant National 
  Legislative Director...........................................     4
    Prepared statement of Mr. Atizado............................    31
Iraq and Afghanistan Veterans of America, Tom Tarantino, Senior 
  Legislative Associate..........................................     7
    Prepared statement of Mr. Tarantino..........................    44
National Military Family Association, Barbara Cohoon, Ph.D., 
  R.N., Government Relations Deputy Director.....................     9
    Prepared statement of Dr. Cohoon.............................    46
Wounded Warrior Project, Ralph Ibson, National Policy Director...     6
    Prepared statement of Mr. Ibson..............................    37

                       SUBMISSIONS FOR THE RECORD

Paralyzed Veterans of America, statement.........................    63
VetsFirst, a Program of United Spinal Association, Heather L. 
  Ansley, Esq., MSW, Director of Veterans Policy, statement......    65

                   MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:

    Hon. Michael H. Michaud, Ranking Democratic Member, 
      Subcommittee on Health, Committee on Veterans' Affairs to 
      Tom Tarantino, Senior Legislative Associate, Iraq and 
      Afghanistan Veterans of America, letter dated March 17, 
      2011, and Mr. Tarantino's responses........................    68
    Hon. Michael H. Michaud, Ranking Democratic Member, 
      Subcommittee on Health, Committee on Veterans' Affairs to 
      Barbara Cohoon, Ph.D., R.N., Government Relations Deputy 
      Director, National Military Family Association, letter 
      dated March 17, 2011, and response letter dated April 8, 
      2011.......................................................    70
    Hon. Michael H. Michaud, Ranking Democratic Member, 
      Subcommittee on Health, Committee on Veterans' Affairs to 
      Hon. Robert A. Petzel, M.D., Under Secretary of Health, 
      Veterans Health Administration, U.S. Department of Veterans 
      Affairs, letter dated March 17, 2011, and VA's responses...    74

 
    IMPLEMENTATION OF CAREGIVER ASSISTANCE: ARE WE GETTING IT RIGHT?

                              ----------                              

                         FRIDAY, MARCH 11, 2011

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. Ann Marie Buerkle 
[Chairwoman of the Subcommittee] presiding.
    Present: Representatives Buerkle, Stearns, Bilirakis, Roe, 
Runyan, Michaud, Carnahan, and Donnelly.

            OPENING STATEMENT OF CHAIRWOMAN BUERKLE

    Ms. Buerkle. I want to begin by thanking all of you in 
attendance this morning for joining us for the very first 
hearing of the Subcommittee on Health of the Committee on 
Veterans' Affairs.
    I also want to take the opportunity to say thank you on 
behalf of our Nation to all of the veterans in this room. We 
live in the greatest Nation in the history of mankind because 
of the service and the sacrifice of our veterans. Please allow 
me, on behalf of a grateful Nation, to say thank you to all of 
you this morning.
    I am honored to have been chosen to be the Chairwoman of 
the Health Subcommittee. And I am very pleased that my 
colleague, Mr. Michaud, has been selected to be the Ranking 
Member.
    Mr. Michaud has a distinguished history of service and 
support to our veterans, and I look forward to closely working 
with him to ensure that those who have so honorably served our 
country receive the highest quality care that they so much 
deserve. I know he shares my conviction that the very least we 
can do for our veterans who put themselves in harm's way is to 
ensure that they have excellent health care.
    We are joined on the Health Subcommittee, and I will go 
through the whole list of Members. I will mention those who 
were here first, Mr. David Roe from Tennessee, and Mr. Cliff 
Stearns from Florida. We have Ms. Corrine Brown of Florida and 
Mr. Michaud from Maine.
    Not here yet is Mr. Gus Bilirakis from Florida, Dr. Dan 
Benishek from Michigan, Mr. Jeff Denham from California, Mr. 
Jon Runyan from New Jersey, Mr. Russ Carnahan from Missouri, 
and Mr. Joe Donnelly from Indiana.
    I am so pleased with the wealth and the diversity of 
knowledge and the experience that they all bring to this 
Subcommittee. I am confident that the work we are going to do 
will be in the best interest of veterans and have a real and 
positive impact on the daily lives of our brave veteran heroes 
and their loved ones, which brings us to the matter that we are 
here to discuss morning.
    Each one of us serves on this Committee because of a deep 
respect and admiration for the service and sacrifice of 
American veterans. Each of us serves on this Subcommittee, 
because we recognize the importance of ensuring that our 
veterans have access to high quality medical care to help them 
cope with the wounds of war and readjust to civilian life. Each 
of us here has a respect for the U.S. Department of Veterans 
Affairs (VA) health care system as it stands and a fervent 
desire to make the system even better.
    At the same time, we recognize that no matter how good a 
health care system is, it can only go so far. We can and we 
must provide the highest quality of care for our veterans. But 
regardless of how hard we try, nothing, can equal the love and 
support given by a family member.
    Some family members are with us this morning. In our 
audience is Sarah Wade and Patty Horan. Sarah is the full-time 
caregiver for her husband, Ted, who was injured in Iraq when 
his Humvee was hit by an improvised explosive device (IED). 
Patty is a full-time caregiver for her husband, Pat, who 
suffered from a gunshot wound during his service in Iraq.
    If I could ask you to stand, we would like to acknowledge 
you and thank you for making the trip here this morning. Sarah 
and Patty have been there for their husbands day in and day out 
through every up and every down in the course of their 
recovery. Because of their commitment to their husbands, they 
have sacrificed jobs, hobbies, and personal free time.
    Last year, Congress passed Public Law 111-163 to ensure 
that family caregivers like Sarah and Patty wouldn't also have 
to sacrifice their financial stability or their own health.
    Congress intended for these benefits to be available by 
January 30th of this year. However, the Department of Veterans 
Affairs has failed to comply with the law and has yet to 
implement the caregiver assistance program.
    Even more unfortunate, when the VA finally released its 
initial implementation plan on February 9th, it was immediately 
met with consternation by lawmakers and stakeholders who raised 
serious concerns about strict eligibility criteria and other 
issues, including the provision for respite care, mental health 
coverage, and in-home monitoring requirements.
    It is my fervent hope that this morning we will bring these 
issues to light and uncover the necessary changes, and those 
changes will be made by the VA to ensure that the benefits 
Congress intended and veteran and family members expected and 
so deserve are provided without further delay.
    Again, I thank you all for being here this morning. I look 
forward to a very positive and productive discussion.
    At this time, I now recognize my colleague and Ranking 
Member, Mr. Michaud.
    [The prepared statement of Chairwoman Buerkle appears on 
p. 28.]

          OPENING STATEMENT OF HON. MICHAEL H. MICHAUD

    Mr. Michaud. Thank you very much, Madam Chair. I want to 
congratulate you for being elected to your position as Chair of 
the Subcommittee, and I think it is definitely a very good 
bipartisan Committee. We work very well together to make sure 
that what we do in the Committee that we ultimately take care 
of the veterans and the caregivers. And I think you will find 
over the next 2 years, that the Committee staff, both on the 
Republican side and Democratic side, work very well together. 
So congratulations. I look forward to working with you.
    And I also want to thank you for holding this hearing 
today. The goals of today's hearing is to identify the gaps in 
the implementation of Public Law 111-163, the Caregivers and 
Veterans Omnibus Health Service Act of 2010. We also seek a 
better understanding of the VA's current efforts to meet the 
needs of the family caregivers of our veterans.
    Public Law 111-163 provides immediate support to the 
mothers, fathers, husbands, and wives and other family members 
caring for the warrior for the current conflict, as well as 
previous conflicts. Today, we have an opportunity to recognize 
their tremendous sacrifice and share the heavy burden that the 
caregivers give.
    As you heard earlier, we do have a couple of caregivers in 
the audience. And Patty and Sarah have demonstrated each and 
every day that family caregivers are the true backbone of the 
U.S. long-term care system. There are more than 50 million 
people who provide informal caregiving for chronically ill, 
disabled, or aged family members or friends in any given year, 
so they are to be commended.
    Clearly, the family caregivers of our veterans have made 
great sacrifices. We have heard from family caregivers who gave 
up their jobs, delayed their schooling, or made other 
sacrifices in their own lives to take care of their loved ones.
    This hearing raises questions about the VA's current 
efforts to help these family caregivers and whether or not 
there are sufficient support services available.
    Today's hearing will give the Subcommittee the opportunity 
to better understand VA's implementation plan as required by 
Public Law 111-163.
    Madam Chair, I would ask unanimous consent that my full 
statement be entered into the record and I think it is very 
important and look forward to hearing the panelists today as we 
move forward with this hearing.
    Ms. Buerkle. Thank you, Mr. Michaud, without objection.
    Mr. Michaud. Thank you. I yield back.
    [The prepared statement of Congressman Michaud appears on 
p. 29.]
    Ms. Buerkle. At this time I would ask our first group of 
panelists to come to the table.
    Thank you all very much. It is my honor to introduce the 
four panelists this morning. Starting from my left is Adrian 
Atizado, who is the Assistant National Legislative Director 
from the Disabled American Veterans (DAV). Good morning and 
welcome.
    Next to Mr. Atizado is Ralph Ibson, the National Policy 
Director for the Wounded Warrior Project (WWP). Good morning.
    Next to Mr. Ibson is Tom Tarantino, who is the Senior 
Legislative Associate for Iraq and Afghanistan Veterans of 
America (IAVA). Good morning.
    And next to him is Barbara Cohoon, Deputy Director of 
Government Relations for the National Military Family 
Association (NMFA). Good morning, and welcome to all of you.
    Thank you all for appearing this morning to lend your 
knowledge and your expertise on all of these issues. I know 
that many of you have been working on these issues for a long 
time behind the scenes. I want you to know that the veterans, 
caregivers, and the Members of Congress appreciate all that you 
have done.
    I would ask that you would limit your opening statements to 
5 minutes and we will enter into the record your complete 
testimony. That way we will ensure that everyone has time to 
ask their questions.
    We will start with Mr. Atizado.

 STATEMENTS OF ADRIAN ATIZADO, ASSISTANT NATIONAL LEGISLATIVE 
  DIRECTOR, DISABLED AMERICAN VETERANS; RALPH IBSON, NATIONAL 
POLICY DIRECTOR, WOUNDED WARRIOR PROJECT; TOM TARANTINO, SENIOR 
    LEGISLATIVE ASSOCIATE, IRAQ AND AFGHANISTAN VETERANS OF 
AMERICA; AND BARBARA COHOON, PH.D., R.N., GOVERNMENT RELATIONS 
     DEPUTY DIRECTOR, NATIONAL MILITARY FAMILY ASSOCIATION

                  STATEMENT OF ADRIAN ATIZADO

    Mr. Atizado. Madam Chairwoman and Members of the 
Subcommittee, I would like to thank you for inviting the 
Disabled American Veterans, an organization of about 1.2 
million members whose sole mission is to build better lives for 
America's disabled veterans, their families, and dependents.
    We are pleased to testify on VA's implementation plan for 
the caregiver assistance program and whether it meets 
Congressional intent embodied in Title I of the Public Law.
    First and foremost DAV would like to thank the 111th 
Congress and this Committee's staff for your hard work in 
passing this law. It is historic legislation, because for the 
first time, support benefits and services will be provided and 
are being tailored directly for veteran's caregivers.
    Second, while eligibility is a core concern, as was 
mentioned, there are other concerns in the implementation plan 
that our organization has, and these concerns are in components 
as well as gateway provisions. Further detail on these matters 
are included in my testimony and I am sure my colleagues on 
this panel will speak to those specifically.
    It does appear to many that VA's implementation plan does 
not fully comport to Congressional intent but rather 
misappropriates it. Now in that context, the question becomes 
why in VA's desire to provide a clear and consistent guideline 
to its front line personnel, did the Department decide to 
engender what appears to be a more restrictive standard across 
these benefits?
    This question is a critical one that requires thoughtful 
consideration. This is to be able to foster a collaborative 
approach and not create an adversarial and divisive environment 
to solve this very big problem in front of us today.
    DAV would like to acknowledge that VA and the 
administration have had to its credit open communications with 
veteran service organizations (VSOs) and undoubtedly with other 
parties as well interested in this matter.
    As it stands now, our concern over VA's implementation plan 
only serves as a reference. This is because we have turned our 
attention to the anticipated Interim Final Rule, the IFR.
    Madam Chairwoman, the natural tendency for Federal agencies 
in rulemaking is to be intolerant and at times defensive once 
it makes a formal rule determination. However, VA has testified 
before the Senate that it considers the IFR to be a good start 
and that VA is open to suggestions.
    The DAV remains cautiously optimistic that the Department 
will adjust accordingly to Congressional oversight, especially 
in light of its implementation plan and the broad concerns it 
raised when it was made public.
    We urge this Subcommittee to ensure that VA carries out the 
required good faith and serious consideration of post-
promulgation comments from the public on the proposed IFR. 
Congressional oversight is critical in this instance to ensure 
the IFR is not perceived as and is not allowed to become an 
autocratic decision.
    Finally, DAV would like to take this opportunity to address 
three overarching concerns. One, the original legislation the 
law is derived from proposed to fragment and rank the veteran 
population. This kind of divisive provision works against the 
leave no one behind. This is a principle, a core belief that 
defines both military service and veteran's benefits.
    DAV has a resolution from our membership calling for 
comprehensive caregiver support based on needs of injured and 
ill veterans of any war. Nevertheless, DAV ultimately supported 
the compromised legislation knowing that it would benefit the 
newest generation, but also allow the VA to expand the 
eligibility to caregivers of veterans from previous wars.
    Two, VA's budget request for this program for fiscal year 
2012 and 2013 is inadequate to meet Congressional intent. As we 
look to VA to correct regulatory inadequacies, we also look to 
Congress to appropriate the necessary funds for the VA to 
successfully implement this program.
    Three, ensuring benefits provided by either VA or U.S. 
Department of Defense (DoD) that are aimed at assisting 
caregivers and families of severely disabled servicemembers or 
veterans are not duplicative, unequal, or otherwise 
unavailable.
    If done properly, a thoughtful inspection followed by a 
well-structured alignment of current benefits and support 
services into a cohesive set of benefits could provide the much 
needed stability during an otherwise overwhelming and turbulent 
time.
    Madam Chairwoman, this concludes my statement. I would be 
happy to answer any questions you or other Members may have.
    [The prepared statement of Mr. Atizado appears on p. 31.]
    Ms. Buerkle. Thank you very much. Mr. Ibson.

                    STATEMENT OF RALPH IBSON

    Mr. Ibson. Thank you. Chairman Buerkle, Ranking Member 
Michaud, Members of the Subcommittee, we greatly appreciate you 
holding this hearing and inviting WWP to testify this morning.
    And we are very, very pleased that the Wades and Horans 
could be here, and I am honored to attempt to speak for them 
and for the many, many more who had placed such hope in the 
Caregiver Act.
    Successful implementation of the caregiver assistance 
program and the law is our highest priority this year. But VA's 
implementation plan in our view is deeply flawed.
    We view the restrictive eligibility criteria to be simply 
unlawful and to disqualify caregivers of as many as several 
thousand veterans, many with severe cognitive and other 
impairments due to traumatic brain injury (TBI).
    The provisions of the Caregiver Act, indeed Title I of the 
Act, some 27 pages long are very detailed, very explicit as to 
who is eligible.
    We, therefore, expect via its implementation plan to 
closely track the law. But its criteria not only bear no 
resemblance to the law, they are all together inconsistent with 
it. And let me offer an example. A veteran who has sustained a 
severe TBI in Iraq can now carry out all activities of daily 
living but is simply unable to live independently because of 
cognitive impairment, impaired judgement, and anxiety when 
alone in the community. His condition requires that his wife 
accompany him at all times and manage virtually all of the 
household affairs, finances, telephoning, medication 
management, and other activities. Without a caregiver, the 
veteran would need to live in a supervised setting.
    But under the VA plan, this veteran would not be eligible, 
because the VA criteria require that a veteran be so impaired 
as to need hospitalization or nursing home care to be eligible 
under this law. As a result under the plan, the spouse would 
not qualify for caregiver supports.
    Let me stress this is not a difficult law in terms of its 
eligibility. The eligibility language is plain on its face. 
Congress directed VA to provide specific services to the 
primary caregiver of the veteran who sustained a serious injury 
on or after 9/11, and who needs personal care services, a 
defined term, either because of an inability to perform one or 
more activities of daily living like toileting or bathing, or 
because the veteran needs supervision or protection based on 
symptoms of neurological injury or other impairment.
    Congress made two specific references in this eligibility 
section to traumatic brain injury. First, as an example of what 
it meant by the terms ``serious injury'' and secondly to 
clarify the kind of condition that would give rise to a need 
for supervision or protection.
    Notwithstanding that, VA has proposed additional 
restrictive requirements that would render most veterans with a 
severe TBI ineligible. This is profoundly troubling, since TBI 
is not only a signature wound of this war, it is a signature 
wound under this law.
    Given that VA's criteria would disqualify a high percentage 
of families who should be eligible in our view under the law, 
we have particularly focused on those eligibility issues.
    But the plan raises other serious problems, as well. In 
summary, it sets unreasonable limits on the scope of covered 
mental health services. It goes far too far in our view in 
requiring routine home visits every 90 days without regard to 
whether the caregiver or veteran have had any problems.
    And particularly for longstanding devoted caregivers, this 
kind of monitoring through frequent home visits is inherently 
intrusive and unwarranted. At very least, a reasonable plan 
would provide for tapering off the frequency of that monitoring 
in the absence of any problems.
    Finally, the plan relies on flawed criteria, which fail to 
take account of traumatic brain injury for determining the 
amount of a stipend.
    Madam Chairwoman, the Caregiver Act represents a solemn 
promise to spouses, parents, and other family members who 
devotedly care for their seriously wounded loved ones. The plan 
in our view would break that promise.
    The Administration must not speed through a regulation that 
covers only a fraction of those eligible. It must not abandon 
vulnerable veterans who cannot live independently because of 
cognitive or other deficits due to TBI. It must be faithful, 
both to the warriors and to the law.
    Thank you for your attention to these deep concerns.
    [The prepared statement of Mr. Ibson appears on p. 37.]
    Ms. Buerkle. Thank you, Mr. Ibson. Mr. Tarantino.

                   STATEMENT OF TOM TARANTINO

    Mr. Tarantino. Madam Chairwoman, Ranking Member, and 
Members of this Subcommittee, on behalf of Iraq and Afghanistan 
Veterans of America's 200,000 members and supporters, I thank 
you for the opportunity to testify here on implementation of 
the Caregivers and Veterans Omnibus Health Services Act of 
2010.
    My name is Tom Tarantino, and I am the Senior Legislative 
Associate with IAVA. I proudly served 10 years in the Army 
beginning my career as an enlisted reservist and leaving 
service as an active duty officer. During these 10 years, my 
family served along with me. Because of the nature of the wars 
in Iraq and Afghanistan, many families like mine are continuing 
to serve long after veterans have left service.
    Wounded servicemembers are coming home to the prospect of 
having someone care for them for the rest of their lives. And 
all across this country family members are stepping up, putting 
aside their own lives and plans to take care of these wounded 
warriors.
    Like IAVA supporter Natalie Cobb, she is an example of the 
selflessness displayed by military families across the country. 
Her husband, Steve, who served in Iraq in 2004, was severely 
wounded when a mortar exploded less than 50 feet from his 
patrol.
    Following his deployment, Natalie immediately noticed a 
change in his behavior. Natalie remained by his side throughout 
his long recovery, and now, over 6 years later, still serves as 
Steve's primary caregiver.
    Natalie had to learn to take care of Steve on her own. She 
navigated the VA by herself. Today, she manages their household 
while taking care of Steve 24 hours a day, and she has not had 
any respite in over 6 years.
    The veterans' community came together 2 years ago to help 
Natalie, Steve, and military families like them across the 
country. IAVA and all of the veteran service organizations 
worked closely with Congress, military families, and the 
caregiver community to craft a law that would meet the needs of 
these selfless caregivers.
    And at the time, we believed that we had accomplished our 
mission. The Caregivers Bill was written specifically to apply 
to more, rather than fewer caregivers in need of support. Ralph 
very accurately outlined that it was extremely explicit in the 
law.
    Now we understand the complexity of regulating this 
program. We also appreciate that the VA has moved forward on 
aspects of the law that didn't require a lot of regulation. The 
creation of a hotline and a Web site for caregivers that 
provides them with information and assistance in accessing 
benefits is absolutely critical. Nonetheless, we are seriously 
disappointed by the regulations for eligibility.
    Along with representatives of our fellow veteran service 
organizations, I spent 2 days at the VA this past October 
discussing how to make sure that the law was regulated 
appropriately.
    Now at the time, we made it clear that the goal was to 
ensure that all caregivers who needed help received it. In real 
numbers, we are really not talking about a lot of people here. 
We are talking roughly 3,000.
    These men and women have given up everything to take care 
of their wounded veterans. And it is absolutely unacceptable to 
shortchange heroes like Natalie at a time when they need our 
help.
    The regulations proposed by the VA are far more limiting 
than the bill intended. To be eligible for caregiver benefits, 
a veteran would have to be hospitalized if there is no 
caregiver present.
    Now many veterans coming home from Iraq and Afghanistan 
might well need constant care. However, they don't need 
institutionalization. I want to be clear. Injuries that require 
caregivers and hospital care are not necessarily synonymous. 
And making the need for institutionalization the threshold for 
eligibility completely misses the goal of this legislation.
    We told the VA that if they relied on specific definitions 
of severely injured and the need for institutionalizations as 
their threshold for eligibility, then far too many veterans and 
their families would simply not get the support their country 
promised them.
    And the VA's explanation of why they did not take this 
feedback into account is simply insufficient. The VA argues 
that we, being the VSOs, ``stated repeatedly that the intent of 
the law was `to avoid having to place a veterans in 
institutions when home care was not a viable option.' ''
    And was indeed part of the intent. The main goal, however, 
was and remains to support a population of caregivers who are 
living in some places with no regular income, no health 
insurance just so that they can take care of veterans who can 
no longer take care of themselves.
    Now is it hard to come up with eligibility criteria and 
regulate this law? Yes, it is hard. Does it mean that the only 
solution is to take the easy way out and settle on restrictive 
criteria? Absolutely not.
    IAVA and our fellow veteran service organizations are more 
than willing to work with officials to identify the best 
criteria. But as it is now the regulation should not stand.
    We would like to see the law implemented properly in order 
to give our veteran caregivers the overdue support that they 
deserve. But before any part of the law is enforced, 
regulations on eligibility must be changed to accurately 
reflect the intent of the law and to ensure that we are not as 
a county leaving anyone behind.
    Madam Chairwoman, I am grateful for this opportunity to 
share the thoughts of Iraq and Afghanistan veterans with this 
Subcommittee. And we look forward working together to solve 
this problem. Thank you for your time and attention. I will be 
happy to answer questions.
    [The prepared statement of Mr. Tarantino appears on p. 44.]
    Ms. Buerkle. Thank you, Mr. Tarantino.
    Dr. Cohoon.

            STATEMENT OF BARBARA COHOON, PH.D., R.N.

    Dr. Cohoon. Chairwoman Buerkle, Ranking Member Michaud, and 
distinguished Members of this Subcommittee, the National 
Military Family Association would like to thank you for the 
opportunity to present testimony.
    Our Association asserts that behind every wounded 
servicemember and veteran is a wounded family. Family members 
along with the caregiver are an integral part of the health 
care team, and their presence has been shown to improve the 
servicemember and veterans quality of life in aid recovery.
    We are pleased with the passage of the Caregivers and 
Veterans Omnibus Health care Service Act of 2010 that will 
provide for training, compensation, and other needed benefits 
for caregivers. This law places the VA in an active role in 
recognizing caregivers' important contributions and enabling 
them to become better caregivers to their loved ones. It is a 
win-win for everyone involved.
    While our Association is extremely appreciative of Members 
of Congress for the passage of this landmark legislation, we 
have some concerns regarding the VA's implementation plan not 
meeting the intent of Congress or the needs of the caregivers.
    The VA has not met the implementation timeline for the 
caregiver portion of the law. Every day the VA waits to 
implement the caregiver provision means those who care for our 
wounded, ill, and injured are going without valuable resources 
that were intended to improve the quality of the caregiver's 
life and of the life they care for. It places additional stress 
on an already strained population. We cannot afford to put this 
off one more day.
    The VA's eligibility establishes a much more stringent 
criteria than the law dictates. Many of our wounded 
servicemembers and veterans have mild to moderate cognitive 
impairment that requires caregiver support. But they certainly 
do not need hospitalization. The law's language was intended to 
capture this population. However, the VA will exclude them and 
subsequently their caregiver.
    The plan states a servicemember and the caregiver cannot 
begin the application process until they receive a date of 
separation. We believe this may not provide enough time for the 
completion of all the VA's eligibility criteria before the 
servicemember and the caregiver enter veteran status. More 
importantly, we are concerned this may impact the seamless 
transition of programs and services of the caregiver.
    Currently, the DoD is providing a caregiver compensation 
benefit to the servicemember. The law states DoD's compensation 
stops 3 months after the servicemember has been medically 
retired. However, the VA's caregiver benefits do not begin 
until training is completed and validated by the VA. Therefore, 
this scenario has the potential to create a gap in monetary 
compensation and impact the family's financial stability.
    Waiting until after the receipt of a separation date will 
prevent caregivers from being able to obtain benefits early 
enough in the recovery process to make a difference. Waiting 
also impacts the ability to obtain time sensitive needed 
benefits. This especially impacts our non-spouse caregivers.
    The VA has decided to begin all of the benefits at the same 
time. They could very easily begin some benefits much earlier 
in the process.
    The VA's decision to delay access to valuable training may 
force each Service to begin their own training program. This 
may cause each Service's training program to vary in its scope 
and practice. Therefore, it may not meet VA's training 
objectives. This could force the caregiver to undergo two 
different training programs.
    Our Association appreciates VA's compensating caregivers 
for providing direct hands-on medical care. However, the 
compensation should also recognize non-medical care.
    The plan states it will not include medication to 
caregivers for mental health. Therefore, we wonder how the 
coordination between the caregiver's medical provider and the 
person or entity providing mental health services will be 
accomplished.
    Caregivers have enough on their plate without having to 
navigate the travel benefit and the burden of submitting forms. 
We recommend the VA should assist caregivers with this benefit.
    The VA is not meeting the intent of the law regarding 
respite care. The intent was to add more respite care hours to 
the current VA policy, not keep the status quo.
    The VA also needs to focus on the well being of the 
caregiver, making sure they are physically, mentally, and 
financially stable. We recommend the VA take a holistic 
approach to care and include the caregiver and family when 
monitoring the veteran. Everyone's health and well being is 
linked together.
    The goal is for a seamless transition of caregiver benefits 
between DoD and VA. We ask this Subcommittee to assist in 
meeting that responsibility.
    Our Association would like to thank you for the opportunity 
to present testimony today. We look forward to working with you 
to improve the quality of life of our veterans, their 
caregivers, and their families.
    Thank you and I await your questions.
    [The prepared statement of Dr. Cohoon appears on p. 46.]
    Ms. Buerkle. Thank you very much. We will begin questions 
now. Each Member will have 5 minutes. I will begin by yielding 
myself 5 minutes.
    This question is for each of the members on the panel. 
Based on your expertise and all of the investigation and work 
you have put into looking at this law and its implementation, 
could each one of you identify for me what it is that you see 
as the single most serious deficit in the implementation of 
this law? And what your solution would be for that deficit. And 
if you just could limit your remarks so everyone would have a 
chance to respond, I would appreciate it.
    We will start with Mr. Atizado.
    Mr. Atizado. Chairman Buerkle, I appreciate that question. 
But, again, I have to caution the Committee that eligibility is 
only one of a number of gateway provisions in this law.
    Certainly if a servicemember and their caregiver or veteran 
and their caregiver are deemed eligible and meet other gateway 
provisions that don't allow them the appropriate services, then 
being eligible becomes a moot point in the end.
    As the other panelists have mentioned, it appears that VA's 
eligibility criteria does raise the bar that a caregiver and 
veteran must meet to be entitled or at least considered 
eligible. And my testimony has a specific example of that.
    But I think in all--in all fairness, I believe VA has--VA 
clinicians know what they need to do. And I think we know what 
they--we know what we want them to do. And I think there seem--
there may have been a little bit of misinterpretation I think 
on both sides.
    My point is is that we all have to step back a little bit 
from this very emotionally charged situation, reassess 
ourselves, and come together on equal grounds, because I fear 
that no matter what we say today, if we continue down this 
path, we will not come to a very amicable solution.
    Ms. Buerkle. Thank you. Mr. Ibson.
    Mr. Ibson. I share my colleague's view that it is difficult 
to isolate a single factor, because there really are a great 
many flaws.
    But honoring your question, I do think that the imposition 
of very, very restrictive eligibility criteria, that are 
inconsistent with the law and have the affect of disqualifying 
three of every four caregivers who probably should be covered 
under this law, is the most profound of the many problems we 
have discussed this morning.
    Ms. Buerkle. Thank you. Mr. Tarantino.
    Mr. Tarantino. I associate myself with the comments of 
Adrian and Ralph. I think they are absolutely correct. You 
know, there are multiple issues with the regulation of this 
law.
    But if we needed to start somewhere, we have to start at 
eligibility, because that is the first gateway. And, you know, 
if you want to look at how to do it I would suggest that they 
read the law, because it is pretty explicit. It is, in fact, 
probably the most explicit piece of legislation that I have 
read since I started working in this field 3 years ago.
    But I actually do--and I share Adrian's term, we need to 
caution ourselves that we don't just stop there. That we have 
to actually look at how this program--how this program is 
implemented holistically.
    And that once if the eligibility criteria is fixed, that we 
don't just stop and say, great, put a win on the board and move 
on. This is a very complicated program, and we have to keep 
looking at it until we get it right.
    Ms. Buerkle. Thank you.
    Dr. Cohoon. Our Association feels it has to do with when 
you are actually going to be starting the benefits. If it is 
not started until all these other requirements are met, it 
pushes eligibility to all these benefits until further down the 
road. And, well maybe, several months or maybe years into 
veteran status.
    And, we would like to see that started earlier, because our 
caregivers need these benefits much earlier in the process than 
when they will possibly be getting them.
    The VA is also rolling out all the benefits at the same 
time. So, we feel that they should be able to start some of the 
benefits earlier in the process, interjecting them at the time 
when the caregiver actually needs them. So, that they have the 
resources that they need, have the right skills to be able to 
provide the care that they need, and, therefore, the veteran 
gets the care or the servicemember is getting the care that 
they need.
    So, our concern is the fact that they are waiting until all 
the wickets are met before they start any of the benefits. And 
one of the major wickets has to be that the veteran has to be 
receiving care 100 percent in the home. And many of our 
servicemembers are still going through the recovery phases 
where they might be having wound revisions or maybe they are 
having their burns grafts taken care of.
    And, so if we are waiting until 100 percent in-home care, 
then that could also delay either of them starting these 
particular benefits. That would be our concern.
    Eligibility also, but starting the benefit is the biggest 
for us.
    Ms. Buerkle. Thank you very much.
    I now yield 5 minutes to the gentleman from Maine, Mr. 
Michaud.
    Mr. Michaud. Thank you very much, Madam Chair. I have a 
question for each of the panelists.
    If you look at--I know Mr. Atizado mentioned that he 
doesn't feel that it is properly funded. Actually when you look 
at fiscal year 2010 and fiscal year 2011 there is actually no 
money appropriated for the Caregiver Act, and I know the VA 
requested $166 million. The Independent Budget actually 
recommended that just for the caregiver's piece that it is $385 
million for that provision for fiscal year 2012. And I believe 
the Department requested $208 million for the caregiver 
legislation. So there is a huge gap between the two.
    My question I guess for each of the panelists is why do you 
think that gap is so large? I know the criteria is narrowed 
under the VA's proposed rule. But do you have any idea why that 
significant gap in the proposal?
    And my second part of that question is as the VA went 
through this process, I know the VSOs have been involved; to 
what extent has the VSOs been involved? And do you feel that 
the VA actually listened to any of your concerns or were you 
just brought in at the end of the process and made a few 
comments?
    Mr. Atizado. Chairman Michaud, thank you for that question. 
As far as answering the first part of your question with 
regards to the gap between both the appropriated amount or I 
should say the amounts dedicated to this program, as you--as 
all the Members here know, in the law the authorized 
appropriation for the law under Congress's intent was $60 
million for implementation, $1.5 roughly billion, $1.54 billion 
over 5 years.
    VA's budget request intimates that they estimated about $20 
million for implementation. They also request $66 million for 
sections 101 through 104 for fiscal year 2012 and then about 
$70.6 million for 2013.
    You know, we have talked about these numbers and these 
budgets as kind of like a bell weather of where everybody is 
going. But what is still unclear to our organization is that 
840 or otherwise 850 individuals that the Department of 
Veterans Affairs has testified that their implementation plan 
would provide, we are not really certain whether we are 
comparing apples to apples as opposed to apples to oranges. It 
would be definitely a question that should be clarified with 
the Administration when they come up with the next panel.
    With regard to listening to our concerns, I believe that 
they did. The DAV is aware that the VA operates in a different 
environment than all of us, all the rest of us do. Just as here 
today they may be listening to us and you may be listening to 
us, but who knows what the VA is going to end up with in their 
interim final rule. And we don't know what Congress is going to 
appropriate for this program.
    So, yes, I believe they listen to us and they continue to 
listen to us today. In fact, it has been pretty constant 
throughout this process, maybe not publicly, but certainly 
there has been communication.
    Mr. Ibson. Thank you as well for the question, Mr. Michaud.
    With respect to that gap, the sense I have is that by 
having set such restrictive criteria, VA could cover only a 
relatively limited number of caregivers and projected only some 
840 for next year. That is striking odds to the projections 
that were at play when your two Committees reached a compromise 
agreement and targeted a number closer to 3,500. So that gap I 
think accounts for the enormous disparity in budget figures.
    With respect to the dialogue we have had with VA, this law 
is really remarkable in many respects. I think as we have said, 
it is remarkable for its detail, for the very careful 
discussion of eligibility, but also for the degree to which 
stakeholders were to be brought in to that process.
    And from my perspective it has been somewhat disappointing. 
We were consulted somewhat last-minute toward the end of VA's 
process. We indeed did have robust discussions for several 
hours over the course of 2 days.
    Unfortunately, we never had a template with which to work. 
We did not have a draft VA implementation plan against which to 
comment. We did not see a final proposed implementation plan 
before it went to the Office of Management and Budget (OMB). We 
remain in the dark with respect to the content of interim final 
regulations.
    I, and I think my colleagues, have offered advice to VA, to 
include middle ground proposals. But is as though we had 
shouted into a forest. There has been no return to that 
conversation.
    And were this a more transparent process, aligned with what 
I think the intent of the law was, we probably would not have 
the kind of disparity that we face today. And so I am 
personally disappointed at that.
    Thank you.
    Ms. Buerkle. Thank you.
    Mr. Stearns from Florida.
    Mr. Stearns. Thank you, Madam Chair.
    Dr. Cohoon, the questions I have are for you. What, if any, 
services does the Department of Defense provide to caregivers? 
And do you anticipate the caregiver assistance program in 
Public Law 111-163 will have any affect on these benefits?
    Dr. Cohoon. The DoD does offer a lot of benefits for the 
servicemember and for the family member. It depends upon if the 
family member is a spouse, therefore, qualifies for benefits, 
because they are married, or if they--are a non-spouse, as mom 
or dad or a sibling as what sort of benefits they have access 
to.
    Currently, in the military treatment facilities, those that 
are on invitational travel orders up to three are provided on a 
space available basis care within a military treatment 
facility. And, so they are allowed to get free health care 
through DoD.
    They are also allowed to be able to have the same care 
through the VA. So, if the servicemember was getting care in a 
polytrauma center, they themselves would also have access to 
the same care. We are under the impression that the VA has not 
implemented this particular program.
    The National Defense Authorization Act 2 years ago included 
a caregiver compensation that is paid directly to the 
servicemember if they have a caregiver. And, the definition is 
catastrophically ill and injured. The amount was originally 
tied to aid and attendance.
    Last year, the National Defense Authorization Act made some 
changes to that particular law where it is still tied to the 
aid and attendance until the VA comes forward with their 
particular eligibility criteria and the stipend that they are 
going to be being paid. Therefore, they would align a little 
bit better.
    There are several places in which there are some 
disparities, the definition within the National Defense 
Authorization Act as far as the servicemember qualifying versus 
the VA. It is injured and ill and it is catastrophic in DoD. 
Where the VA it is not clear if illness is even included. Also 
too as far as the health care piece, which I described. 
Training, if we look at training, the VA is going to be 
providing training. But, currently right now DoD is not 
providing any training. And, where and when will that start. 
The stipend will be the same as far as what the caregiver would 
be receiving directly through the servicemember regarding the 
compensation piece now the VA has come out with their 
implementation. There is some issue as far as mental health 
services as well, sir.
    Mr. Stearns. Let me follow up. I think in your opening 
statement you said, ``It appears the VA is focused exclusively 
on the care and well being of the veteran rather than making 
sure the caregiver is also physically, mentally, and 
financially stable.''
    So I guess the question is this in-home monitoring, is that 
not also a benefit to the caregiver who will have many 
opportunities to interact with the VA regarding additional 
needs, and concerns, and success? And I guess is there a 
balance that we have to strike here between, you know, assuring 
that you have proper and appropriate care as provided to the 
veteran and at the same time opportunity to check on the well 
being of the caregiver?
    Dr. Cohoon. Yes, sir. Our organization is asking that the 
VA, while they are doing all of this monitoring on the veteran, 
they should also be making sure that they are monitoring how 
well the caregiver is doing, because it is often shown that the 
caregiver will be the last person they will look at as far as 
taking care of themselves, and to look internally when you are 
the caregiver.
    So it is important when the VA is monitoring the veteran 
they also have an opportunity to put eyes on the caregiver to 
see how they are doing and also making sure that they make 
recommendations if they need to go see a doctor or asking are 
they utilizing enough respite care.
    And, when you read the implementation plan, it dictates as 
far as what they are looking for in the veteran. But there 
isn't anything in there as far as what they are going to be 
looking at as far as the caregiver's well being.
    Mr. Stearns. For how long of a period is this monitoring by 
the VA on the caregiver?
    Dr. Cohoon. Well the monitoring doesn't start until the 
caregiver qualifies for the benefits. And then they monitor on 
three different bases. And I think Ralph alluded to that as far 
as the amount of times.
    Mr. Stearns. Okay. Thank you, Madam Chair.
    Ms. Buerkle. Thank you. I yield 5 minutes to the gentleman 
from Indiana, Mr. Donnelly.
    Mr. Donnelly. Thank you very much, Madam Chair.
    This question is for everyone. In regards to traumatic 
brain injury or TBI, which is often considered the signature 
wound of the Afghanistan and Iraq wars, do you believe the 
current criteria in this implementation plan sufficiently 
understands the nature of that injury and will enable coverage 
for our vets who have suffered this injury?
    Mr. Atizado, if you would lead off.
    Mr. Atizado. Thank you, Mr. Donnelly.
    In my testimony, I outline a number of issues with regards 
to the VA's implementation plan in making sure that veterans, I 
am sorry, caregivers of veterans who suffer from traumatic 
brain injury are provided the appropriate services and support 
that they need.
    Generally this is determined by assessing not only the 
veteran's need as well as the caregiver's need. And it appears 
that there is--there was no such tool included in the plan. In 
fact, the plan talks about two specific assessment instruments, 
the Katz Scale and something called patient behavioral scale. I 
think anybody who has worked around this issue is well aware of 
what the Katz Scale is. I am not familiar with the patient 
behavioral scale.
    But there is certainly nothing that would otherwise be able 
to capture the needs of the veteran and thus the needs of the 
caregiver who is suffering from traumatic brain injury. This is 
a very different injury and has very different needs assessment 
requirements from one that is suffering from a physical 
disability or that that is suffering from mental health 
disability.
    And I would urge the VA to take this into consideration, 
because this is a prevalent injury that servicemembers are 
suffering from from wars in Iraq and Afghanistan.
    Mr. Donnelly. Thank you. Mr. Ibson.
    Mr. Ibson. Thank you for the question, Mr. Donnelly. I 
happen to have spoken the day before yesterday with a single 
mom in Texas who has been caring for her son who sustained a 
gunshot wound, very like the wound that Representative Giffords 
sustained.
    This young man has regained most of his capacity to carry 
out activities of daily living. He can walk; he can bathe 
himself, toilet, et cetera. But he cannot be left alone. He 
cannot be left alone. Now if this young man were assessed under 
VA's criteria, clinicians would likely conclude that he would 
not require hospitalization or nursing home care. So, he would 
be ineligible.
    His mom, 4 years ago, gave up her job, moved from 
Pennsylvania--well, actually flew from Pennsylvania to Germany 
to be at his bedside, relocated to Tampa, Florida, subsequently 
relocated to Texas where her health is failing in the strain of 
caregiving. She has no income whatsoever.
    Mr. Donnelly. Is the relocation to Texas, because that is 
the closest facility that can provide assistance to him as well 
in the VA world?
    Mr. Ibson. I think she was unhappy with the care that he 
was receiving in Florida and moved to Texas in order to get 
better care.
    You know, the concern that I had for her situation and the 
concern she, of course, has is that under the criteria in terms 
of need for nursing home care, as well as the criterion that 
speaks to the individual being at high risk for personal 
safety, which is a pretty high threshold, he would be deemed 
ineligible and she would not qualify for comprehensive 
supports.
    This young man may not be at that high a risk. But he is 
certainly well within the meaning of the law, which as I 
indicated earlier, twice speaks to traumatic brain injury as a 
point of reference to make it crystal clear that young men and 
women as badly injured as he is who have regained physical 
capacities but cannot live independently should be covered 
under the law yet would not be under VA's plan.
    Mr. Donnelly. Thank you. I apologize, Mr. Tarantino and Dr. 
Cohoon, I am out of time. But we appreciate your answers to 
that question. Thank you.
    Ms. Buerkle. Thank you. I yield now to the gentleman from 
Tennessee, Mr. Roe.
    Mr. Roe. Thank you for yielding. Well, first I want to 
introduce a guest I have with me today, Ann Reuschel. Ann, if 
you would stand. Ann does my VA work back in the district. Her 
husband was a victim of Agent Orange from the Vietnam War, and 
so she has been a caregiver herself.
    Ann, thank you for being here, the intent of this law in 
Congress was to aid people who are assisting wounded warriors. 
That was the intent of the law. Not to make it so complicated 
that nobody could possibly figure out how to get this help.
    I am going to tell you a story, just a brief story, about 
an encounter and I said this the other day, a little less in 
detail, about a veteran's wife that I saw who was 64 years old. 
Her husband was shot through the chest in Vietnam in 1966. This 
woman, 19 years old with one child, has taken care of him for 
40 years. And this man would have died, no doubt in my mind 
about it, had he been left to an institution or whatever.
    I looked at the ten things that she had to go through, 
medication management, vital signs, pain control, infection 
control, nutrition, and on, and on, and on. She took care of 
him without any of this training.
    He was told by physicians that his life expectancy probably 
was 7 years at that time, and I certainly believe it would 
have--as a physician I believe this was true, were it not for 
the unbelievable care that this caregiver gave.
    Now she is 64 years old and is not eligible for Social 
Security, because she didn't have a job during that time. She 
was taking care of her family, her husband and her child; and 
her husband got to watch their child grow up. So we as a Nation 
can never repay her for what she has done. I don't know how we 
are going to. But we are going to try.
    I just looked at the minimal amount of money that the 
caregivers are given. And it is not a lot of money. Just her 
caregiving, not the institutional, the time that he would have 
been in a hospital that would have paid for it, is over $1 
million. This woman has given her husband over $1 million in 
care.
    And I say this to these young families out there, because I 
want you to understand that there were a group of veterans and 
their families who were left alone after the Vietnam War, after 
World War II, and quite frankly every war up until today.
    It is now time to get this right. And I honestly believe we 
can. And I know that is the intent of this Congress, both the 
Democrats and Republicans, is to get this right.
    I could go on about her, because I think she is one of the 
true American heroes of this country. I really believe it. I am 
getting a little emotional, but I believe that. I truly do.
    So the questions I have, and we can get them answered later 
in writing, is how long, and how, and who has to do this 
training? I want to know how much of the resources go to the 
trainers and to the clipboard carriers and not to the actual 
caregivers. That will be for a later panel.
    No one visited her home every 90 days. And yet she gave 
wonderful care. Why? Because she loved her husband. That is 
why. She loved her family. And that is why most of these family 
members, as Mr. Donnelly pointed out do this. They do this 
because they love their families. And it is time we stopped 
piddling around, and get this right, and get these resources to 
these families who give up their Social Security, their jobs, 
and their careers.
    Two years ago we had the folks in for the Veterans 
Integrated Service Network (VISN). One young woman was at Duke 
University and gave up her career to take care of her blinded 
husband.
    I don't know how much to go into the administration of 
this. The absolute majority of this money needs to go to the 
caregivers, to the folks out there every day. And this is hard 
work. I mean the work that this woman did was bowel evacuation, 
wound care, and on and on. Stuff that is really not a lot of 
fun every day was done because they love their families.
    And I didn't mean to use all my time giving a speech. But 
it meant a lot to me to meet this family. And I see these young 
family members out here who are doing exactly that to their 
families. And thank you every single day from this veteran to 
you for what you do.
    And if you have any comments fine or otherwise I will yield 
back my time.
    Mr. Atizado. Mr. Roe, I can certainly appreciate your 
comments. And I want to thank you, ma'am, for what you do. Our 
membership is predominantly, just by virtue of reality, Vietnam 
veterans, Korean, Persian Gulf, other conflicts, and now Iraq 
and Afghanistan veterans.
    But I have to say we are deeply concerned about the stance 
that has been taken on monitoring. I can tell you, sir, ma'am, 
that monitoring is not intended as a punitive nature. It is not 
intended to--it is not intended as a safeguard against those 
that are well meaning or doing a good job.
    In fact, if you look at advocacy groups, grass root 
advocacy groups, of caregivers, both of the disability and the 
aging movement, are very well aware of the necessary--of the 
need for monitoring, for the need for self-assessment. Some of 
these caregivers who are extremely committed forget that they 
have to take care of themselves. There have to be fresh eyes to 
make sure that the caregiver's well being is attended to. That 
they themselves don't forget about themselves, much less the 
veterans.
    And I can tell you--I can tell you that if there is a 
proposal to remove the monitoring aspect of this, which is not 
only a safeguard for the veteran and the caregiver, but the 
credibility of this program, I think that would be a very poor 
choice.
    Ms. Buerkle. Thank you, Mr. Atizado.
    Mr. Roe. I yield back.
    Ms. Buerkle. Thank you. I yield to the gentleman from New 
Jersey, Mr. Runyan.
    Mr. Runyan. Thank you, Madam Chair.
    You kind of just talked where I wanted to go. I have had 
some personal experiences in my life with care. I had a 
grandmother who suffered from Alzheimer's for 13 years. We went 
through much of the same issues, which led me directly to 
becoming very involved in the Alzheimer's Association.
    In dealing with that, we talk about monitoring. It is 
necessary. But with that, I think we have to be very conscious 
of the support aspect to the caregiver. We did talk about being 
financially stable, being mentally stable. It is a strain 
dealing with Alzheimer's disease.
    And it relates to what my colleague, Mr. Donnelly, was 
talking about and myself in my past career dealing with TBI, 
with concussive incidents. There is a direct correlation 
between concussive incidents, dementia, Alzheimer's, which 
these are long-term issues.
    And ultimately, yes, we did--we did ultimately have to put 
my grandmother into a home, because our family could not do it 
anymore. But we did everything we possibly could to keep her 
out of that situation, because quite frankly she spent her life 
savings. We spent her life savings putting her in a home.
    And we really have to tackle this and be up front about it, 
because it is--the direction I think we are going here in 
health care in general, we talk about wellness. We talk about 
keeping people in the home, keeping them with loved ones. We 
don't talk about the psychological aspects of having the loved 
ones home, being in home, and not being in those clinical 
situations and quality of life.
    And I am going to sit here and tell you that I have 
experienced it. I have lived it. I understand it. And we need 
to fight for it. But, you know, with the monitoring aspect, 
there is--it has to correlate with the training. And the 
training does adapt, because as we grow older, our issues 
change. And I think that is a huge part of it.
    And I would like any of you to address how we actually 
would go about the training and retraining on a yearly basis to 
make sure that our warriors are getting the long-term treatment 
they need, because they are going to have a better quality of 
life being at home.
    Anybody have a comment on how we basically improve our care 
that our loved ones are giving our warriors?
    Dr. Cohoon. As I have mentioned before, the way the VA's 
implementation plan is set, none of this starts until after 
they have been to the training and then all the benefits start.
    When the servicemember is initially injured, the caregiving 
starts at that particular point in time. They will cycle in and 
out of the hospital. As far as going home for recovery, then 
the caregiver at that particular point is going to be giving 
care at that juncture as well. So, training is going to be 
taking place all across the recovery phases of the 
servicemember and then into veteran status.
    So, that is why our Association brought up the concern and 
the fact as when do you start the training? And let us make 
sure that whatever training is put into place that it is 
consistent across both DoD and VA.
    So if they are still on active duty that the training is 
still happening at that particular point. But whatever they are 
trained and given at that point, it is acceptable to the VA 
when they enter veteran status.
    And, how do you go about reevaluating? Our Association 
asked that as well, because when you look at the implementation 
plan, even though they are monitoring on a regular basis, it 
doesn't tell you how often the caregiver and the veteran are 
reevaluated for their activities of daily living and basically 
the care that the caregiver is giving to determine if the 
stipend is then reassessed at that particular point or stays 
the same.
    Mr. Runyan. You really addressed it. And I think it's--I 
think the oversight is more, you know, just checking in to make 
sure that the money--the money is the issue. That is not the 
issue. The care is the issue.
    And how the warrior actually either progresses or regresses 
in their disability, I think really needs to be addressed. And 
with that I yield back.
    Ms. Buerkle. Thank you, Mr. Runyan.
    At this time, we will ask our second panel to join us. I 
would like to thank panel number one for all of your answers 
and your willingness to testify today. Thank you very much.
    Joining us on the second panel is Dr. Petzel, who is Under 
Secretary for Health for the Veterans Health Administration. 
Dr. Petzel is accompanied by Mr. Walter Hall, who is the 
Assistant General Counsel from the Office of General Counsel, 
as well as Ms. Deborah Amdur, who is the Chief Consultant for 
Care Management and Social Work at the Veterans Health 
Administration.
    Thank you all for joining us today. I know we are all 
anxious to get and to hear your testimony, so we will begin. We 
have been advised that we are going to have a vote in about 15 
minutes.
    So, Dr. Petzel, if I could ask your indulgence and maybe 
keep your comments brief, so we could at least get to some of 
our questions. Any questions we don't get to we will submit to 
you in writing. Thank you very much. And thank you for being 
here.

 STATEMENT OF HON. ROBERT A. PETZEL, M.D., UNDER SECRETARY FOR 
  HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
  VETERANS AFFAIRS; ACCOMPANIED BY WALTER A. HALL, ASSISTANT 
GENERAL COUNSEL, OFFICE OF GENERAL COUNSEL, U.S. DEPARTMENT OF 
 VETERANS AFFAIRS; DEBORAH AMDUR, LCSW, CHIEF CONSULTANT, CARE 
  MANAGEMENT AND SOCIAL WORK, VETERANS HEALTH ADMINISTRATION, 
              U.S. DEPARTMENT OF VETERANS AFFAIRS

    Dr. Petzel. Chairman Buerkle, Ranking Member Michaud, and 
now sitting in for him, Congressman Donnelly, before I begin I 
do want to recognize the presence of the Wades and Horans, two 
couples who really symbolize why it is very important that we 
get this piece of legislation correct from the very beginning.
    Members of the Committee, I want to thank you for the 
opportunity to discuss VA's implementation plan for the family 
caregiver program required by the Caregivers and Veterans 
Omnibus Services Act of 2010.
    I am accompanied by, as mentioned, Mr. Walt Hall, the 
Assistant General Counsel, and Ms. Deborah Amdur who is Chief 
Consultant for Care Management and Social Work. I ask that my 
written comments be introduced into the record.
    Ms. Buerkle. Without objection. Thank you.
    Dr. Petzel. Servicemembers injured today are surviving 
injuries that would have been fatal in past conflicts. We 
understand how critical family caregivers are for these 
veterans. And we know veterans are best served if they can live 
their lives as independently as possible, surrounded by those 
people that they love and who love them.
    The Caregivers Act enhances VA's existing authority to 
provide for these services for caregivers and will allow VA to 
provide comprehensive--a rather comprehensive set of benefits 
and services to certain caregivers of eligible veterans.
    We are fully committed to ensuring that injured veterans 
and their families receive these benefits and the support that 
they need. There is no better way to express my and all of VA's 
commitment than the title of this hearing.
    VA must get the implementation of these new caregiver 
provisions right. We understand very clearly the concerns 
expressed here today. Dialogue between VA and Congress is 
important. And it is especially important in the context of 
this legislation.
    We have had good discussions with Committee staff this 
week--during this week--on the most acute concerns about 
eligibility and other issues and we look forward to a 
continuing exchange with you and with your staff, again so that 
we get this legislation right.
    My written statement provides a thorough account of our 
efforts to develop VA's implementation plan and I won't go into 
the details therein.
    Completing the remaining detailed steps of implementation 
in a way that makes the program practicable and clear is no 
easy task. But the challenge before us is nothing compared to 
the challenges that these caregivers, as symbolized by the 
Wades and the Horans, face on a daily basis.
    I second the Secretary's regret that our plan was not 
submitted on plan and also that the implementation date set in 
the law was not met. This process has taken longer than any of 
us would have liked.
    As you know, VA submitted on February 28 a proposed interim 
final rule to the Office of Management and Budget. And this 
procedure will result in faster implementation than had been 
earlier expected.
    The Secretary has set the mark for getting the program 
operational by early summer. But we must not lose sight of what 
is most important and that is, again, to reiterate, to get it 
right.
    The success of this effort depends on putting forward 
standards that will secure those additional benefits for 
caregivers of seriously injured veterans who are in greatest 
need. These standards must be able to be applied consistently 
by our front-line clinicians. And we have an obligation to be 
able to explain to an injured veteran why he or she would or 
would not qualify for these benefits. Making sure these 
additional benefits are focused on the right caregivers who are 
giving so much that is so vital to them.
    Our highest priority is delivering world-class health care 
services and benefits to our seriously injured veterans, and 
servicemembers, and their caregivers.
    We look forward to working with Congress, the veterans 
service organizations, and all of you, again, to ensure that we 
get this right.
    Thank you for inviting me to testify today about this 
incredibly important and new groundbreaking program. My 
colleagues and I are prepared now to answer your questions.
    [The prepared statement of Dr. Petzel appears on p. 56.]
    Ms. Buerkle. Thank you, Dr. Petzel.
    I am going to yield 5 minutes to Dr. Roe.
    Mr. Roe. Thank you, Madam Chairman.
    Quickly, I have watched this now for the third year. It 
seems that all the programs that we see are slow, and glacial 
to get going.
    And I know that it is a very complicated program. But as 
you clearly pointed out, it is not nearly as complicated as 
having no arms or legs, and getting around in your home, or 
with a traumatic brain injury where you can't balance a 
checkbook and someone has to be there for you to do that. That 
is a lot harder as you just pointed out. I could not agree 
more.
    So why is it taking so long? And, I mean, this doesn't--
this program doesn't seem as complicated to me as many of the 
programs that the VA has.
    Dr. Petzel. Thank you, Congressman Roe. I will turn to 
Debbie Amdur in a minute to elaborate on this.
    But I think the biggest aspect of this is that it is a 
completely new concept for us. We have never been engaged in 
the business of providing a stipend to somebody who is 
providing caregiving services.
    And developing the regulations for this, getting all of the 
correct input before the regulations are actually in place, 
takes a long time. I apologize as I had before for the fact 
that we are so late in doing this. But I think the fact that 
this was new and it required relatively complex regulations is 
part at least of the explanation.
    Mr. Roe. We have regulations now for home health care 
people that go in. It looks to me like it would have been 
fairly simple to look at those and say there is some criteria 
there that would have been pretty easy.
    I think we micromanage this down to what if, I think the 
intent of Congress was to provide this to as many families. And 
I think right now, just like in the Housing and Urban 
Development-Veterans Affairs Supportive Housing (HUD-VASH) 
Voucher Program, we found out we have 11,000 vouchers out there 
and yet still have homeless veterans.
    So I think what you are going to find out with this is that 
there is going to be a lot more need than we thought. But we 
don't even know what that is now, because it is so hard for 
people to get in.
    As Mr. Tarantino pointed out, the gateway is eligibility. 
But that is just the first step. So we really don't know right 
now how many people. And do you know how many people have 
applied or how many have to date?
    Dr. Petzel. Of course, there hasn't been an application 
period yet, Congressman. But we have an estimate of somewhere 
between 750 and 1,000 people would probably be applying or 
would be eligible under the way the criteria are presently 
delineated.
    Mr. Roe. Well I guess that seems like an awfully small 
number to me in a country with millions of veterans. It seems 
to me like--I bet it will be 10, or 20, or 30 times that many.
    Dr. Petzel. Well--
    Mr. Roe. Unless the criteria is so narrow that they don't 
qualify.
    Dr. Petzel. But first of all we have defined this as 
people--the result of the present conflict. So all of the other 
era veterans would not be considered in that group to begin 
with.
    And I will ask Mr. Amdur if she can elaborate briefly on 
the eligibility criteria and perhaps the number of people.
    Ms. Amdur. Thank you. As a clinician who has many years of 
experience in the field working directly with disabled veterans 
and their family caregivers, I would like to say firsthand that 
I do recognize that the kinds of incredible sacrifices that 
these family members make. And it is really an honor to be here 
with Sarah Wade and Patty Horan who are two examples of this.
    I can tell you also that VA is fully committed to ensuring 
that this important benefit gets to the families of our most 
seriously injured servicemembers and was very concerned to hear 
the interpretation that we would not be covering veterans with 
traumatic brain injury.
    When we put together the eligibility criteria, we brought 
forward subject matter experts from across VA, including 
leadership of our Federal Recovery Coordination Program, our 
polytrauma programs, traumatic brain injury programs, and so 
forth. And there was significant recognition of the challenges 
that are faced by family members caring for individuals with 
traumatic brain injury.
    And so without a doubt, our intention is that those 
individuals will be included and eligible if you have an 
individual who requires supervision to remain at home.
    I would like to also say that the eligibility criteria were 
created in a context really of VA's wide range of existing in-
home services that are designed specifically to support 
veterans and families, keeping them at home, and avoiding at 
all costs the possibility of institutionalization, because we 
know that--
    Mr. Roe. Not to interrupt, but my time is about up. In July 
if we have this same Health Subcommittee meeting again, will 
there be families getting help?
    Ms. Amdur. Our intention is that we are fully operational 
early summer. Yes, sir.
    Mr. Roe. So we are going to be able to have resources going 
out to family members who take care of wounded warriors this 
summer?
    Ms. Amdur. That is our intention, yes.
    Mr. Roe. Guaranteed?
    Ms. Amdur. We know how important--
    Mr. Roe. Which will be 6 months later than it was supposed 
to be. But if we can get it done then so they will have some 
time certain, that would be good.
    And my time is up. So I will finish by just saying that no 
institution, I have practiced medicine for--I have been a 
doctor for 40 years. No one will give you better care, loving 
care, than your family.
    Ms. Amdur. I agree wholeheartedly, sir. Thank you.
    Ms. Buerkle. Thank you, Doctor. I will yield now to Mr. 
Donnelly.
    Mr. Donnelly. Thank you, Madam Chair.
    Dr. Petzel, the VA plan calls for routine home visits about 
every 90 days. And so after a while, you know, three, four 
visits, you see there is a pattern, everything is the same time 
after time.
    Do you think that there could be a framework put in place 
to perhaps make it every 4 months after that or every 6 months 
after that, or do you think it is necessary to stay on the 3-
month visit schedule?
    Dr. Petzel. Congressman Donnelly, I certainly think that 
that can all be looked at. The purpose of those visits are 
primarily as sort of training and checkup if you will, 
episodes. They are not meant to be punitive. They are not meant 
to be, you know, looking out for trouble particularly. We 
really would like to have them be an opportunity to talk with 
the caregiver, talk with the patient about how things are 
going. See if there are new and other things that need to be 
done.
    Certainly after a period of time it may not be necessary to 
do it four times a year. I think we would want to periodically 
have a system to ensure that there isn't deterioration in the 
patient that needs further and other kinds of training on the 
part of the caregiver but absolutely. We don't necessarily have 
to stick forever to four times a year.
    Mr. Donnelly. Yes. And that is where I was going to go next 
was what you had just mentioned, which is in between visits. 
What kind of support structure are we going to put in place so 
the caregiver can call and say, I am really struggling this 
month?
    Dr. Petzel. Let me turn to Ms. Amdur, and she can go I 
think briefly again through what other supports are available.
    Ms. Amdur. We do think that a--
    Mr. Donnelly. I can't hear you.
    Ms. Amdur. We think that a key component of the program is 
direct support to caregivers. That is really what this is all 
about.
    So VA has put a full-time caregiver support coordinator 
position at every VA medical center and their role will be to 
ensure that the caregivers have a direct line to someone who is 
able to respond immediately to their needs, link them to the 
appropriate resources, and so forth.
    In addition, we are instituting through these caregiver 
support coordinators, support groups, education and training 
that will happen in group formats, all of which are geared 
directly at providing support to the caregiver.
    In the training that will be part of the overall program, 
we have included modules in the core curriculum that focus on 
stress management, self care for caregivers, and also things 
like advocacy, legal issues, and so forth, because we know how 
very challenging those can be for caregivers.
    Mr. Donnelly. Dr. Petzel, getting back to the TBI issue. It 
is so tricky to know exactly how they are going to turn out or 
where it is going to go. How will you determine in cases where 
you are not sure whether or not they will be included in 
providing this assistance?
    As was heard in the first panel, the fellow was talking 
about the mom taking care of her son and that physically it 
didn't look all that different, but that he couldn't be alone. 
How are we going to make those calls?
    Dr. Petzel. Well, thank you, Congressman. In the 
implementation plan, we talk about the concept of if someone 
cannot live safely by themselves, and that is a fundamental you 
are in, you are eligible. If you cannot be safely left home 
alone, that in and of itself is going to be--make you 
fundamentally eligible for the program.
    I am not quite sure where the misinterpretation of what is 
in the interpretation plan. But we anticipate that large 
numbers of TBI patients are indeed going to be eligible for 
this program.
    Mr. Donnelly. Because it is my expectation that what you 
see on first blush is obviously not going to be always where a 
lot of our veterans who are struggling with TBI will be the 
next day, or the next week, or the next month.
    Dr. Petzel. Correct.
    Mr. Donnelly. So if we could just keep an open mind on 
that, I would appreciate it.
    Thank you very much, Doctor. And thank you for all you have 
done for our veterans over the years. I have met with you many 
times. And I know the veterans of my district and all our 
districts are appreciative of the hard work of all of you 
folks.
    Dr. Petzel. Thank you.
    Ms. Buerkle. Thank you, Mr. Donnelly. I am going to yield 5 
minutes to Mr. Roe.
    Mr. Roe. Just one question, did you say that there was a 
caregiver at every VA medical center?
    Ms. Amdur. We have instituted a caregiver support 
coordinator position at every VA medical center.
    Mr. Roe. Okay. Let me stop right there--
    Ms. Amdur. Yes, sir.
    Mr. Roe [continuing]. And then do some math. There are 154 
of those in the country?
    Ms. Amdur. That is correct.
    Mr. Roe. You have 1,000 people. That is one for every six 
people we are going to have in this program?
    Ms. Amdur. One of the things that we feel very committed to 
is that we provide services to all era veteran's caregivers. 
And so these positions will not only be assisting directly 
those who are eligible for this particular benefit, but will be 
doing support, education, and training activities for the 
caregivers of all era veterans. So we anticipate they will have 
actually a very busy schedule doing so.
    Mr. Roe. Okay, thank you. I yield back.
    Ms. Buerkle. Thank you, Dr. Roe.
    I will yield myself 5 minutes just for some questions since 
they haven't called the vote yet.
    As we chatted when you first entered and I came to the 
meeting this morning, we mentioned that I am a registered nurse 
and I have been involved in health care for many years. And I 
too, like Members of the Committee, have lived up close and 
personal with a family member. I had a sister who was 
quadriplegic for 25 years. My mother cared for her at home. So 
I know up close and personal--the immense sacrifice that the 
family makes to make that decision, the benefits that the 
patient derives from it, and the fact that it affects the 
entire family.
    So I am sitting here this morning, and I am so concerned 
that we are talking so much and we are not going to get this 
done. Time is of the essence.
    When a family is frustrated or overwhelmed with the 
prospect of what they need to give--to keep that patient at 
home, to keep their loved one at home, and the ramifications of 
the decision to keep them home, they need us then. They don't 
need us talking about early summer.
    So I guess my question to you is what assurance can you 
give us? We heard early summer. But what assurance can you give 
us that we will make this a priority, will figure this out, and 
will get it done?
    Because as was mentioned by the Committee Members earlier, 
home health care is not new for the VA. But giving assistance 
to home health care members, and home care assistants, and the 
whole theory of home health care is not new. It is not like we 
have to reinvent the wheel. We just need to apply it to our 
veterans who need this care, and this help, and assistance so 
dramatically.
    So what assurance can you give us that we are going to 
proceed with the utmost pace and get this done by early summer 
so we can begin getting family members into this system? And we 
can do for our veterans to get this thing done.
    Dr. Petzel. Well, Madam Chairwoman, you have my absolute 
promise and assurance that we will get this done by summer. 
That we will by early summer be paying people to provide care 
in the communities.
    This is part of the reason why I think it is very important 
that right now we get this right. About 95 percent of what we 
need is already done. And I think people generally agree on 
most of those points.
    There are three or four areas where we need to develop a 
consensus as to how we should move forward. If we can get those 
things cleared and if they entail some change to the interim 
final rule, we can get that done and meet that timeline.
    So I absolutely hear your angst about the time, and we 
share it. We want to get this done as quickly as possible as 
well, and we will.
    Ms. Buerkle. Thank you. Do you have any idea when you will 
get the findings of the interim rule?
    Mr. Hall. The plan is 60 days from the time. OMB had 60 
days from the time that we provided them with the draft rule, 
which would be about May 1st. And it would go into effect 30 
days later.
    [Mr. Hall subsequently submitted the following 
information:]

           Mr. Hall would like to amend that statement to convey that 
        if OMB approves the regulation for publication as an interim 
        final rule, it will go into effect on the date specified in the 
        regulation, expected to be on the date of publication.

    Ms. Buerkle. Thank you. Anyone else on the Committee have 
any questions?
    We also discussed this morning my visit to our veterans 
hospital in Syracuse. And I was so impressed with the 
satisfaction of the patients there and the commitment that the 
staff had during our meeting.
    I mentioned to Secretary Shinseki that it was apparent to 
me that for the veterans and for all of the health care 
providers in the medical center, it was a mission and not just 
a job to them.
    I hope that as a result of this hearing we will make this 
our mission to get this bill done, to do what is right for our 
veterans, and for their families.
    So I thank you all very much for being here today, for you 
taking the time and giving us your testimony. I will allow 5 
days for the Members of the Committee to submit any questions 
or opening statements for the record.
    And with that, thank you again for appearing here today. 
This hearing is adjourned.
    [Whereupon, at 11:27 a.m. the hearing was adjourned.]

                            A P P E N D I X

                              ----------                              

       Prepared Statement of Hon. Ann Marie Buerkle, Chairwoman,
                         Subcommittee on Health
    The Subcommittee will come to order.
    Good morning. I want to begin by thanking all of those in 
attendance for joining us today at the first Subcommittee on Health 
hearing of the 112th Congress.
    I am honored to have been selected to serve as Chairwoman of this 
important Subcommittee and I am pleased that my friend, Mr. Mike 
Michaud of Maine was designated by his colleagues to serve as the 
Ranking Member.
    Mr. Michaud has a distinguished history of support for our veterans 
and I look forward to working closely with him to ensure that those who 
have honorably served our Nation receive the highest quality care. I 
know he shares my conviction that that is the least we can do for those 
who willingly put themselves in harm's way to protect our freedoms.
    We are joined on the Health Subcommittee by:

    Mr. Cliff Stearns of Florida,
    Mr. Gus Bilirakis of Florida,
    Mr. David Roe of Tennessee,
    Dr. Dan Benishek of Michigan,
    Mr. Jeff Denham of California,
    Mr. Jon Runyan of New Jersey,
    Ms. Corrine Brown of Florida,
    Mr. Silvestre Reyes of Texas,
    Mr. Russ Carnahan of Missouri, and
    Mr. Joe Donnelly of Indiana.

    I am heartened by the wealth of diversity, knowledge, and 
experience we have among us and I am confident that the work we do here 
will have a very real and positive impact of the daily lives of 
America's brave veteran heroes and their loved ones--which brings us to 
the crux of the matter before us this morning.
    Each of us serves on this Committee because of our deep respect and 
heartfelt admiration for the service and sacrifices of American 
veterans. Each of us serves on this Subcommittee because we recognize 
the importance of ensuring that those same veterans have access to high 
quality medical care to help them cope with the wounds of war and 
readjust to civilian life. Each of us has respect for the VA health 
care system as it stands and a desire to make the system even better.
    At the same time, we recognize that no matter how good a health 
care system is, it can only go so far. We can--and should--provide the 
highest quality care by the highest quality physicians and therapists 
in the highest quality facilities. But nothing can equal the support 
provided by a loving and loyal family member.
    Some of those family members are with us this morning. In our 
audience is Sarah Wade and Patty Horan. Sarah is a full time caregiver 
for her husband, Ted, who was injured in Iraq when his Humvee was hit 
by an Improvised Explosive Device. Patty is a full time caregiver for 
her husband, Pat, who suffered from a gunshot wound during his service 
in Iraq.
    Sarah and Patty has been there for their husbands day in and day 
out through every up and every down. Because of their commitment, they 
have sacrificed jobs, hobbies, and free time.
    Last year, Congress passed Public Law 111-163 to ensure that family 
caregivers like Sarah and Patty wouldn't also have to sacrifice their 
financial stability or their own health.
    Congress intended for these benefits to be available by January 
30th of this year. However, the Department of Veterans Affairs (VA) has 
failed to comply with the law and has yet to implement the caregiver 
assistance program.
    Even more unfortunate, when VA finally released its initial 
implementation plan on February 9th, it was immediately met with 
consternation by lawmakers and stakeholders who raised serious concerns 
about the strict eligibility criteria and other issues, including the 
provision for respite care, mental health coverage, and in-home 
monitoring requirements.
    It is my hope that during today's hearing we will bring these 
issues to light and the necessary changes will be made by VA to ensure 
that the benefits Congress intended and veteran and family members 
expected are provided without further delay.
    Again, I thank you all for being with us this morning. I look 
forward to a very productive discussion.
    Mr. Michaud you are now recognized for any opening statement you 
may have.

                                 
   Prepared Statement of Hon. Michael H. Michaud, Ranking Democratic
                     Member, Subcommittee on Health
    Thank you, Madam Chair.
    I would like to thank you for holding today's hearing. The goal of 
today's hearing is to identify the gaps in the implementation of Public 
Law 111-163, the Caregivers and Veterans Omnibus Health Services Act of 
2010. We also seek a better understanding of the VA's current efforts 
to meet the needs of family caregivers of veterans.
    P.L. 111-163 provides immediate support to the mothers, fathers, 
husbands, and wives and other family members caring for warriors from 
the current conflicts, as well as previous conflicts. Today, we have 
the opportunity to recognize their tremendous sacrifice and share their 
heavy burden.
    I would like to recognize in attendance today Ted and Sarah Wade, 
as well as Pat and Patty Horan. Army Captain Pat Horan is from 
Springfield, VA, and was part of the Stryker Brigade at Ft. Lewis in 
Washington State. Over 4 years ago, Pat sustained a gunshot wound to 
the head in Iraq, leaving him completely and totally disabled. Pat has 
made major strides in his rehabilitation, and all along, his wife Patty 
has been by his side.
    For the last 6 years, Sarah Wade has acted as her husband's primary 
caregiver and case manager. In February 2004, her husband, Army 
Sergeant Ted Wade, was in Iraq when his Humvee was hit by an improvised 
explosive device (IED). Ted was one of the first major explosive blast 
polytrauma cases from Operation Iraqi Freedom, and Sarah suspended her 
studies to serve as an advocate and caregiver for her husband.
    Thank you all for your service and sacrifice to this Nation.
    As Patty and Sarah demonstrate each and every day, family 
caregivers are the true back-bone of the U.S. long-term care system. 
There are more than 50 million people who provide informal caregiving 
for a chronically ill, disabled, or aged family member or friend in any 
given year.
    Studies of the general family caregiver population show the real 
adverse financial and physical toll that caregiving has on these 
individuals. For example, women family caregivers are more than twice 
as likely to live in poverty. Also, family caregivers report having a 
chronic health condition at twice the rate of their non-caregiver 
counterparts and those who provide 36 or more hours of weekly 
caregiving are more likely to experience symptoms of depression and 
anxiety than non-caregivers. In the end, this has serious implications 
for our veterans. In order to ensure that our country's heroes receive 
the highest quality of care from their family caregivers, it is 
important that we arm them with the right tools and offer appropriate 
supportive services so that they are less apt to be overwhelmed by the 
difficult day-to-day realities of being a caregiver.
    Clearly, the family caregivers of our veterans have made great 
sacrifices. I have heard from family members who gave up their jobs, 
delayed their schooling, or made other significant life-changing 
sacrifices in order to be by their loved one's side. This raises 
questions about the VA's current efforts to help these family 
caregivers and whether there are sufficient supportive services in 
place.
    Today's hearing will give the Subcommittee the opportunity to 
better understand the VA's implementation plan as required by Public 
Law 111-163. As many of you may be aware, there are numerous concerns, 
including:

      The delays in the rollout of the implementation plan. 
This law required a plan for implementation that was due to the 
Committee in November 2010, with full implementation of the program in 
January 2011. However, the VA is only now preparing regulations--which 
will have to undergo a lengthy public comment and approval process--and 
there is still no definitive date when veterans and caregivers will 
begin receiving the services required by P.L. 111-163.
      Second, the narrowing of criteria for eligibility of 
these benefits. VA has put forth in the regulations, criteria that 
would seriously limit access to the stipend and health care benefits 
for caregivers that the law was intended to include. The law was 
written in a way to allow for about 3,500 caregivers who would be 
eligible for the program, while the regulations narrow the eligibility 
to about 800 to 1,000. Specifically it outlines as one of the 
``clinical eligibility requirements'' that without ongoing caregiver 
support, the veteran would require hospitalization, nursing home, or 
other institutional care.
      Finally, moving forward. These setbacks increase my 
apprehension towards VA's capabilities to successfully implement the 
caregivers program. This is a major concern, and we will continue to 
actively engage VA as we move forward with a plan that is more in line 
with the intent of Congress.

    Madam Chair, the implementation of the Caregivers and Veterans 
Omnibus Health Services Act of 2010 demands our immediate attention. I 
hope that it is clear to our panelists before us today that by making 
this our first hearing of 2011, we demonstrate the importance of the 
subject at hand.
    This hearing provides the VA with an opportunity to present clear 
details to our Subcommittee about where the VA currently stands with 
regard to the implementation of the new caregiver requirements. Our 
goal continues to be that veterans and their caregivers are ensured 
these critical benefits.

                                 
              Prepared Statement of Hon. Gus M. Bilirakis
    Chairwoman Buerkle, Ranking Member Michaud and Members of the 
Subcommittee: I want to thank you for calling this hearing today to 
learn more about and evaluate the implementation plan for the 
caregiver-assistance program established in Public Law 111-163 (the 
Caregivers Act).
    When family members, loved ones and friends willingly put the needs 
of a wounded veteran above their own by becoming a primary caregiver, 
it is clear that the wounded and disabled veterans are not the only 
ones who suffer. Veteran caregivers often sacrifice careers, social 
lives, and responsibilities in order to ensure that their loved one can 
receive care and recover at home. The men and women who selflessly 
support our wounded soldiers in this manner are as heroic to me as our 
men and women in uniform, and I am grateful to them for their service.
    Congress recognized the myriad sacrifices that veteran caregivers 
make by passing the Caregivers Act into law in 2010. This legislation 
was originally designed to provide supportive services and 
comprehensive assistance for family caregivers of veterans. However, 
the VA's implementation plan for the law contains troubling new 
criteria that could limit the scope and inclusiveness of the program. 
It is very worrisome that the VA would seek to restrict a program 
customized to support our veterans and their caregivers. Additionally, 
the VA's continued delay in the roll-out of the caregiver assistance 
program is extremely frustrating. Veteran caregivers have waited long 
enough; to ask them to wait longer for the benefits we promised them, 
which will help them provide better care to our wounded veterans, is 
simply unacceptable.
    I look forward to hearing from the witnesses today on how we can 
ensure that this legislation retains its Congressional intent. Thank 
you.

                                 
               Prepared Statement of Hon. Silvestre Reyes
    Thank you Chairwoman Buerkle and Ranking Member Michaud for 
bringing this issue before the Committee today. And thank you to the 
members of the panel for your service to our veterans and for being 
here today. It is always the goal of the members of this Committee to 
ensure that our Nation's veterans receive the finest care possible once 
they leave the service. With that goal in mind, we passed the 
Caregiver's Assistance Act. We intended to extend the benefit provided 
by the Department of Defense to our military's brave men and women who 
sustained injuries serving this great Nation. These injuries include 
not only external physical wounds, but also internal and psychological 
ailments that can result from military service.
    It is a great concern to me and my colleagues that 9 months after 
enactment of this law, the program has not been implemented. I 
understand this is a complex program with many considerations, but this 
is not a new program in military health care. In fact this is simply 
meant to ensure soldiers, sailors, airmen and marines receive the same 
level of care and compensation they received will under Department of 
Defense medical care. For this reason, I am in disbelief that the VA 
could not create a plan to extend this care in less than 9 months.
    Like many new programs, the legislation governing this initiative 
is not perfect. Many people for whom we intended to provide support to 
have been excluded from the benefits they deserve. I hope today's 
dialogue will give us a clear path to correcting the shortcomings of 
the current Caregivers Legislation.
    Thank you Madam Chairwoman and I yield back the balance of my time.

                                 
                  Prepared Statement of Russ Carnahan
    Chairwoman Buerkle and Ranking Member Michaud, thank you for 
holding this needed hearing to address the Implementation plan of the 
Caregivers Assistance Program.
    As you know more than 50 million people in the U.S. provide some 
type of care giving for a chronically ill, disabled or aging family 
member or friend. Our Nation's caregivers typically provide financial 
support and physical care for those who have severe chronic health 
conditions.
    Included in the group of individuals that rely on caregivers to 
help them with their day-to-day functions are our some of our most 
severely wounded veterans. That's why it is important that during this 
implementation stage of the caregiver assistance program, we must work 
in tandem with each other to get it right.
    Caregivers are depending on us to develop a concrete and cohesive 
plan that will meet their needs by providing financial/physical 
assistance but also keep them in a position to continue providing the 
best care to their loved ones. Caregivers not only play a critical role 
in recovery and maintaining quality of life for the veterans but 
without them the VA could face a tremendous burden in providing direct 
care to those many veterans that depend on family caregivers. It is my 
hope that through implementation of the caregivers assistance program, 
we can begin to payback our debt to the individuals who are committed 
to a lifelong responsibility of providing care to those so desperately 
in need.
    To all the witnesses and panelist with us--thank you for taking 
time out of your busy schedules to appear before us. I look forward to 
hearing your testimony.

                                 
        Prepared Statement of Adrian Atizado, Assistant National
            Legislative Director, Disabled American Veterans
    Madam Chairwoman and Members of the Subcommittee:
    On behalf of the more than 1.2 million members of the Disabled 
American Veterans (DAV) and its Auxiliary, thank you for inviting our 
organization to submit testimony for this important oversight hearing. 
We appreciate the opportunity to offer our views on the Department of 
Veterans Affairs (VA) implementation plan for the caregiver assistance 
program and whether it meets Congressional intent embodied in Title I 
of Public Law (P.L.) 111-163, the Caregivers and Veterans Omnibus 
Health Services Act of 2010.
    As this Committee is aware, Title I, which was enacted on May 5, 
2010, contains reporting requirements for VA with prescribed timelines 
to include the following:

    1.  Not later than 180 days after the date of enactment (November 
1, 2010), VA was required to submit a report to the House and Senate 
Veterans Affairs' Committees an implementation plan for subsection 
1720G(a)(1), as amended by the Act.\1\
---------------------------------------------------------------------------
    \1\ P.L. 111-163, Section 101(b).
---------------------------------------------------------------------------
    2.  Within 270 days of enactment (January 30, 2011), VA was 
required to initiate the programs required by (a) and (b) of section 
1720G of Title 38, United States Code, as amended.\2\
---------------------------------------------------------------------------
    \2\ P.L. 111-163, Section 101(a)(3).
---------------------------------------------------------------------------
    3.  Not later than 2 years after the effective date (January 30, 
2013), two reports must be submitted to the House and Senate Veterans 
Affairs' Committees:

       a.  A comprehensive annual evaluation on implementation;\3\
---------------------------------------------------------------------------
    \3\ P.L. 111-163, Section 101(c).
---------------------------------------------------------------------------
       b.  A report on the feasibility and advisability of expanding 
the provision of caregiver assistance under section 1720G(a) of title 
38, United States Code, to caregivers of veterans seriously injured in 
the line of duty prior to September 11, 2001.\4\
---------------------------------------------------------------------------
    \4\ P.L. 111-163, Section 101(d).

    Unfortunately, VA did not meet timeliness requirements for either 
submission of an implementation plan or the commencement of assistance 
and support services for caregivers. The annual evaluation report and 
the report on expansion of caregiver assistance, however, can be 
submitted at any time prior to January 30, 2013.
    While the caregiver assistance program's date of prescribed 
implementation could be viewed by some as optimistic, caregivers of 
severely disabled veterans largely view this timeline as appropriate 
considering how long they have willingly cared for their loved ones 
with little to no relief from VA.
    On February 28, 2011, VA submitted to the Office of Management and 
Budget an Interim Final Rule (IFR) to speed the Federal rulemaking 
process to implement, not all, but certain provisions of P.L. 111-163 
by early this summer. Madam Chairwoman, the natural tendency for 
Federal agencies in rulemaking is to be close-minded and defensive once 
they have made a ``final'' rule determination. Although VA considers 
the IFR as a good start and has indicated it is open to suggestions as 
to the scope of the benefit to be provided, \5\ DAV is cautiously 
optimistic the Department will adjust accordingly to Congress' intent, 
in light of its initial interpretation contained in the VA's 
implementation plan, and the broad concerns raised by that plan.
---------------------------------------------------------------------------
    \5\ United States Senate Committee on Veterans' Affairs, Hearing on 
the President's Budget, March 2, 2011.
---------------------------------------------------------------------------
    In this matter, we urge this Subcommittee to ensure that VA 
exhibits the required good faith and seriously considers post-
promulgation comments from the public, including the concerns of our 
community. Congressional oversight is critical in this particular 
instance to ensure the IFR is not perceived as and is not allowed to 
become, an autocratic action.
    Before addressing our organization's evaluation of VA's 
implementation plan, DAV wishes to highlight four items that best 
describe the wide gulf that exists between the intent of Congress and 
VA in this program.
    Assuming VA's budget request for Sections 101 through 104 of P.L. 
111-163 is based on the cost of its caregiver implementation plan, VA 
requests $65.9 million for Fiscal Year (FY) 2012 and $70.6 million for 
FY 2013. Even by any reasonable estimation of growth in VA's version of 
the caregiver assistance program, this funding request falls well short 
of Congress' authorized appropriation of $60 million for the first year 
and $1.542 billion for the subsequent 5 years.\6\ In addition, VA also 
recently testified the implementation plan would serve only 840 
caregivers as opposed to the 3,500 caregivers Congress intended to 
cover with this legislation.
---------------------------------------------------------------------------
    \6\ Congressional Record, page S2567.
---------------------------------------------------------------------------
    DAV is concerned that in its zeal, VA has developed a plan that may 
well abandon most of those caregivers the law was intended to aid and 
support.
Eligibility:
    P.L. 111-163 prescribes eligibility criteria that a veteran or 
servicemember must meet before support and services can be provided to 
primary caregivers (their supporting family caregivers) and general 
caregivers under Sec. 1720G. The criteria also provides VA the 
authority to consider, ``such other matters as the [Department] 
considers appropriate,'' in making eligibility determinations.\7\
---------------------------------------------------------------------------
    \7\ 38 U.S.C. Sec. 1720G(a)(2)(C)(iii) and (b)(2)(C).
---------------------------------------------------------------------------
    We believe this last criterion was intended by Congress to give VA 
the flexibility to act responsibly by ensuring caregivers and veterans 
who would benefit from this program but are not otherwise considered in 
the prescribed eligibility criteria, would still be made eligible for 
primary and family caregiver assistance. However, it appears the 
Department has ignored this authority took a strict interpretation of 
the intent of the law--to avoid institutional care placements--to 
develop and propose a complex and restrictive eligibility criteria that 
will serve to deny these benefits to thousands of service-disabled 
veterans.
    In its implementation plan, VA indicates a veteran must meet P.L. 
111-163 eligibility criteria and all items in the following conditions 
to be eligible for Primary Caregiver benefits: 8,9
---------------------------------------------------------------------------
    \8\ Plan for Implementation Public Law 111-163 ``Caregivers and 
Veterans Omnibus Health Services Act of 2010,'' Title I Caregiver 
Support Section 101 Assistance and Support Services for Caregivers; 
Page 16.
    \9\ Additional criteria for veterans/servicemember undergoing 
military medical discharge: ``Meet the clinical eligibility criteria 
(listed below) based on VA aid and attendance and compensation benefits 
(based on 38 U.S.C. Sec. 1114 and implementing regulations).'' Ibid. 
Page 34.

    1.  Require continuing medical management or be at high risk for 
personal safety and cannot live independently in the community without 
caregiver support.
    2.  Without caregiver support providing personal care services at 
home in an ongoing manner, would require hospitalization, nursing home, 
or other institutional care.
    3.  Require at a minimum 6 months of continuous and approved 
caregiver support.\10\
---------------------------------------------------------------------------
    \10\ In addition, the fourth requirement listed above that the 
veteran must need, at a minimum, 6 months of continuous and approved 
caregiver support is based on the premise that their family members may 
be able to utilize 26 weeks of unpaid leave under the Family and 
Medical Leave Act (FMLA). However, this condition assumes that the 
family member will not have used any of the 26 weeks at the time this 
requirement will be applied.
---------------------------------------------------------------------------
    4.  Receive care at home once caregiver training is complete.
    5.  Receive ongoing care from a VA Patient Aligned Care Team (PACT) 
or other VA health care team due to VA's responsibility, as outlined in 
the statute, to monitor the well-being of each eligible Veteran 
receiving personal care services under the program.
    6.  Services provided by the primary family caregiver will not be 
simultaneously provided by another entity.

    If the veteran or servicemember is undergoing military medical 
discharge, an additional criterion must be met:

    7.  Meet clinical eligibility criteria based on VA aid and 
attendance and compensation benefits (based on 38 U.S.C. Sec. 1114 and 
implementing regulations).

    DAV appreciates VA's desires for a clear and consistent clinical 
guideline for VA personnel to apply. Such a guideline could ensure 
equity in light of the various injuries veterans have sustained from 
the wars in Iraq and Afghanistan and the subjective nature of 
eligibility determinations. However, the eligibility criteria outlined 
in P.L. 111-163 can be considered open to misinterpretation or 
misapplication. We believe the language in VA's proposed criteria 
contains similar qualities that require interpretations and subjective 
judgments, even as it proposes criteria more restrictive than Congress 
intended.
    In the law, Congress specified an eligible veteran or servicemember 
must be, among other deficits, unable to perform one or more activities 
of daily living (ADL) or be in need of supervision or protection based 
on symptoms or residuals of neurological or other impairment or injury. 
VA combined these two discretionary requirements (be at high risk for 
personal safety and show inability to live independently in the 
community without caregiver support).
    DAV appreciates VA's desire for a clear and consistent clinical 
guideline for the purposes of determining eligibility for caregiver 
assistance under 38 U.S.C. Sec. 1720G. However, using the example of 
the underlying problem causing the Department's disability claims 
backlog to grow, standard application of any guideline is most 
influenced by proper training and education as it is by avoiding ill-
defined words such as ``continuing medical management'' or ``high 
risk.'' In addition, we recommend VA develop retrospective root cause 
analyses to identify the cause of, and improve upon variability of, 
eligibility determinations on families denied these services.
    With regard to the additional criteria for veterans or 
servicemembers undergoing military medical discharge, it appears VA 
intended this additional criterion to be in line with the special 
compensation for severely injured military servicemembers under Section 
603(a) of P.L. 111-84, the National Defense Authorization Act for 
Fiscal Year 2010 (NDAA).\11\
---------------------------------------------------------------------------
    \11\ 37 U.S.C. Sec. 439
---------------------------------------------------------------------------
    However, the purpose of this special compensation benefit is for 
both the Department of Defense (DoD) and VA to ensure the seamless 
transition of care of all servicemembers retiring for medical 
disability. This NDAA provision would recognize that family members are 
making life-altering sacrifices in order to care for servicemembers at 
home. The provision would cap the amount of special compensation at the 
amount authorized for aid and attendance compensation for veterans 
under section 1114(r)(2) of title 38, United States Code. By aligning 
the NDAA authority with the authority to provide aid and attendance 
compensation for veterans under section 1114 of title 38, United States 
Code, the conferees expected to close gaps in coverage and care for 
catastrophically injured servicemembers transitioning from DoD to 
VA.\12\
---------------------------------------------------------------------------
    \12\ Conference Report 111-288 to accompany H.R. 2647, Page 755-
756.
---------------------------------------------------------------------------
    If VA has concerns with aligning the eligibility criteria for 
caregiver assistance under 38 U.S.C. Sec. 1720G to the special monthly 
compensation rates, we suggest VA look to the eligibility criteria for 
the special compensation under 37 U.S.C. Sec. 439 (b). Since this DoD 
special compensation is primarily a financial benefit, we believe it is 
more appropriate to remove VA's proposed eligibility that references 38 
U.S.C. Sec. 1114 and address its alignment concerns under the stipend 
provisions of P.L. 111-163.
    We have testified many times and written in The Independent Budget 
our concerns with respect to transition of active duty servicemembers 
to civilian veteran status. Numerous reports have revealed great 
weaknesses between VA and DoD in effectively promoting a seamless 
transition even in cases where the individuals concerned are severely 
wounded and in need of an array of health and benefits services from 
both agencies. In this implementation plan, VA may have failed to 
coordinate its decisions with DoD with respect to severely injured 
active duty and veterans. Lack of coordination will exacerbate existing 
issues that hamper a seamless transition and could result in caregiver 
support services being unnecessarily duplicated, unequal, or 
unavailable across both systems at the detriment of caregivers and the 
quality of care and rehabilitation of the individuals concerned. As VA 
reviews its implementation plan for caregiver support services as a 
result of strong Congressional oversight and involvement of this 
community, we urge VA to work closely with DoD counterparts in 
fashioning change.
Stipend:
    Due to the number of concerns DAV has identified about the 
potential caregiver stipend, we believe a closer inspection is needed 
to determine if this benefit as proposed by VA is both appropriate and 
valid in light of Congress's intent.
    First, the amount of personal caregiver services that will be 
required of a caregiver may include skilled nursing care (wound care, 
bowel and bladder care, tracheostomy or ostomy care, etc.), physical 
and occupational therapy, home health aide care and homemaker duties. 
As amended by P.L. 111-163, title 38, United States Code, 
Sec. 1720G(a)(3)(C)(ii)(V), recognizes this potential and States the 
stipend be, ``not less than the monthly amount a commercial home health 
care entity would pay an individual in the geographic area of the 
eligible veteran to provide equivalent personal care services to the 
eligible veteran.'' (Emphasis added.)
    However, VA proposes to take the intended minimum monthly stipend 
amount and convert it to the maximum amount payable. The Department 
proposes to base the stipend payment on the Department of Labor's 
Bureau of Labor Statistics (BLS) wage rate for a home health aide, with 
no other option. In doing so, VA may not fully recognize all the 
personal care services a primary caregiver will provide.
    Second and subsequent to the previously mentioned proposal, VA 
incorporates an especially grievous proposal that sets a bar caregivers 
must overcome but is not recognized by the stipend benefit despite VA's 
statement that, ``[t]he stipend is an acknowledgement of the sacrifices 
that families are making to care for seriously injured eligible 
Veterans.'' \13\ This situation is evident in two forms:
---------------------------------------------------------------------------
    \13\ Plan for Implementation, Public Law 111-163, ``Caregivers and 
Veterans Omnibus Health Services Act of 2010,'' Title I, Caregiver 
Support, Section 101, Assistance and Support Services for Caregivers, 
Department of Veterans Affairs. Page 23.

    1.  VA proposes that in order for the caregiver to be eligible for 
the monthly stipend, the caregiver must be able to provide personal 
care services that include any additional care requirements prescribed 
by the PACT or veteran's primary care team\14\--that is, other personal 
care services such as skilled nursing care that a home health aide 
would not or could not otherwise provide. Yet, VA proposes to limit the 
stipend amount to that paid to a home health aide; and
---------------------------------------------------------------------------
    \14\ Ibid. Page 13
---------------------------------------------------------------------------
    2.  In another set of requirements VA's implementation plan 
includes a standardized veteran/caregiver assessment tool (Appendix B) 
that will be used to evaluate and validate caregiver competence, which 
is required for the primary caregiver to begin receiving the stipend 
and other benefits.\15\ Part of the assessment tool includes whether 
the caregiver furnished needed Instrumental Activities of Daily Living 
(IADL).\16\ In calculating the hours of work that VA estimates a 
primary caregiver will need to--provide required personal care 
services, it appears that no weight is given to the hours of care 
needed to perform IADLs in calculating the monthly stipend.
---------------------------------------------------------------------------
    \15\ Ibid. Page 28.
    \16\ Ibid. Page 56.

    Third, DAV is also concerned about the calculation of hours of care 
VA estimates a primary caregiver will need to perform the required 
personal care services.
    VA states that nothing in Sec. 1720G, as added by section 101 of 
P.L. 111-163, shall be construed to create ``an employment relationship 
between VA and an individual in receipt of assistance or support,'' to 
include primary family caregivers. However, VA's implementation plan 
uses a 40-hour work week as a standard and proposes a maximum 40 hours 
of care without consideration for the time needed to provide personal 
care services during evenings, weekends, or holidays.\17\ This 
restriction is proposed despite VA's eligibility requirement that a 
veteran must need ``continuous and approved personal care services.''
---------------------------------------------------------------------------
    \17\ Ibid. Page 23-24.
---------------------------------------------------------------------------
    Fourth, according to VA, behavior points from the Patient Behavior 
Scale assessment will be subtracted from the ADL points from the Katz 
ADL Scale. Combined results of these scales are given a numeric value 
to determine the level of the stipend payment:

      VA's implementation plan assumes behavior points are 
equal to ADL points without explanation or validating evidence to 
support this assumption.
      VA's implementation plan lacks explanation of how the 
combination of ADL and behavior points relate to the amount of hours-
of-care needed.
      VA's implementation plan does not conform to Section 101, 
P.L. 111-163, where IADLs are not specified as a tool to be used in the 
evaluation and calculation of stipend amounts.

Assessment Instruments:
    Determining the type of ADL and IADL care that a patient needs 
permits a clear idea of whether or not living at home with care is an 
option. Further, recognizing a person's functioning level as it relates 
to ADL and IADL is the first step in developing a care plan (or making 
a referral for care) to provide the appropriate type and level of 
assistance. This is also recognized in Appendix B (page 56), the 
Veteran/Caregiver Assessment Tool, which evaluates both ADL and IADL 
limitations.
    VA's implementation plan proposes to use the Katz Index of 
Independence in Activities of Daily Living, a patient behavior scale to 
determine the levels of the caregiver stipend payable. The Katz Index 
uses a dichotomous rating (0 = independent; 2 = dependent) for each 
activity; Alternatively, VA proposes a trichotomous rating (1 = high 
dependence; 2 = medium dependence; 3 = low dependence). These three 
levels of dependency are ill-defined and will most certainly lead to 
wide variations in scoring among health care providers, and will fail 
to meet VA's stated goal for a clear and consistent guideline.
    We recommend VA consider a rating scale with each item assigned 
points according to a defined decision rule (e.g., 0 = no help needed; 
1 = uses a device; 2 = needs human assistance; 3 = completely 
dependent). Alternatively, the Lawton IADL scale developed by Lawton 
and Brody in 1969 assesses the more complex ADLs necessary for 
independent living in the community where competence in skills such as 
shopping, cooking, and managing finances are necessary tasks. VA could 
consider using the trichotomous rating used in the Lawton IADL 
instrument (1 = unable; 2 = needs assistance; 3 = independent). In any 
case, VA provides no evidence about the validity of using other than 
the dichotomous rating of a patient as either dependent or independent 
for an ADL in conjunction with the Katz Index.
    DAV is also concerned VA's implementation plan does not propose to 
use an IADL instrument to assess the personal care needs a veteran or 
servicemember may require, which the primary caregiver will undoubtedly 
perform. Katz developed another scale for instrumental activities of 
daily living such as heavy housework, shopping, managing finances and 
telephoning but it is not referenced in the implementation plan.
    Of equal concern is the lack of information in VA's implementation 
plan on whether the proposed Patient Behavioral Scale is a valid 
instrument in determining veterans' needs and amounts of personal care 
services that primary caregivers must provide.
    Madam Chairwoman, DAV would like to highlight a missing yet 
critically important component in VA's implementation plan--any 
instrument to assess the personal care needs of a veteran or 
servicemember suffering from neurological or cognitive impairment due 
to traumatic brain injury (TBI).
    Although impairment in cognitive function is a recognized concern 
in P.L. 111-163 (Sec. 1720G(a)(2)), VA did not propose to assess 
veterans' or servicemembers' executive functions (planning, organizing, 
problem solving, sequencing, self-monitoring and controlling behavior). 
Deficits in executive functions may be devastating to someone's ability 
to cope with everyday life, work, and relationships. Executive 
functions are assumed to be located in the frontal lobes of a human 
brain. These are particularly vulnerable to damage after TBI because 
they sit on bony projections in the skull, and thus are at greater risk 
of injury and damage. Although the Katz ADL Index is sensitive to 
changes in declining health status, it is limited in its ability to 
measure small increments of improvements seen in the rehabilitation of 
patients.
    It is not clear from VA's implementation plan whether the proposed 
Katz Scale or the Patient Behavioral scale will be used to assess 
cognitive, neurological impairment, and other residuals of TBI. 
Notwithstanding there is no assessment instrument proposed for veterans 
suffering from TBI, we appreciate VA's not intimating the use of the 
Global Assessment of Functioning (GAF) Scale as a proxy. GAF scores are 
used in conjunction with a multiaxial evaluation of a psychological 
disorder, whereas severe TBI can result in not only psychological, but 
physical, cognitive, and psychosocial impairments and functional 
disabilities.
    For example, damage to the frontal lobes is often associated with 
good recovery of motor, sensory, and linguistic functions as seen on 
neuropsychological testing. Thus, the person with frontal lobe or 
executive functioning damage may appear normal in testing, or in the 
context of a highly structured and routine environment. On the other 
hand, executive dysfunction can cause many problems despite good 
recovery in the aforementioned areas, and debilitating complications 
can be seen with managing cognitive, social and communicative 
functioning, and behaviors. It can result in difficulty in executive 
functions such as attending, planning, organizing, learning, problem-
solving, and reasoning in the unstructured reality of life tasks even 
though these individuals may show good performance on highly structured 
neuropsychological tests.
    Research has generally supported hierarchical arrangement of 
functional skills by demonstrating IADLs are affected earlier in the 
course of cognitive impairment,\18\ whereas ADLs are preserved until 
relatively late.\19\ There is robust discussion on subdividing IADLs or 
higher level functional skills to reflect relevant underlying cognitive 
abilities. In essence, there is a need to establish a tool or series of 
tools that has a proven ability to link domains of daily function to 
particular domains of cognitive function. This would improve VA's 
ability to make meaningful predictions about which specific functional 
impairment might result from specific cognitive impairment.
---------------------------------------------------------------------------
    \18\ Kemp et al., 2002; Richardson, Nadler and Malloy, 1995; 
Tomaszewski et al., 2005
    \19\ Sclan and Reisber, 1992; Suurmeijer et al., 1994
---------------------------------------------------------------------------
    There are three general approaches to measuring everyday function: 
Self-report, Informant report and Performance based measuring. Self-
report has been shown to be problematic in individuals with cognitive 
impairment.\20\ Performance based measuring is argued to be the most 
valid and reliable method of assessing functional abilities of patients 
with cognitive impairment, but a caveat must be stressed. That is, all 
reasonable effort must be made to ensure the measurement is not 
administered under artificial conditions in which the individual is 
``prompted'' to engage in a task and provided all the materials he or 
she requires in completing the task.
---------------------------------------------------------------------------
    \20\ Debettignies, Mahurin, and Pirossolo, 1990; Seltzer et al., 
2001
---------------------------------------------------------------------------
    Critics cite performance based measuring as time consuming and 
requires extensive equipment, thus making it impractical for routine 
use. More practical would be the use of the caregiver or similar 
individual--who knows the patient best--as a proxy rater.
Respite Care:
    A significant new array of respite services is also authorize under 
P.L. 111-163, that are intended to be provided in a flexible and 
helpful way to caregivers of severely wounded veterans. Research has 
shown that providing respite for caregivers can have a positive effect 
on the health of the caregiver as it provides the much needed temporary 
break from the often exhausting challenge imposed by constant 
attendance of a severely disabled person.
    Currently, VA's system for providing respite care is fragmented and 
inflexible, governed by local policies for Community Living Center 
(formerly VA Nursing Homes) and Adult Day Care programs. Moreover, the 
Government Accountability Office and other independent reviewers have 
cited a series of weaknesses in VA existing respite program.
    In previous testimony, DAV indicated a significant majority of 
veterans do not avail themselves of such services due to lack of 
knowledge of such a benefit or the services are simply not available in 
the veteran's community. The majority of in-home respite care is 
purchased by VA from community agencies that may not provide weekend or 
overnight respite services. Furthermore, trust and privacy remain 
significant barriers when an individual who is to provide in-home 
respite, homemaker and home health programs, is perceived as a 
stranger.
    Despite VA's recognition of the importance of respite care for 
caregivers of disabled veterans, DAV is deeply concerned the 
implementation plan contains no discussion to address any of these 
existing issues in its current respite care program. At the very least, 
DAV had hoped VA would have proposed establishing clearer policies 
regarding in-home respite and that such policies would also include an 
expectation that every Community Living Center and Adult Day Care 
Program to provide priority for age-appropriate respite care for 
severely injured veterans. We urge VA to have a more deliberate plan to 
implement a robust and flexible respite program.
Conclusion:
    Madam Chairwoman, in the absence of family caregivers, an even 
greater burden of direct care would fall to VA at significantly higher 
cost to the government and reduced quality of life for these veterans 
who have sacrificed so much. They play a critical role in facilitating 
recovery and maintaining the veteran's independence and quality of life 
while residing in their community, and are an important component in 
the delivery of health care by the VA. These family members, relatives, 
or friends are motivated by empathy and love, but the very touchstones 
that have defined their lives--careers, love relationships, 
friendships, and their own personal goals and dreams--have been 
sacrificed, and they face a daunting lifelong duty as caregivers.
    Along with other veterans service organizations, DAV has been 
working for years with the Administration and VA to address these 
lapses. DAV is concerned that VA's implementation plan will not result 
in actions rooted in Congress' intent when in passing P.L. 111-163. We 
are keenly aware of VA's ability to do what is right by veterans and 
their caregivers. VA recently issued a news release on the topic, 
``Resources for Enhancing Alzheimer's Caregivers Health (REACH) VA.'' 
REACH VA is an initiative translated from a VA randomized control 
trial. The clinical trial showed significant improvement in caregiver 
burden, depression, health/self-care, social support, and management of 
patient behaviors. The goal of REACH VA is to implement nationally an 
effective intervention to decrease stress among caregivers who 
typically provide the majority of care for those with dementia, on 
average 16-20 hours per day, and improve the management of patient 
behaviors throughout the VHA system.
    VA is indeed capable of administering a caregiver assistance 
program envisioned by caregivers of disabled veterans, the veteran 
community, and Congress. In time, we will know if VA has listened to 
the concerns, considered them, and adjusted its position when the IFR 
and subsequent amendments are issued, and when a final regulation is 
published.
    Again, we thank you for the opportunity to present our views on 
VA's implementation plan for Title I of P.L. 111-163. The DAV is 
committed to working constructively with Congress, VA and the 
Administration to ensure family caregivers do not remain undertrained, 
underpaid, underappreciated, undervalued, and exhausted by their 
duties.

                                 
      Prepared Statement of Ralph Ibson, National Policy Director,
                        Wounded Warrior Project
    Chairwoman Buerkle, Ranking Member Michaud and Members of the 
Subcommittee:
    Thank you for inviting Wounded Warrior Project (WWP) to testify on 
the Department of Veterans Affairs' (VA) implementation plan for the 
caregiver-assistance program established in Public Law 111-163 (the 
Caregivers Act). VA's implementation plan has profoundly concerned and 
disappointed us, and we greatly appreciate your holding this early 
hearing.
    With our mission of honoring and empowering wounded warriors, WWP's 
vision is to foster the most successful, well-adjusted generation of 
veterans in our Nation's history. WWP's highest legislative priority 
during the last Congress was the enactment of legislation requiring the 
Department of Veterans Affairs to establish a program of comprehensive 
supports for family caregivers of those seriously wounded in Operation 
Enduring Freedom and Operation Iraqi Freedom. In light of Congress' 
decisive action last year in passing a very strong Caregivers Act, 
successful implementation of that program is now our top priority. But 
VA's implementation plan falls far short of our goal. More importantly 
it falls far short of what the law requires. Among its most egregious 
flaws are rigid clinical eligibility criteria that have no foundation 
in the law and would disenfranchise several thousand veterans intended 
to be covered under the Act, many of whom have severe cognitive and 
other impairments resulting from traumatic brain injury.
Background: VA's Fierce Opposition to Caregiver Legislation
    In attempting to understand why VA has submitted a plan that is so 
fundamentally flawed, it is worth noting VA's longstanding, deep 
opposition to caregiver-assistance legislation. From the perspective of 
an organization that saw the profound need for caregiver assistance and 
advocated hard for it, VA's position during the period of this law's 
development and consideration was deeply disappointing.
    Over a period of several years during which caregiver-assistance 
legislation was under consideration in Congress, VA seemingly struggled 
to identify a rationale for its consistent opposition to the concept. 
In 2008, VA testified before this Subcommittee that such legislation 
was unnecessary because ``VA already has a program in place that 
accomplishes [its] goals more efficiently and effectively.'' \1\ The 
following year, it advised the Senate Veterans Affairs Committee at a 
legislative hearing that it ``strongly opposes'' the then-pending 
caregiver-assistance bill, \2\ which it characterized as ``divert[ing] 
VA from its primary mission of treating veterans and training 
clinicians.'' VA's testimony also stated that such legislation was 
premature in that Congress should not mount a program of this 
complexity without piloting it first; yet VA also expressed the 
contradictory view that any caregiver-support initiative should not be 
limited by date of service. \3\ At a subsequent hearing before this 
Subcommittee, VA expressed ``recogni[tion] that some veterans, 
particularly young veterans, will need care for the rest of their 
lives'' and stated that it was ``currently undertaking a comprehensive 
reassessment of caregiver programs . . . and look forward to working 
with Congress to identify the most feasible and effective caregiver 
program improvements.'' \4\ VA's strongest point of opposition appeared 
to have been aimed at providing modest financial assistance to any 
caregivers. As VA Secretary Shinseki testified recently in 
acknowledging the Department's efforts to strip the stipend from any 
caregiver legislation, ``[o]ur proposal . . . was to use an existing 
mechanism . . . called Aid & Attendance [which already provides special 
monthly compensation to the veteran] . . . , [but] our position didn't 
prevail.'' \5\
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    \1\ Statement of Gerald Cross, MD; Department of Veterans Affairs, 
before the Subcommittee on Health, House Committee on Veterans Affairs, 
September 9, 2008.
    \2\ S. 801, 111th Cong., established the framework for what became 
the comprehensive caregiver-assistance program.
    \3\ Statement of Gerald Cross, MD; Department of Veterans Affairs, 
before the Senate Committee on Veterans Affairs, April 22, 2009.
    \4\ Statement of Madhulika Agarwal, MD; Department of Veterans 
Affairs, before the Subcommittee on Health, House Committee on Veterans 
Affairs, June 4, 2009.
    \5\ Testimony of Secretary Eric Shinseki before the House Committee 
on Veterans Affairs on VA's budget for FY 2012, February 17, 2011. 
Indeed even after both the Senate and House had passed caregiver bills 
that both included a stipend provision, senior VA staff sought 
unsuccessfully in a meeting on December 1, 2009, to negotiate for an 
alternative that would scale back the legislation to eliminate 
provision of a stipend.
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    The bottom line is that from the outset of the legislative process 
VA balked at the notion of providing caregivers with vitally needed 
supports and, despite a clear statutory mandate in the Caregivers Act, 
VA's very restrictive eligibility criteria continue to evidence that 
opposition.
VA Caregiver-Assistance Implementation Plan
    The Caregivers Act directed VA to develop a plan, in consultation 
with stakeholders, for implementing the comprehensive assistance 
program, and to submit that plan to the Senate and House Veterans 
Affairs Committees not later than 180 days after enactment. The Act 
further directed VA to implement the program 90 days later.
    The provisions of the Caregivers Act are noteworthy in several 
respects. First, the law is detailed and prescriptive, and is quite 
explicit as to who is an eligible veteran. \6\ Second, it provides a 
very robust role for stakeholders like WWP. Specifically, the law 
directs VA to consult with stakeholders in the development of an 
implementation plan and to report to Congress on the recommendations 
stakeholders offer and, where such recommendations are not adopted, to 
provide the rationale for that decision. Finally, the law sets critical 
due dates: VA was to develop and submit an implementation plan to 
Congress 6 months after enactment (which fell on November 1st, 2010) 
and was to implement the law 9 months after enactment, January 30th, 
2011.
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    \6\ Contrast the Act with H.R. 3051, 110th Congress, a similar-
purpose measure which in pertinent part provided simply that ``The 
Secretary of Veterans Affairs shall establish a program on training and 
certification of family caregivers of veterans and members of the Armed 
Forces with traumatic brain injury as personal care attendants of such 
veterans and members . . . . [and] shall determine the eligibility of a 
family member of a veteran or member of the Armed Forces for 
participation in the program required by subsection (a) . . . based on 
the clinical needs of the veteran or member of the Armed Forces 
concerned, as determined by the physician of such veteran or member . . 
. A family caregiver of a veteran or member of the Armed Forces who 
receives certification as a personal care attendant under this section 
shall be eligible for compensation from the Department of Veterans 
Affairs for care provided to such veteran or member.'' Accessed at 
http://www.thomas.gov/cgi-bin/query/D?c110:1:./temp/c110wUzrc0::
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    Based on those requirements of the Act, WWP had three general 
expectations. First, we had every reason to expect that VA would 
develop an implementation plan for the comprehensive-assistance program 
that honored the plain meaning of the law. We expected, therefore, that 
it would closely track the law and cover caregivers of those who in 
line of duty on or after 9/11 had sustained a serious injury--including 
``traumatic brain injury, psychological trauma, or other mental 
disorder'' \7\--and were ``in need of personal care services because of 
(i) an inability to perform one or more activities of daily living; 
[or] (ii) a need for supervision or protection based on symptoms or 
residuals of neurological or other impairment or injury.'' \8\ Our 
second expectation was that VA would work diligently and in 
coordination with the Administration to ensure that the deadlines set 
in the law were met. And our third expectation, based on the 
consultation provision of the law, was that there would be open 
dialogue and transparency vis a vis stakeholders in the program's 
development and implementation.
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    \7\ 38 U.S.C. sec. 1720G(a)(2)(B).
    \8\ 38 U.S.C. sec. 1720G(a)(2)(C); the term ``personal care 
services'' is defined at U.S.C. sec. 1720G(d)(4).
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    None of these expectations has been met. As you know, VA has failed 
to meet the deadlines set in the law. Communication with stakeholders 
has been decidedly one-sided. VA staff solicited stakeholders views 
only very late in the process. At no time were stakeholders given a 
glimpse of a preliminary implementation plan, or a basis for believing 
that our recommendations were even being seriously considered. VA's 
deliberation and decision-making regarding implementation has been 
marked by a level of secrecy more appropriate to a military combat 
operation than to an effort to help families. But most tragic, the 
substance of VA's implementation plan falls far short of the 
requirements of the law; indeed with respect to the question of who 
would be eligible for comprehensive caregiver support, the plan bears 
almost no resemblance to the law.
VA Clinical Eligibility Criteria: Who Will Be Hurt and Why
    WWP was given no inkling of the contents of the VA implementation 
plan prior to its submission to the House and Senate Committees, but we 
have since presented VA officials with a detailed critique of their 
plan. Most recently, in response to the suggestion that the 
Administration was moving to expedite its implementation, we presented 
VA a paper entitled ``Caregiver Law Implementation: Accelerated Start 
Is Less Vital than Getting the Plan Right.'' Among the problems we 
highlighted were the plan's unreasonably rigid ``clinical eligibility 
criteria.'' It is critical to appreciate that these criteria are 
fundamentally inconsistent with those set in the law; in fact, a core 
requirement of the VA plan was considered and rejected during the 
course of development of the legislation itself. To underscore the 
implications of these criteria, we offered the following examples of 
the impact these criteria would have on wounded warriors and their 
caregivers, drawing on our direct experience with these families.

     Case 1: A veteran sustained a severe traumatic brain injury. Five 
years post-injury, he lives with his wife, and while he can carry out 
all activities of daily living he cannot live independently due to 
residual cognitive impairment, impaired judgment, and anxiety when in 
the community. His condition requires that his wife manage all 
household affairs, finances, telephoning, etc., and accompany him when 
traveling. While the veteran cannot live independently, he could live 
in another supervised setting, but because he is not so impaired as to 
need nursing home care he would not be deemed an ``eligible veteran'' 
under the VA implementation plan, and his wife would not be eligible 
for caregiver supports. Even if that were not an obstacle, coverage 
would likely be denied under the VA plan's definition of ``serious 
injury'' based on its requirement that the veteran be ``at high risk 
for personal safety''--a particularly high threshold this veteran might 
not meet.

     Case 2: A veteran has sustained polytraumatic injuries that have 
resulted in blindness and cognitive deficits. Because of his cognitive 
impairment he has not achieved maximum benefit of blind rehabilitation 
and needs regular assistance with food preparation, shopping, laundry, 
finances, housekeeping and transportation. His mother provides this 
assistance on a daily basis. But because his condition is stable, he 
does not require ``continual medical management;'' and although there 
are some issues of personal safety, he is not ``at high risk for 
personal safety''--he does not meet one of the VA's required clinical 
eligibility criteria (or the definitions of the term ``serious injury'' 
or ``personal care services'').

    WWP sees no need for VA to establish clinical eligibility criteria 
beyond those set forth in the law itself. But we also see absolutely no 
basis in law for VA to superimpose the following requirements, which 
have the effect of severely limiting eligibility, particularly for 
those with one of the signature wounds of this war, traumatic brain 
injury:

    a.  Requiring that without caregiver support, the veteran would 
require institutional care: The language of the law provides no 
credible basis for inserting this criterion. It sets an unreasonably 
high bar, and is fundamentally inconsistent with the explicit criteria 
in the law. Under the law, the critical issue in determining whether an 
individual is an ``eligible veteran,'' for purposes of the 
comprehensive caregiver assistance program, is whether the veteran ``is 
in need of personal care services because of . . . an inability to 
perform one or more activities of daily living . . . [or] a need for 
supervision or protection based on symptoms or residuals of 
neurological or other impairment or injury.'' But VA, by imposing the 
much higher requirement--need for institutional care--would deem 
ineligible many veterans who cannot live independently and need the 
full-time supervision or protection afforded by a family member because 
of residuals of traumatic brain injury, but are not so profoundly 
impaired as to need institutional care. VA is saying in effect that 
even though a veteran needs personal care services, the caregiver who 
provides those needed services would not be deemed eligible for 
support. Under this bizarre construct, VA tells a single mother who has 
left the workforce to care for her son, that she's not eligible for the 
modest stipend and other support because--although her son can't live 
independently, he doesn't need nursing home care. What makes this 
strange reading of the law even more disturbing is that the ``need for 
institutional care'' criterion was considered in the development of 
this legislation and rejected, as discussed in the Explanatory 
Statement describing the compromise agreement on the Caregivers Act 
developed by the Senate and House Veterans Affairs Committees.\9\ It is 
unreasonable for VA to revive this rejected standard, and in so doing 
dramatically restrict eligibility.
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    \9\ As noted in the Joint Explanatory Statement accompanying the 
amendment of the House of Representatives to S. 1963, enacted as Pub. 
L. No. 111-163, under the earlier House-passed caregiver-assistance 
bill, H.R. 3155, ``[e]ligible OEF or OIF veterans are defined as those 
. . . in need of caregiver services without which the veteran would be 
hospitalized, or placed in nursing home care or other residential 
institutional care . . . '', but ``[t]he Compromise Agreement contains 
the Senate provision'' and only ``follows the House bill in creating a 
separate program of general family caregiver support services for . . . 
caregivers of veterans of any era.''
---------------------------------------------------------------------------
    b.  Requiring that the veteran must either need ``continuing 
medical management'' or be ``at high risk for personal safety:'' In 
creating this criterion, VA again goes too far. Requiring ``continuing 
medical management'' has nothing to do with a need for personal care. A 
veteran's condition can be medically stable, yet make it impossible for 
the individual to live independently. The plan provides an 
alternative--a finding that the veteran is ``at high risk for personal 
safety.'' But such a requirement sets an artificially high threshold: 
to require that a veteran be at ``high risk for personal safety'' is to 
say that a young mother with a brain-injured spouse who poses ``only'' 
a moderately high risk of leaving the stove unattended or crossing the 
street unaware of cars does not merit caregiver support. This high 
threshold also reads the phrase ``need for supervision'' out of the 
statute. The law clearly is not focused solely on safety, but also on 
behaviors often associated with traumatic brain injury or severe 
behavioral health problems, either of which could require a caregiving 
attendant to provide needed supervision.
    c.  Defining the term ``serious injury'' so narrowly that it 
frustrates the purposes of the law: VA's plan defines the term 
``serious injury'' by stating that an individual with a serious injury 
is one who, due to that injury, (i) ``require[s] ongoing care,'' (ii) 
exhibits impaired ability to function independently, (iii) is 
vulnerable, (iv) is ``at high risk for personal safety,'' and (v) 
requires at least 6 months of continuous caregiver support to enable 
them to live outside an institutional care setting. This definition 
would artificially create a far higher eligibility standard than the 
criteria expressly set forth in the law: need for personal care 
services because of an inability to perform one or more activities of 
daily living or a need for supervision or protection based on symptoms 
or residuals of neurological or other impairment or injury. \10\ The 
language of the law \11\ is consistent with VA policy, \12\ and 
expressly identifies specific kinds of trauma and injury as encompassed 
by the term ``serious injury.'' As made clear in the Joint Explanatory 
Statement, seriously injured veterans are those who need personal care 
services under the criteria specified in the law.\13\ VA, in utterly 
distorting the term ``serious injury,'' has not only ignored the plain 
meaning of the law, but ignored its own recent definition. VHA 
Directive 2009-018 defines virtually the same term, ``seriously injured 
or ill Operation Enduring Freedom (OEF) or Operation Iraqi Freedom 
(OIF) Veteran,'' as one who has ``one or more of the following 
diagnoses or medical conditions . . . : (a) Burns; (b) Spinal Cord 
Injury; (c) Amputation or loss of function of arm, leg, hand, or foot; 
(d) Post-traumatic Stress Disorder; (e) Visual impairment; or (f) 
Traumatic brain injury.'' \14\
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    \10\ 38 U.S.C. sec. 1720G(a)(2)(C).
    \11\ ``. . . an eligible veteran is any individual who . . . has a 
serious injury (including traumatic brain injury, psychological trauma, 
or other mental disorder) . . . '', 38 U.S.C. sec. 1720G(a)(2)(B).
    \12\ VHA Directive 2009-018, Tracking Severely Injured or Ill 
Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) 
Veterans Using the Non-primary Care Team Function in the Primary Care 
Management Module (PCMM), March 24, 2009. Sec. 2.c.(1), Accessed at 
http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1863.
    \13\ Joint Explanatory Statement, ibid.
    \14\ VHA Directive 2009-018, Tracking Severely Injured or Ill 
Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) 
Veterans Using the Non-primary Care Team Function in the Primary Care 
Management Module (PCMM), March 24, 2009. Sec. 2.c.(1), Accessed at 
http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1863.
---------------------------------------------------------------------------
    d.  Defining the term ``personal care services'' in a manner 
inconsistent with law: The VA plan defines the term in pertinent part, 
as a need for assistance ``to prevent harm to self or others . . . .'' 
while the law employs very different terminology specifying ``a need 
for supervision or protection based on symptoms or residuals of 
neurological or other impairment or injury'' (38 U.S.C. sec. 
1720G(a)(2)(C)(ii)). The plan definition not only reads the word 
``supervision'' out of the statute, but inappropriately substitutes a 
test that comes closer to the strict standard applied to involuntary 
civil commitment.
VA's Rationale for Setting Eligibility Requirements Far Stricter than 
        Those Set in Law:
    VA's Office of General Counsel recently provided the Senate 
Veterans Affairs Committee a ``white paper'' \15\ which responded to 
the suggestion that it was not lawful for VA to condition eligibility 
on a requirement that ``without caregiver support providing personal 
care services at home in an ongoing manner, [the Veteran] would require 
hospitalization, nursing home, or other institutional care.'' The 
General Counsel's paper offered a thin rationale for its conclusion 
that ``there would be a `rational basis' for including such a criterion 
. . . such that it would likely withstand any legal challenge.'' We 
respectfully differ with that view. But more importantly, the white 
paper raises the question whether the Secretary of Veterans Affairs, 
who ``is responsible for the proper execution and administration of all 
laws administered by the Department,'' \16\ or any officer of the 
Department acting in his behalf on this matter, ever asked the Office 
of General Counsel a question such as, ``What IS the Secretary's 
responsibility to caregivers of wounded warriors and to Congress and 
the American people under the Caregivers Act?'' Had that question been 
posed and the opinion followed, we are confident VA's implementation 
plan would have looked markedly different. But, rather than attempting 
to carry out the clear intent of a law it had opposed from the outset, 
we believe VA sought to impose the strictest-conceivable limitations on 
who would be eligible.
---------------------------------------------------------------------------
    \15\ VA Office of General Counsel, ``Family Caregiver Program 
Implementation Plan: Question on Proposed Eligibility Requirements,'' 
February 22, 2011.
    \16\ 38 U.S.C. sec. 303.
---------------------------------------------------------------------------
    Thus, in its recent white paper, VA's Office of General Counsel 
suggests that because the phrase ``serious injury'' \17\ is not defined 
in the Caregivers Act, implementing regulations ``must'' supply an 
appropriate definition to promote consistency of application. Counsel 
offers no support for the proposition that ``consistency of 
application'' trumps conformity to the plain language of the statute. 
Even more troubling, Counsel makes no effort to explain how the phrase 
``serious injury'' could be read to be synonymous with the phrase 
``catastrophic injury.'' Congress defined the term ``catastrophic 
injury or illness'' in the context of injured or ill servicemembers as 
``a permanent, severely disabling injury, disorder, or illness that . . 
. compromises the ability of the afflicted person to carry out the 
activities of daily living to such a degree that the person requires 
personal or mechanical assistance to leave home or bed, or constant 
supervision to avoid physical harm to self or others.'' \18\ Counsel 
further conflated scattered provisions of the law that are neither 
structurally nor logically related to the eligibility language, \19\ 
together with phrasing deleted from earlier legislation, \20\ to arrive 
at a richly imagined ``implied intention.''
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    \17\ ``. . . an eligible veteran is any individual who . . . has a 
serious injury (including traumatic brain injury, psychological trauma, 
or other mental disorder) . . . [who] is in need of personal care 
services . . . .'' 38 U.S.C. sec. 1720G(a)(2) (emphasis added).
    \18\ National Defense Authorization Act of 2010, Pub. L. No. 110-
84, sec. 603 (2010).
    \19\ Counsel places heavy reliance on two provisions of the law 
relating to respite care benefits as supporting its reading. But surely 
VA social workers, if not its lawyers, would appreciate that a family 
caregiver would need periodic respite whether or not the veteran was so 
impaired as to require nursing home care.
    \20\ Counsel would have it both ways. It assigns significance to a 
statement of purpose dropped from an earlier Senate bill, while 
rejecting the notion that there is any significance to be attached to 
the fact that the compromise agreement did not adopt the pertinent 
provisions of House-passed H.R. 3155, which had included the phrase 
``without such services, the veteran would require hospitalization, 
nursing home care, or other residential institutional care.''
---------------------------------------------------------------------------
    Having studied the VA plan, we were frankly mystified by VA's 
perplexing misreading of the Caregivers Act. Finally, Madam Chairwoman, 
your questioning of the Secretary at the Committee's recent hearing on 
the VA budget for FY 12 provided the catalyst to better understanding 
what was at play. Responding to your question, Secretary Shinseki 
attempted to defend the Administration's budget for the new 
comprehensive caregiver-assistance program, which he admitted would 
cover only 840 families. He acknowledged that in developing eligibility 
criteria, the goal was ``to write a regulation that meets the immediate 
requirement . . . to Iraq and Afghanistan vets and caregivers--and yet 
keep the opportunity open'' to expand the law to other populations. 
``So, it's an issue of fairness,'' \21\ he asserted. In short, he as 
much as stated that VA's eligibility criteria were set very narrowly, 
and exclude many OEF/OIF veterans covered under the law, and 
particularly those with severe traumatic brain injury--so that these 
criteria might at some future date be applied to other era-veterans.
---------------------------------------------------------------------------
    \21\ Testimony of Secretary Eric Shinseki before the House 
Committee on Veterans Affairs on VA's budget for FY 2012, February 17, 
2011.
---------------------------------------------------------------------------
    Such a position is fundamentally at odds with the law, which 
directs VA to establish parallel programs of caregiver support--a 
comprehensive program for caregivers of warriors wounded on or after 9/
11 as well as a ``program of general caregiver support services'' 
(codified at 38 U.S.C. sec. 1720G(b)) for caregivers of all veterans 
enrolled in the VA health care system who need personal care services. 
\22\ Under the general program, VA is to provide counseling, respite 
care, and educational support to eligible caregivers. The law further 
directs the Secretary, within 2 years after the law's implementation, 
to report on the feasibility and advisability of expanding the 
comprehensive program to caregivers of veterans injured prior to 9/11.
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    \22\ Under the Caregivers Act the criteria employed in describing 
what constitutes a ``need for personal care services'' for purposes of 
the program of general caregiver support services are the same as for 
the program of comprehensive assistance; cf. 38 U.S.C. sec. 
1720G(a)(2)(C) and 38 U.S.C. sec. 1720G(b)(2).
---------------------------------------------------------------------------
    In short, Congress established a very deliberate framework in the 
Act--to assist caregivers of all eras of service--while requiring more 
comprehensive supports for those caring for veterans with recent 
injuries--an approach that could be viewed as initially limiting the 
scope of the comprehensive program to those in most immediate and 
compelling need.\23\ While offering real help for all-era caregivers, 
the law recognizes not only the prevalence of unique kinds of wounds 
this war's veterans have survived--wounds so profound they would likely 
have been mortal in earlier wars--but the fact that those with recent 
injuries are in most instances still undergoing rehabilitation from 
those injuries. As such, it is altogether understandable that Congress 
would provide more robust supports for those warriors to help assure 
the fullest and greatest possible rehabilitation.
---------------------------------------------------------------------------
    \23\ Limiting the scope of the comprehensive program in this 
manner, Congress was arguably drawing lines consistent with VA's 
earlier testimony counseling that caregiver assistance be approached in 
phases, beginning as VA proposed with a pilot effort.
---------------------------------------------------------------------------
    With all due respect, for Secretary Shinseki, representing the 
Administration before Congress, to imply that eligibility rules for the 
Caregivers Act's comprehensive program should be tightly restricted to 
enable some future Congress to extend the Act's provisions to other 
populations is to suggest that the Administration's idea of good policy 
should trump Congress's. Sadly, arising in the context of the 
Administration's efforts to trim the FY 12 budget, the fact that only 
very limited numbers would likely receive comprehensive supports under 
the plan's cramped eligibility requirements invites speculation as to 
whether fiscal considerations--rather than ``fairness''--have trumped 
compliance with law and keeping faith with brain-injured warriors.
Other Serious Flaws in the VA Plan:
    While eligibility issues have been the principal focus of 
controversy, VA's plan raises other serious issues. Let me summarize:

    1.  Unreasonable limits on the scope of covered mental health 
services: The law calls for providing needed mental health services to 
a primary-caregiver under the comprehensive services program. But VA's 
plan would provide that caregiver only the very limited coverage 
afforded under the law's program of general caregiver support. That 
coverage is expressly limited (under 38 U.S.C. sec. 1782) to 
circumstances where providing services is necessary to the veteran's 
treatment. So if a warrior's condition were stable and did not require 
ongoing treatment, a caregiver who, for example, was experiencing 
severe anxiety associated with caregiving might not be covered--
defeating the very purpose of the benefit. And, under the plan, a 
caregiver experiencing a bout of depression associated with the 
stresses of caregiving, for example, would likely not be covered for 
drug therapy under the plan's strictures. In sum, this limited coverage 
falls far short of the law's intent as well as short of the kind of 
support contemplated in the White House's ``Strengthening Our Military 
Families'' program.
    2.  Ongoing monitoring through routine home-visits at least every 
90 days: The VA plan calls for ongoing monitoring at least every 90 
days. Yet as noted in the Joint Explanatory Statement, the compromise 
agreement contains the Senate provision which was modified to delete a 
provision that called for ``mak[ing] home visits every 6 months.'' \24\ 
Having successfully pressed the point that routine home visits are 
inherently intrusive and unwarranted as applied to longstanding, 
devoted caregivers, WWP finds it very troubling that VA's plan requires 
routine home-visits twice as frequently as earlier proposed. The 
intrusiveness of such monitoring is heightened for the many caregivers 
who also serve as the veteran's fiduciary. As such, they are subject to 
periodic home visits to check on the veteran's well-being. While the 
monitoring requirements are highly problematic, the plan is still more 
objectionable for its failure to address these overlapping inspections. 
A reasonable plan would at least provide for tapering off the frequency 
of any monitoring in the absence of problems, and for eliminating the 
dual intrusion posed for many caregivers by fiduciary-oversight visits.
---------------------------------------------------------------------------
    \24\ Joint Explanatory Statement, ibid.
---------------------------------------------------------------------------
    3.  Flawed Criteria for Determining Stipend Amount: Under the law, 
an individual's stipend is to be based on ``the amount and degree of 
personal care services provided.'' The term ``personal care services'' 
is defined in the law to mean ``assistance with one or more independent 
activities of daily living'' (as well as any other non-institutional 
extended care). (Independent activities of daily living (IADL's) 
include the ability to use the telephone, shopping, food preparation, 
housekeeping, laundry, ability to travel, responsibility for one's 
medication, and handling finances.) But VA's plan--rather than 
determining stipend amount by reference to IADL's, as required by the 
law--does so principally by reference to activities of daily living 
(ADL's). The implications of this misapplication of the law are all too 
apparent to families caring for a loved one with cognitive and other 
impairments associated with traumatic brain injury, since IADL's take 
account of such impairments while ADL's do not. The following example 
illustrates the point:

            A veteran sustained severe traumatic brain injury as a 
result of an IED blast in Iraq. While he also suffered a below-the-knee 
amputation, he is able to perform all the activities of daily living. 
But he cannot live independently because significant cognitive 
impairment, markedly impaired judgment and impulsivity create a very 
serious risk for safety. His father, who has left the workforce, is 
with him almost constantly, providing for his safety, and also attends 
to a wide range of the veteran's needs, including telephoning, food 
preparation, laundry, housekeeping, finances, and transportation. While 
the veteran meets the VA plan's eligibility criteria, the father would 
receive only a very nominal stipend under the VA plan because it bases 
the magnitude of the stipend on the extent of deficits in activities of 
daily living (feeding, toileting, etc.)--which the veteran can do--
rather than independent activities of daily living--which the veteran 
cannot, and which render him highly dependent.

    Madam Chairwoman, the Caregivers Act is not only historic 
legislation; it represents a solemn promise to spouses, parents, and 
other family members who devotedly care for their seriously wounded 
loved ones. The VA plan would break that promise, and we urge you to 
stand firm and join us in voicing strong objection. The Administration 
must not speed through a regulation that covers only a fraction of 
those eligible under the law. It must not abandon those vulnerable 
veterans who cannot live independently because of cognitive or other 
deficits due to traumatic brain injuries.
    Thank you for your attention to these deep concerns.

                                 
   Prepared Statement of Tom Tarantino, Senior Legislative Associate,
                Iraq and Afghanistan Veterans of America
    Madam Chairwoman, Ranking Member and Members of the Committee, on 
behalf of Iraq and Afghanistan of America's 200,000 Member Veterans and 
supporters, thank you for the opportunity to testify here today on the 
critical issue of the implementation of the Caregivers and Veterans 
Omnibus Health Services Act of 2010 (S. 1963) and specifically 
caregivers' assistance.
    My name is Tom Tarantino and I am a Senior Legislative Associate 
with IAVA. I proudly served 10 years in the Army beginning my career as 
an enlisted Reservist, and leaving the service as an Active Duty 
Cavalry Officer. During these 10 years, my family served along with me. 
They experienced every deployment as well as the challenges of every 
transition home. Because of the nature of the wars in Iraq and 
Afghanistan, many families like mine continue to serve long after their 
veterans have returned home.
    The wars in Iraq and Afghanistan are unique. In the last 10 years, 
improvements in medical technology have decreased the overall number of 
combat deaths. But while more servicemembers are returning home, 
thousands are coming back with injuries that will require a lifetime of 
care. Since the start of the wars, the Department of Defense has 
counted more than 40,000 servicemembers wounded in action.
    Soldiers, Marines, Airmen and Sailors, as young as eighteen, are 
coming home to the prospect of having someone feed, clothe and care for 
them for the rest of their lives. All across the country, mothers and 
fathers, husbands and wives, brothers and sisters, and boyfriends and 
girlfriends are stepping up, putting aside their own lives and plans to 
take care of these wounded warriors.
    Many caregivers have had to leave their full-time jobs, losing 
income and benefits. A recent study by the National Alliance for 
Caregiving (NAC) found that 62 percent of veteran caregivers reduced 
their job hours and half quit their jobs or opted for early 
retirement--compared to only 10 percent of caregivers nationally. 
Moreover, half of veteran caregivers reported that they experienced a 
high degree of financial hardship.\i\ Even though helping their veteran 
is now their full-time job, veteran caregivers right now do not receive 
the necessary financial support to do so without financial risk.
---------------------------------------------------------------------------
    \i\ Caregivers of Veterans--Serving on the Homefront, National 
Alliance for Caregiving, November 2010, p. 17: http://
www.unitedhealthfoundation.org/download/cov_exec.pdf.
---------------------------------------------------------------------------
    Far too many are also working without any formal instruction, 
training or support to care for their veteran. As a result, the NAC 
study found that 88 percent of veteran caregivers reported increased 
stress or anxiety. Only 15 percent of them received respite care from 
the VA or another community support service in the past 12 months. \ii\
---------------------------------------------------------------------------
    \ii\ Ibid., p. 18.
---------------------------------------------------------------------------
    Natalie Cobb is an example of the selflessness displayed by 
military families across the country. Her husband Steve, who served in 
Iraq in 2004, received a concussion in a vehicle accident and then 
later was severely wounded during patrol when a mortar exploded less 
than 50 feet away. Following his deployment, Natalie immediately 
noticed a difference in his behavior. A CT scan revealed an ambiguous 
spot in his brain and he was sent to Walter Reed Army Medical Center. 
Steve spent 13 months receiving care there after doctors diagnosed him 
with Traumatic Brain Injury and Post-Traumatic Stress Disorder. A short 
time after his release, Steve suffered a heart attack as a result of 
his anxiety. Natalie remained by his side throughout his long recovery 
and now, over 6 years later, still serves as Steve's primary caregiver.
    Natalie had to learn to take care of Steve on her own. She 
navigated the VA paperwork by herself. Today, she manages their 
household while taking care of Steve 24 hours a day. Since she doesn't 
trust anyone to replace her as his caregiver, she has not had any 
respite in over 6 years.
    The veterans' community came together 2 years ago to help Natalie 
and Steve and the many families like them across America. IAVA and all 
of the veterans' service organizations worked closely with Congress, 
military families and the caregiver community to craft a law that would 
meet the needs of these selfless caregivers.
    This Committee and its counterpart in the Senate worked tirelessly 
to ensure that families like the Cobb's would get the support that they 
needed, including health care, mental health care, respite care and 
living stipends. Our goal was to make caregivers' lives easier, so that 
they could devote more time to their wounded warriors without wearing 
themselves out both physically and financially.
    At the time, we believed that we had accomplished our mission. The 
Caregivers and Veterans Omnibus Health Services Act of 2010 (S. 1963) 
outlined the law we expected to see from the VA. It was written 
specifically to apply to more, rather than less, veterans in need of 
caregivers. It also was intended to cover veterans with Traumatic Brain 
Injury and Post-Traumatic Stress Disorder, the signature wounds of this 
war.
    We expected to see the implementation plan from the VA within 180 
days of enactment of the law on May 5, 2010, and we hoped that 
caregivers would start receiving much-needed support within 270 days as 
was stated in the law. But October 2010 came and went without the 
implementation plan and benefits did not start flowing to caregivers in 
January as required.
    We understand the complexity of regulating S. 1963. This will be 
the first time that the VA provides direct benefits to family members, 
outside of a small group of family members who qualify for CHAMPVA. 
Moreover, the VA must come up with equitable definitions of eligibility 
for wounded veterans, which is undoubtedly complicated.
    We also appreciate that the VA has moved forward on aspects of the 
law that did not require regulation. The creation of a hotline and Web 
site for caregivers that provides them with information and assistance 
in accessing benefits is critical. One of the main challenges 
caregivers face is a lack of understanding of the benefits available to 
them. Aggregating these resources and making it easier to find and 
access them is a big step forward.
    Nonetheless, we are disappointed by the delay in implementing the 
law and specifically in the regulations for eligibility. Since the 
regulatory process is finally moving forward, I will state that we 
believe it should continue to move forward quickly. We need to ensure 
that caregivers do not have to wait any longer for the help that we 
promised them almost a year ago.
    But urgency should not lead us to make more mistakes. The current 
eligibility requirement is a significant mistake that, if it stands, 
will gut the spirit of the legislation that we worked so hard to push 
forward and that this Committee put so much time into crafting.
    The law states that eligibility for personal care services will 
hinge on: one, ``an inability to perform one or more activities of 
daily living,'' and two, ``a need for supervision or protection based 
on symptoms or residuals of neurological or other impairment or 
injury.'' \iii\ The law also specifically mentions ``traumatic brain 
injury, psychological trauma, or other mental disorder'' as serious 
injuries that would make a veteran eligible. \iv\
---------------------------------------------------------------------------
    \ii\ Ibid., p. 18.
    \iii\ Caregivers and Veterans Omnibus Health Services Act of 2010, 
S. 1963, 111th Congress, Sec. 1720G.
    \iv\ Ibid.
---------------------------------------------------------------------------
    Along with representatives of our fellow Veterans Service 
Organizations, I spent 2 days at the VA this past October discussing 
how to make sure that the law was regulated appropriately. At the time, 
we made it clear that the goal was to ensure that all caregivers who 
needed help received it. In real numbers, we are not talking about a 
huge segment of the American population--roughly only 3,000 caregivers. 
These men and women have given up everything to take care of their 
wounded veterans. It is unacceptable to shortchange this small 
population at a time when they need our help. Congress made sure this 
would not be the case by appropriating $1.5 billion from 2011-2015 for 
support of primary and non-primary family caregivers. \v\
---------------------------------------------------------------------------
    \v\ Ibid.
---------------------------------------------------------------------------
    Yet, the regulations proposed by the VA are far more limiting than 
S. 1963 intended when it comes to eligibility for the critical services 
that primary caregivers need. The VA's proposed regulations 
specifically require that the veteran ``without caregiver support 
providing personal care services at home in an ongoing manner, would 
require hospitalization, nursing home, or other institutional care.'' 
\vi\ Many veterans coming home from Iraq and Afghanistan with TBI or 
post-traumatic stress disorder (PTSD) might well need constant care; 
however, they don't necessarily need institutionalization. These 
injuries and hospital care are not synonymous, and making the need for 
institutionalization the threshold for eligibility misses the goal of 
S. 1963.
---------------------------------------------------------------------------
    \vi\ Plan for Implementation, Public Law 111-163, ``Caregivers and 
Veterans Omnibus Health Services Act of 2010'' Title 1, Caregiver 
Support, Section 1010, Assistance and Support Services for Caregivers, 
p. 4.
---------------------------------------------------------------------------
    In addition, the definition that the VA uses in the S.1963 
regulations for ``serious injury'' is very specific: ``Individuals with 
a serious injury are individuals who, due to their injury, 
psychological trauma, or mental disorder, require ongoing medical care, 
exhibit impaired ability to function independently in their community, 
are vulnerable and at high risk for personal safety, and for whom at 
least 6 months of continuous and approved caregiver support is required 
to enable them to live outside of an institutional care setting.'' 
\vii\ Yet, the definition of ``seriously injured or ill OEF or OIF 
veteran'' according to a directive by the Veterans Health 
Administration from 2009 is defined as ``having one or more of the 
following diagnoses of medical conditions . . . (a) Burns; (b) Spinal 
Cord Injury (SCI); (c) Amputation or loss of function of arm, leg, hand 
or, foot; (d) post-traumatic stress disorder (PTSD); (e) visual 
impairment, or (f) Traumatic Brain Injury.'' \viii\ In this case, the 
more restrictive definition used by the VA unnecessarily limits which 
caregivers will be eligible to act as primary caregivers and receive 
stipends and support.
---------------------------------------------------------------------------
    \vii\ Ibid., p. 4-5.
    \viii\ ``Tracking Severely Injured or Ill operation Enduring 
Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans Using the Non-
Primary Care Team Function in the Primary Care Management Module 
(PCMM), VHA Directive 2009-018, March 24, 2009.
---------------------------------------------------------------------------
    The VA has acknowledged that in the VSO meetings some participants 
``verbalized concern that this [reliance on specific definitions of 
`severely injured' and reference to prevention of institutionalization 
as criteria to assess eligibility] could lead to a `restrictive' 
interpretation of eligibility.'' \ix\ Those of us who voiced that 
opinion were speaking from the experience of our members and their 
families--and we were right. This regulation is too restrictive. As a 
consequence, far too many veterans and their families will simply not 
get the support our country promised them.
---------------------------------------------------------------------------
    \ix\ VA Plan for Implementation, p. 34.
---------------------------------------------------------------------------
    The VA's explanation of why it did not take this feedback into 
account in regulation has so far been insufficient. It ultimately 
argues that VSO representatives ``stated repeatedly that the intent [of 
the law] was `to avoid having to place veterans in institutions.' '' 
\x\ That, indeed, was part of the intent. The main goal, however, was 
and remains to support a population of caregivers who had to change 
their lives to care for their wounded warrior; women and men who are 
living in some cases with no regular income and no health insurance, 
just so that they can take care of veterans who can no longer take care 
of themselves.
---------------------------------------------------------------------------
    \x\ Ibid.
---------------------------------------------------------------------------
    Is it hard to come up with the right eligibility criteria? Yes. 
Does this mean that the only solution is to settle on restrictive 
criteria? No. To the extent it will help the VA, IAVA and our fellow 
Veteran Service Organizations are more than willing to work with 
officials to identify the best criteria. But as it is now the 
regulation should not stand.
    Madam Chairwoman, we are grateful for this opportunity to share the 
thoughts of Iraq and Afghanistan veterans and their families on the 
implementation of S. 1963. We also appreciate the VA's efforts to 
regulate this complicated law and expedite its enforcement. We would 
like to see it implemented as quickly as possible to give our veteran 
caregivers the overdue support they deserve. Before any part of the law 
is enforced, however, regulations on eligibility as they were submitted 
to the Office of Management and Budget must be changed. We look forward 
to working with you to ensure this happens swiftly.

                                 
Prepared Statement of Barbara Cohoon, Ph.D., R.N., Government Relations
         Deputy Director, National Military Family Association
    Chairwoman Buerkle and Distinguished Members of this Subcommittee, 
the National Military Family Association would like to thank you for 
the opportunity to present testimony on ``Implementation of Caregiver 
Assistance: Are we getting it right?'' The National Military Family 
Association will take the opportunity to discuss our concerns regarding 
the Department of Veterans Affairs' Caregiver Implementation Plan and 
several issues of importance to family caregivers of the wounded, ill, 
and injured servicemembers, veterans, their families, and caregivers in 
the following subject areas:

    I. Wounded Servicemembers Have Wounded Families
    II. Caregivers
    III. VA Caregiver Implementation Plan
    IV. Budget
    V.  Additional Caregiver Compensation
    VI. Senior Oversight Committee
Wounded Servicemembers Have Wounded Families
    The National Military Family Association asserts that behind every 
wounded servicemember and veteran is a wounded family. Spouses, 
children, parents, and siblings of servicemembers injured defending our 
country experience many uncertainties. Fear of the unknown and what 
lies ahead in future weeks, months, and even years, weighs heavily on 
their minds.
    Transitions can be especially problematic for wounded, ill, and 
injured servicemembers, veterans, and their families. The Department of 
Veterans Affairs (VA) and the Department of Defense (DoD) health care 
systems, along with State agency involvement, should alleviate, not 
heighten these concerns. Our Association believes the government must 
take a more inclusive view of military and veterans' families. Those 
who have the responsibility to care for the wounded servicemember and 
veteran must also consider the needs of the spouse, children, parents 
of single servicemembers, siblings, and especially the caregivers.
Who are the Families of Wounded Servicemembers?
    In the past, the VA and DoD have generally focused their benefit 
packages for a servicemember's family on his/her spouse and children. 
Now, however, it is not unusual to see the parents and siblings of a 
single servicemember presented as part of the servicemember's family 
unit since they offer primary support. Almost 50 percent of the members 
are single in the active duty, National Guard, and Reserve. Having a 
wounded servicemember is new territory for family units. Whether the 
servicemember is married or single, their families will be affected in 
some way by the injury. As more single servicemembers are wounded, more 
parents and siblings must take on the role as caregiver helping their 
son, daughter, or sibling through the recovery process. Family members 
are an integral part of the health care team. Their presence has been 
shown to improve the servicemember and veteran's quality of life and 
aid in a speedy recovery.
    Our Association gathered information about issues affecting our 
wounded servicemembers, veterans, and their families through numerous 
encounters with families, including a focus group held 2008 at Camp 
Lejeune and our Operation Purple Healing Adventures Family Retreats in 
2008, 2009, and 2010. Families said they find themselves having to 
redefine their roles following the injury. They must learn how to 
parent and become a spouse/lover with an injury. Spouses talked about 
the stress their new role as caregiver has placed on them and their 
families. Often overwhelmed, they feel as if they have no place to turn 
to for help. We found many have put their own lives on hold while 
caring 24/7 for their loved one. Even with all of the additional 
support by the individual Services and corrective legislative action by 
Members of Congress, caregivers of the wounded, ill, and injured still 
find their responsibilities to be overwhelming.
Caregivers
    Caregivers need to be recognized for the important role they play 
in the care of their loved one. Without them, the quality of life of 
the wounded, ill, and injured servicemembers and veterans, such as 
physical, psycho-social, and mental health, would be significantly 
compromised. They are viewed as an invaluable resource to VA and DoD 
health care providers because they tend to the needs of the 
servicemembers and the veterans on a regular basis. Their daily 
involvement saves VA, DoD, and State agency health care dollars in the 
long run.
    Caregivers of the severely wounded, ill, and injured servicemembers 
and veterans have a long road ahead of them. In order to perform their 
job well, they must be given the skills to be successful. The National 
Military Family Association is pleased with the passage of the 
Caregivers and Veterans Omnibus Health Services Act of 2010 (P.L. 111-
163) that will provide for the training and compensation for caregivers 
of wounded, ill, and injured, servicemembers undergoing medical 
separation and veterans. This law places the VA in an active role in 
recognizing caregivers' important contributions and enabling them to 
become better caregivers to their loved ones. It is a ``win-win'' for 
everyone involved.
VA Caregiver Implementation Plan
    While our Association is extremely appreciative of Members of 
Congress for the passage of this landmark legislation, we have some 
concerns regarding the VA's implementation plan. These concerns include 
a delay in implementation and the interpretation of the law's intent by 
the VA regarding veteran and caregiver eligibility requirements and 
available benefits.
Delay
    The VA has not met the implementation timeline for the caregiver 
portion of P.L. 111-163. The bill was signed into law by President 
Barack Obama on May 5, 2010, with an implementation plan date no longer 
than 180 days and the commencement of programs no longer than 270 days 
after enactment of the Act. This required the VA to provide a caregiver 
implementation plan no later than November 2010 and begin providing the 
benefit by January 31, 2011. The VA just submitted an Interim Final 
Rule to the Office of Management and Budget on March 1, 2011 and has 
posted information about its caregiver implementation plan. The VA is 
now late in implementing the law. Every day the VA waits to implement 
the caregiver provision means those who care for our wounded, ill, and 
injured are going without valuable resources that were intended to 
improve the quality of the caregiver's life and of the life of those 
they care for. Our Association acknowledges the VA has not implemented 
other provisions provided in the law as well. These include: women 
veteran's health care; rural health improvements; mental health 
services for veterans; and other health care matters. These provisions 
must also be implemented as quickly as possible.
    Our Association, along with other Veteran and Military Service 
Organizations, frequently states how important this piece of 
legislation is for our Nation's caregivers. Every day the VA delays its 
implementation only places additional stress on an already strained 
population. We really cannot afford to put this off even one more day. 
The least the VA could do in order to compensate for its delay is to 
provide retroactive stipend payments to caregivers from the original 
date of implementation required by law.
Congressional Intent
    Our Association, along with several others, was involved with the 
careful drafting of the caregiver legislation. We all worked hard 
ensuring the language included important provisions to provide valuable 
support to the caregivers of our wounded, ill, and injured 
servicemembers and veterans. We feel very fortunate to have played such 
an important role in the development of the legislation. We are also 
thankful to the VA for inviting us to participate in the VA's 
roundtable discussion and provide our input on the caregiver program's 
implementation. However, we have concerns with the VA's interpretation 
of the caregiver provision in P.L. 111-163 in two areas: veteran and 
caregiver eligibility and available benefits. We feel the VA is not 
meeting the intent of Congress or the needs of caregivers the law was 
intended to help.
Eligibility
    The VA's eligibility establishes a much more stringent criteria 
then the law dictates. According to the VA's caregiver implementation 
plan, the veteran's eligibility is tied to:

      the veteran's inability to live independently in their 
community without the support from a caregiver;
      the caregiver providing personal care services at home 
continuously; and
      the veteran being hospitalized, placed in a nursing home, 
or in other institutional care settings without the support of the 
caregiver.

    It appears the VA chose not to incorporate the law and the intent 
of Congress and to capture a larger less medically disabled population. 
The inclusion of language, ``has a serious injury (including traumatic 
brain injury, psychological trauma, or other mental disorder)'' and ``a 
need for supervision'' was intended to allow for wounded, ill, and 
injured servicemembers and veterans to be included without the 
requirement of a catastrophic medical condition or the need for 
institutional level of care. Many of our wounded, ill, and injured 
servicemembers and veterans have mild to moderate cognitive impairment 
that require caregiver support, but they certainly do not need 
hospitalization or to be institutionalized. The law's language was 
intended to capture this population and allow their caregivers to be 
eligible to receive benefits. However, the VA's interpretation will 
exclude this population. More importantly, the VA's interpretation will 
now cause a much smaller number of caregivers to qualify. Original 
estimates stated the law would have assisted 3,500 caregivers; however, 
during recent testimony the VA stated only 840 caregivers would qualify 
under these criteria.
    The application process cannot begin until after the servicemember 
has completed the DoD disability evaluation process, has been found 
unfit for duty due to their medical condition, and received a date of 
separation. According to the Army's MILPER Message #09-067 regarding 
the Army Transition Center Policy and Procedures for Disability 
Evaluation System (DES) Separation Processing, a soldier found unfit 
for duty by the physical evaluation board will be assigned a separation 
date not later than 90 days. The VA's implementation plan state the 
servicemember and the caregiver cannot begin the application process 
until they receive a date of separation. Our Association believes this 
may not provide enough time for the completion of all of the VA's 
eligibility criteria before the servicemember and their caregiver enter 
veteran status. Our Association is concerned this may impact the 
seamless transition of programs and services for the servicemember, but 
more importantly for the caregiver.
    Currently, the DoD is providing a caregiver compensation benefit to 
the servicemember for services provided by their caregiver. The law 
states DoD's compensation stops 3 months (90 days) after the 
servicemember has been medically retired. However, the VA's caregiver 
benefits do not begin until training and pre-defined competencies have 
been successfully completed by the caregiver, in the home, and 
validated by the VA. Ninety days until the servicemember medically 
retires, along with DoD's additional 90 days following medical 
retirement to receive caregiver compensation, may not provide enough 
time for:

      the VA's caregiver application process to be completed;
      the VA to determine the servicemember and caregiver are 
eligible; and
      the caregiver to successfully complete the required 
caregiver training.

    This scenario has the potential to create a gap in monetary 
compensation and impact the family's financial stability because the 
DoD's caregiver compensation benefit has stopped and the VA caregiver 
stipend benefit has not started.
    Eligibility dictates that the servicemember and veteran will 
receive care at home once caregiver training is complete. This means 
that even if a servicemember has a date of medical separation the 
caregiver will still not qualify if the servicemember/veteran is still 
receiving care from a hospital. Therefore, the servicemember would need 
to be finished with all treatment and ready to be cared for solely at 
home in order to qualify for this program. This would also delay the 
servicemember's ability to submit the application and for the VA to 
begin caregiver benefits.
    There is a strong possibility given the eligibility criteria that 
some servicemembers with multiple injuries, such as a mild or moderate 
TBI, a loss of an extremity, PTS or PTSD, and 10 percent burn, may not 
qualify for this program. Multiple injuries are commonly seen in our 
returning servicemembers from war. The potential disqualifying criteria 
states, ``incapacity, physical or mental which requires care or 
assistance on a regular basis to protect the veteran from hazards or 
dangers incident to his or her daily environment.'' It is the word 
``incapacity'' that will most likely disqualify them and subsequently 
the caregiver from receiving any benefits. Again, this was not the 
intent of the law. Co-morbid injuries may require the servicemember and 
veteran to need the assistance and support of a caregiver; therefore, 
they should be included in these benefits.
    The inclusion of the language ``has a serious injury (including 
traumatic brain injury, psychological trauma, or other mental 
disorder)'' and ``a need for supervision'' was intended to allow for 
wounded, ill, and injured servicemembers and veterans to be eligible. 
Illness was one condition that was intended to be included. It is 
unclear whether or not illness is considered an eligible medical 
condition for the VA caregiver benefit. If illness is not included, 
then there is the potential for DoD's caregiver compensation benefit 
and the VA's caregiver benefit to apply to different sets of 
servicemembers and veterans. DoD's would include illness and the VA's 
would not. This could potentially create a disparity in benefits and a 
lack of a seamless transition regarding compensation. Therefore, our 
Association recommends that illness be included as an eligibility 
requirement by the VA. Maintaining financial compensation will be key 
in ensuring these families' financial situations stay stable during 
transition from active duty to veteran status.
    The time to acknowledge the caregiver's important role and to 
implement a standardized, certified program, and begin compensation is 
while the wounded, ill, and injured servicemember is still on active 
duty status. The self-selection process of a caregiver occurs during 
the early phase of the recovery process. All branches of the Services 
are holding onto their wounded, ill, and injured servicemembers much 
longer than previous wars. Years may have passed before the caregiver 
and the wounded, ill, and injured servicemember reach eligibility and 
can benefit from the VA's important programs and services. Therefore, 
we recommend that the designation and education of caregivers be 
established while they are still upstream on active-duty, rather than 
wait until they have transitioned to veteran status.
Benefits
    Waiting until after the receipt of a medical separation date will 
prevent caregivers from being able to receive training and obtain 
benefits early enough in the recovery phase to make a difference in 
their quality of life and in the quality of care they provide. 
Servicemembers often receive care in a military hospital and/or VA 
Polytrauma Center and then recover at home, and then return to the 
hospital for follow on care/surgeries. This training requirement will 
prevent eligible caregivers from receiving any advance training for in-
home care until the servicemember is being medically retired from the 
military. Our Association finds this troubling because a recent survey 
by the National Alliance for Caregiving, ``Caregivers of Veterans--
Serving on the Homefront,'' found a top challenge faced by veteran 
caregivers was not knowing what to expect medically with the veteran's 
condition and not knowing how to address post-traumatic stress disorder 
or mental illness. Caregivers have frequently stated they did not know 
how to care for a servicemember and veteran when they were discharged 
from the hospital and went home during their recovery phase. This can 
cause increased stress on an already anxious caregiver. Our Association 
believes the sooner you provide caregivers with the skills they need to 
perform their duties, the sooner they will be able to provide a higher 
quality of care to the wounded, ill, and injured servicemember and 
veteran. The VA's decision to wait until the servicemember is medically 
retired from the military and getting care only at home before 
beginning the application process will certainly prevent this valuable 
training opportunity from occurring at the appropriate time to make a 
difference in the quality of care of the wounded, ill, and injured 
servicemember.
    The delay in eligibility also impacts the ability to obtain time 
sensitive needed benefits, such as access to mental health counseling, 
health care benefits, and financial compensation. This especially 
impacts non-spouse caregivers who would greatly benefit from these 
services. According to the recent survey, ``Caregivers of Veterans--
Serving on the Homefront'' one in four respondents were parents caring 
for Operation Enduring Freedom and Operation Iraqi Freedom veterans. 
Also, a larger proportion of veteran caregivers compared to their 
National (civilian) counterparts reported mental illness, such as 
depression or anxiety (70 percent) or PTSD (60 percent) compared to 
their National counterparts (28 percent). Veteran caregivers also 
reported their situation to be highly stressful (68 percent versus 31 
percent Nationally) and 75 percent stated it placed a stress on their 
marriage (74 percent).
    According to this recent survey, there are widespread impacts on 
the caregiver's health, such as increased levels of stress and anxiety 
(77 percent) and not sleeping (77 percent), and a decrease in the 
utilization of healthy behaviors, such as seeing their medical 
provider. Our Association is hearing that caregivers are reaching the 
stage of burnout and many are deciding to walk away from their roles as 
caregivers. The longer the VA waits to begin benefits, the more 
opportunity there is for the caregiver's quality of life to worsen and 
for the caregiver to reach the stage of burnout. The caregiver survey 
highlighted the increased stress our veteran caregivers are under 
compared to their National counterparts. The law and Congressional 
intent were to allow the VA to provide assistance through value-added 
benefits to the caregiver early enough in the process to make a 
difference and prevent the development of physical health, mental 
health, and/or financial problems. Caregivers of our wounded, ill, and 
injured need these services now, and sooner in the recovery process 
than later.
    The VA has decided to begin all of the benefits at the same time. 
They could very easily make training information and access to valuable 
VA and DoD resources available much earlier in the process than their 
proposed timeline. Again, the earlier access to pertinent resources and 
information related to VA and DoD benefits for the servicemember, 
veteran, and themselves, will only be a win-win for everyone involved. 
Allowing early access to information validates the important role 
caregivers provide. Plus, an educated caregiver will only provide 
better care in the long run. Our Association recommends the VA begin 
caregiver benefits as early as possible while the servicemember is 
still on active duty status and not wait until they have received a 
final determination.
    We acknowledge and applaud VA's recent launch of a caregiver 
section on their Web site. However, the outreach to potential 
recipients was not included in their caregiver implementation plan. How 
will caregivers of our wounded, ill, and injured servicemembers and 
veterans of all eras be made aware of this valuable resource?
Training
    The VA's decision to delay access to valuable training may force 
each Service to begin their own training program in order to compensate 
for this delay. Most likely, this may cause each Service's training 
program to vary in its scope and practice; therefore, it may not meet 
VA's training objectives. This could force the caregiver to undergo two 
different training programs in order to provide care and receive needed 
benefits.
Stipend
    Many caregivers have given up their jobs. Therefore, the family has 
less money to make ends meet. The caregiver stipend will most likely 
not equal the caregiver's lost wages, but it will be better than not 
having any additional income. Our Association appreciates VA's 
acknowledging the need to compensate caregivers for providing direct 
hands-on medical care. We support the VA's decision to use a stipend 
matrix applying the U.S. Department of Labor's Bureau of Labor 
Statistics (BLS) hourly wage index in the geographic market times the 
number of hours/Full Time Equivalent (FTE) required to perform a 
determined number(s) of Activities of Daily Living in determining the 
caregiver's stipend. However, we notice that the VA did not include a 
provision to pay caregivers for performing non-medical care services.
    Our Association has always proposed that financial compensation 
should recognize the types of medical and non-medical care services 
provided by the caregiver. We have also advocated for this compensation 
to begin while the hospitalized servicemember is still on active duty, 
continue throughout transition, and into veteran status.
    Our Association's proposal for a non-medical compensation for 
caregivers would be on a sliding scale with a minimum and maximum 
amount allowed under this provision. The payment would reflect the 
amount of services the caregiver was providing, such as traveling to 
appointments or making appointments. The amount would increase as the 
demand for services increased, such as following a surgery, and 
decrease as the need dissipated after recovery. This need would have to 
be assessed quickly without delay in order to provide the correct 
amount of compensation. The compensation could begin with the level 
determined during the initial evaluation and could increase, but not 
decrease, until the servicemember enters veteran status and establishes 
a permanent residence. The amount should remain the same regardless of 
where the caregiver resides from the time of eligibility until they 
reach veteran status and establish a permanent residence.
    The reason for wanting to include a non-medical compensation 
benefit is because there are many hours in a day spent performing these 
activities that play an integral part in maintaining the servicemember 
and veteran's quality of life yet are not captured by the VA's BLS 
stipend matrix. Plus, Section 1115 of title 38 of the United States 
Code provides compensation to the veteran only when the spouse cannot 
perform the duties of a caregiver. This same level of stipend should be 
applied to non-medical care services provided by caregivers to 
servicemembers and veterans.
    The VA's stipend is paid directly to the caregiver for their 
services, which we appreciate. We are concerned over the VA's statement 
that the caregiver stipend may be considered taxable income. This was 
certainly not an intended consequence. Our Association looks forward to 
working with the VA and Members of Congress on addressing this 
potential issue.
CHAMPVA
    Our Association is pleased caregivers will have the opportunity to 
benefit from the Civilian Health and Medical Program of the Department 
of Veterans Affairs, known as CHAMPVA. We appreciate caregivers being 
allowed to access health care through community based CHAMPVA providers 
or on a space available basis at VA Medical Centers. The population 
most likely to use this benefit will be the veteran's parent. They will 
at some point become eligible for Medicare. Therefore, we would 
recommend the VA include a provision to help guide them during this 
transition process to ensure continuity of health care services.
Mental Health Services
    The VA caregiver implementation plan states, ``Primary family 
caregivers will be covered . . . for mental health services in 
connection with the treatment of the Veteran'' and ``mental health 
services needed by the primary family caregiver but not related to the 
treatment of the Veteran.'' The implementation plan states further, 
``but not medication.'' We wonder if medication will be provided by the 
caregiver's medical provider. If so, how will the coordination between 
the caregiver's medical provider and the person/entity providing mental 
health services be accomplished? We recommend VA provide coordination 
of mental health services and appropriate medication when indicated by 
the caregiver's primary health care provider to ensure the caregiver is 
receiving a holistic approach to mental health care. Also, the 
caregiver implementation plan does not explain what the VA means by 
expanded ``counseling'' services under the law. We would appreciate it 
if the VA would clarify what these counseling services for family 
caregivers will include.
Travel, Lodging, and Per Diem
    Our Association is concerned over the reimbursement process. Being 
paid after the event may cause an unwarranted financial burden on the 
family. We would recommend the VA evaluate the financial impact on the 
caregiver before granting travel and offer advance travel compensation 
if warranted. What does the VA mean they will provide reimbursement 
``when appropriate'' and determine costs based on ``any other 
extenuating circumstance?'' These are vague and open-ended statements 
that need further clarification. The implementation plan is not clear 
on who submits the request for travel authorization, the caregiver, 
veteran, or the case manager? Our Association would recommend the case 
manager or a VA employee be assigned to provide this service. 
Caregivers have enough on their plate without the added burden of 
submitting forms.
Respite Care
    The VA currently has authority to provide respite care and says it 
does not require additional authority to expand respite care services 
under the new law. The VA policy currently allows up to 30 days 
annually and states additional days may be offered due to unforeseen 
circumstances. And, they say they will assess the veteran and caregiver 
for appropriate respite care services. The VA is not meeting the intent 
of the law regarding this benefit. The intent was to add more respite 
care hours to the current VA policy, not keep the status quo. 
Caregivers of our wounded, ill, and injured veterans are experiencing 
tremendous stress and strain. This fact has been validated in the 
recent caregiver survey where veteran caregivers experienced higher 
burden of care (65 percent) compared to National caregivers (31 
percent). We recommend caregivers have immediate access to these 
additional hours on top of the hours already provided in VA's current 
policy without the need to be ``assessed'' by the VA to determine if 
they are eligible for additional hours.
Monitoring
    The intent of the law is for the VA to be as unobtrusive as 
possible when monitoring the caregiver's performance. The plan's 
statement that ``on-going monitoring will include home visits . . . at 
least every 90 days,'' means to us that this could occur more 
frequently. If so, how frequent and what would trigger the visit? It 
appears the VA is constantly monitoring and will collect data during 
three separate occasions: in-home visits, ongoing visits, and well-
being visits. Where is this information going and who is coordinating 
all of the data? How often will the veteran's activities of daily 
living and the caregiver's hours be re-evaluated? What does the VA mean 
by ``the initial validation of caregiver competence will be done in a 
timely manner?'' What does the VA consider timely?
    It appears the VA is focused exclusively on the care and well-being 
of the veteran rather than making sure the caregiver is also 
physically, mentally, and financially stable. We recommend the VA take 
a holistic approach to care and include the caregiver and the family 
when assessing the veteran. Everyone's health and well-being is linked 
together, especially when caring for the wounded, ill, and injured 
servicemember and veteran. This would require the VA to assess the 
primary caregiver and their family's well-being during each of their 
visits and make appropriate referrals for care and/or services to 
address the issue(s). Timely intervention is key in making sure 
caregivers get the right care at the right time and the issue is 
quickly resolved. The VA must also look for abuse of the caregiver by 
the veteran and provide appropriate mediation when necessary.
Revocation of Primary Family Caregiver
    Our Association is pleased the VA provided an implementation plan 
if the primary caregiver decides to no longer provide the required 
personal care services. The VA states all benefits for the primary 
caregiver will end once their role ends. We appreciate the VA offering 
to work with the primary caregiver during transition; however, we would 
request the VA provide a definite timeline and criteria required to be 
met prior to the stopping of the stipend. We hope the potential 
financial impact on the caregiver and family is also taken into 
consideration before discontinuing the stipend and the impact of ending 
any benefits on the veteran, caregiver, and their family.
    The VA needs to clarify additional revocation concerns. What if the 
veteran is mentally unable to make the decision to revoke the 
caregiver's benefit? How does the legal guardian fit into this 
scenario? What if the primary caregiver is also the veteran's legal 
guardian and/or medical power of attorney? What if the veteran has 
difficulty controlling their anger related to their medical condition 
and this is the underlying reason for the revocation request(s)? The 
caregiver implementation plan does not provide any insight on how these 
matters will be dealt with by the VA.
Budget
    The VA budget will provide $208 million for the implementation of 
the Caregivers and Veterans Omnibus Health Service Act of 2010 (P.L. 
111-163) for Fiscal Year 2012 (FY 2012). The money will be used to 
provide: specialized caregiver training for individualized veteran 
health care needs; a stipend payment paid directly to caregivers for 
care provided; and health care and mental health care services for 
caregivers. The Independent Budget for the Department of Veterans 
Affairs Fiscal Year 2012 recommended the VA will need approximately 
$385 million to fund the provisions in P.L. 111-163 in FY 2012. They 
further state the advance appropriations for FY 2011 will be 
insufficient to meet the increased workload placed on the VA by the 
P.L. 111-163, which may require supplemental funding. We encourage 
Members of Congress to make sure the law is sufficiently funded to meet 
all of its requirements.
Additional Compensation for the Caregiver
    Our Association is appreciative of the generous benefits included 
in the Caregivers and Veterans Omnibus Health Service Act of 2010. 
However, there were some areas not addressed. Our Association would 
like to take the opportunity to present recommendations.
    A report by the Center for Naval Analysis determined 85 percent of 
caregivers left employment or took a leave of absence from work or 
school while performing their caregiver duties. They found that the 
average loss of earnings per caregiver was approximately $3,200 per 
month. The financial strain placed on the family of our wounded, ill, 
and injured servicemember and veteran by the caregiver leaving outside 
employment has a trickle down affect. Caregivers who have been saving 
for retirement now find they are ineligible for their employers' 
401(k)s. We believe a mechanism should be established to assist 
caregivers to save for their retirements, for example, through the 
Federal Thrift Savings Plan.
    Once the recovery process is finished and the veteran's care has 
stabilized, the caregiver may decide to work outside the home in order 
to help make financial ends meet. These caregivers may need the ability 
to learn new skills in order to compete in today's workforce. We 
recommend VA offer these caregivers the opportunity to participate in 
VA's vocational rehabilitation programs and help retool the caregiver's 
resume. We must also find innovative ways to encourage civilian and 
government employers to hire these caregivers, especially when the 
veteran is unable to work.
    According to the Center of Naval Analysis, wounded, ill, and 
injured servicemembers and veterans, their families, and caregivers are 
assisted by many non-governmental organizations (NGOs) and charities. 
This assistance is important with the overall financial stability of 
these families during the recovery phase. Our Association's concern, as 
we continue into another year of economic downturn, is that we may find 
many of these NGOs and charities no longer able to assist in the manner 
they have previously. We believe the availability of outside assistance 
by others will need to be monitored closely by both the VA and DoD to 
make sure these families are still being helped. If they are no longer 
being assisted, we believe the VA and DoD may need to begin providing 
assistance in those areas previously done by NGOs and charities.
Relocation Allowance
    Active duty servicemembers and their spouses qualify through the 
DoD for military orders to move their household goods (known as a 
Permanent Change of Station (PCS)) when they leave the military 
service. Medically retired servicemembers are given a final PCS move. 
Medically retired married servicemembers are allowed to move their 
family; however, medically retired single servicemembers only qualify 
for moving their own personal goods.
    The National Military Family Association suggests medically retired 
single servicemembers be allowed the opportunity to have their 
caregiver's household goods moved as a part of the medically retired 
single servicemember's PCS move. This should be allowed for the 
eligible primary caregiver and their family. The reason for the move is 
to allow the medically retired single servicemember the opportunity to 
relocate with their caregiver to an area offering the best medical 
care, rather than the current option that only allows for the medically 
retired single servicemember to move their belongings to where the 
caregiver currently resides. The current option may not be ideal 
because the area in which the caregiver lives may not be able to 
provide all the health care services required for treating and caring 
for the medically retired servicemember. Instead of trying to create 
the services in the area, a better solution may be to allow the 
medically retired servicemember, their caregiver, and the caregiver's 
family to relocate to an area where services already exist, such as a 
VA Polytrauma Center.
    The decision on where to relocate for optimum care should be made 
with the help of the Federal Recovery Coordinator (case manager), the 
servicemember's physician, the servicemember, and the caregiver. All 
aspects of care for the medically retired servicemember and their 
caregiver shall be considered. These include a holistic examination of 
the medically retired servicemember, the caregiver, and the caregiver's 
family for, but not limited to, their needs and opportunities for 
health care, employment, transportation, and education. The priority 
for the relocation should be where the best quality of services is 
readily available for the medically retired servicemember and his/her 
caregiver.
Veteran Housing
    Many of our wounded, ill, and injured servicemembers and veterans 
from this current conflict are being cared for by their parents. Also, 
many adult children of our senior veterans are experiencing firsthand 
trying to juggle the needs of the parents along with the needs of their 
children, and are referred to as the ``sandwich'' generation. Parent 
caregivers worry about who will care for their wounded son or daughter 
as they age and are unable to fulfill the role of caregiver. Caregivers 
may reach burnout and will need alternative solutions for providing 
care. The VA needs to be cognizant of the ever changing landscape and 
needs of their veteran population and those who care for them. The VA 
needs to offer alternative housing arrangements, such as assisted 
living facilities and family/retirement villages, which allow a 
diversified population to live together in harmony. This will go a long 
way in allowing for family units to stay together, foster independent 
living, and maintain dignity for the veteran.
    Brooke Army Medical Center (BAMC) has recognized a need to support 
our wounded, ill, and injured families by expanding the number of 
guesthouses co-located within the hospital grounds and providing a 
family reintegration program for their Warrior Transition Unit. The on-
base school system is also sensitive to issues surrounding these 
children. A warm, welcoming family support center located in guest 
housing serves as a sanctuary for family members. VA medical facilities 
could benefit from looking at successful programs like BAMC's that 
embrace the family unit and commit to building family friendly 
environments of care for our wounded, ill, and injured servicemembers, 
veterans, and their families. We recommend the development of 
alternative housing and living arrangements for veterans, their 
families, and those who care for them.
Mental Health
    The need for mental health services will remain high for some time 
even after military operations scale down and servicemembers and their 
families transition to veteran status. Veterans' families and caregiver 
requirements for a full spectrum of mental health services--from 
preventative care and stress reduction techniques, to individual or 
family counseling, to medical mental health services--will continue to 
grow. It is also important to note if DoD has not been effective in the 
prevention and treatment of mental health issues, the residual will 
spill over into the VA health care system. The VA must be ready. They 
must partner with DoD and State agencies in order to address mental 
health issues early on in the process and provide transitional mental 
health programs. They must maintain robust rehabilitation and 
reintegration programs for veterans, their families, and caregivers 
that will require VA's attention over the long-term.
    The National Military Family Association is especially concerned 
with the scarcity of services available to the veterans' families and 
caregivers as they leave the military following the end of their 
activation or enlistment. Military families will no longer qualify for 
many of the Services' family support programs and DoD's Military 
OneSource. Our Association recommends the VA increase outreach to 
veterans, their families and caregivers, and the communities they live 
in about available mental health resources to help them deal with the 
residual effects of long frequent deployments.
Children of the Veteran and Caregiver
    The impact of the wounded, ill, and injured veteran on their 
children is often overlooked and underestimated. These children 
experience a metaphorical death of the parent they once knew and must 
make many adjustments as their parent recovers. Many families relocate 
to be near the treating Military Treatment Facility (MTF) or the VA 
Polytrauma Center in order to make the rehabilitation process more 
successful. As the spouse focuses on the rehabilitation and recovery, 
older children take on new roles. They may become the caregivers for 
other siblings, as well as for the wounded parent. Many spouses send 
their children to stay with neighbors or extended family members, as 
they tend to their wounded, ill, and injured spouse. Children get 
shuffled from place to place until they can be reunited with their 
parents. Once reunited, they must adapt to the parent's new injury and 
living with the ``new normal.'' We must remember the caregiver may not 
be the veteran's spouse. They may be the wounded veteran's parent, 
sibling, or friend. These children are also affected and Congress and 
the VA must be cognizant of their potential psychological needs as 
well.
    We encourage partnerships between government agencies, VA, DoD, and 
State agencies and recommend they reach out to those private and non-
governmental organizations who are experts on children and adolescents. 
They could identify and incorporate best practices in the prevention 
and treatment of mental health issues affecting these children. We must 
remember to focus on preventative care upstream, while still in the 
active duty phase, in order to have a solid family unit as they head 
into the veteran phase of their lives. VA, DoD, State, and our local 
communities must become more involved in establishing and providing 
supportive services for our Nation's children.
Expansion of Caregiver Pilot Programs
    The VA currently has eight caregiver assistance pilot programs to 
expand and improve health care education and provide needed training 
and resources for caregivers who assist disabled and aging veterans in 
their homes. These pilot programs are important; however, there is a 
strong need for 24-hour in-home respite care, 24-hour supervision, 
emotional support for caregivers living in rural areas, and coping 
skills to manage both the veteran's and caregiver's stress. We are 
appreciative that P.L. 111-163 will provide for increased respite care 
hours, along with counseling and mental health services for caregivers, 
but neither addresses the 24-hour supervision. We recommend if these 
pilot programs are found successful, they should be implemented by the 
VA as soon as possible and fully funded by Congress. Another program 
not addressed is the need for adequate child care. The caregiver may 
have non-school aged children of their own or the wounded, ill, and 
injured veteran may be a single parent. The availability of child care 
is needed in order to attend their medical appointments, especially 
mental health appointments. Our Association encourages the VA to create 
a drop-in child care program for medical appointments on their premises 
or partner with other organizations to provide this valuable service.
Senior Oversight Committee
    Our Association is appreciative of the provision in the National 
Defense Authorization Act for Fiscal Year 2009 (NDAA FY09) continuing 
the DoD and VA Senior Oversight Committee (SOC) until December 2010. 
The DoD established the Office of Wounded Warrior Care and Transition 
Policy to take over the SOC responsibilities. The office has seen 
frequent leadership and staff changes and a narrowing of their mission. 
We urge Congress to put a mechanism in place to continue to monitor 
this Office for its responsibilities in maintaining VA and DoD's 
partnership and making sure joint initiatives create a seamless 
transition of services and benefits for our wounded, ill, and injured 
servicemembers, veterans, their families, and caregivers.
Recommendations

      Broaden eligibility criteria to meet Congressional 
intent;
      Clarify eligibility requirements and benefits provided by 
the VA;
      Provide retroactive stipend payments to the original date 
of implementation required by law;
      Begin caregiver benefits as early as possible while the 
servicemember is still on active duty status and not wait until they 
have received a final determination;
      Provide extra respite care as required by law;
      Provide adequate funding to implement caregiver benefits;
      Maintain seamless transition of benefits and programs;
      Coordinate and collaborate health care and behavioral 
health care services between the VA, DoD, and State and governmental 
agencies in sharing of resources;
      Approve relocation allowances and provide alternative 
housing and living arrangements;
      Increase outreach to veterans, their families, and the 
communities they live in about available benefits;
      Provide opportunities for the entire family to reconnect 
and bond as a family again;
      Provide a holistic approach to care that incorporates the 
impact of the wound, illness, or injury on the family unit;
      Expand all of the VA's caregiver pilot programs; and
      Continue oversight of the SOC by Members of Congress.

    The National Military Family Association would like to thank you 
again for the opportunity to provide testimony on the VA's caregiver 
implementation plan for P.L. 111-163. Military families support the 
Nation's military missions. The least their country can do is make sure 
servicemembers, veterans, their families, and caregivers have 
consistent access to high quality health and behavioral care. Wounded 
servicemembers and veterans have wounded families. The system should 
provide coordination of care, and VA and DoD need to work together to 
create a seamless transition. We ask this Subcommittee to assist in 
meeting that responsibility. We look forward to working with you to 
improve the quality of life for servicemembers, veterans, their 
families and caregivers, and survivors.

                                 
             Prepared Statement of Robert A. Petzel, M.D.,
      Under Secretary for Health, Veterans Health Administration,
                  U.S. Department of Veterans Affairs
    Chairwoman Buerkle, Ranking Member Michaud, and distinguished 
Members of the Committee: thank you for the opportunity to discuss the 
Department of Veterans Affairs (VA) Implementation Plan (the Plan) for 
the provisions of title I of Public Law 111-163, the Caregivers and 
Veterans Omnibus Health Services Act of 2010 (the Act). I am 
accompanied today by Mr. Walt Hall, Assistant General Counsel, and Ms. 
Deborah Amdur, Chief Consultant for Care Management and Social Work, 
VHA.
    VA has provided support to caregivers of veterans for almost eight 
decades. We understand how critical family caregivers are for the 
veterans they support with such dedication. Veterans are best served 
when they can live their lives as independently as possible and when 
surrounded by their loved ones. VA remains committed to ensuring 
veterans receive the care they need in the least restrictive 
environment possible. The Act enhances VA's existing authority to 
provide services for caregivers of veterans and will allow VA to 
provide groundbreaking new benefits and services to certain caregivers 
of eligible veterans whose serious injuries were incurred or aggravated 
in the line of duty on or after September 11, 2001.
    This is an historic law that provides unprecedented benefits to 
caregivers of certain seriously injured veterans and servicemembers. 
Many veterans and caregivers, Veterans Service Organizations, and 
community partners have worked to enact this legislation and have 
provided input into VA's Implementation Plan. VA is working as quickly 
and responsibly as possible to deliver the enhanced benefits authorized 
by the Act to eligible veterans and their caregivers and will keep the 
Committee closely apprised of its progress.
    Servicemembers injured in Afghanistan and Iraq are surviving 
injuries that would have been fatal in past conflicts, due in part to 
advanced protective equipment and medical treatment. VA and the 
Department of Defense see the full range--and countless combinations--
of injuries suffered by these returning veterans and servicemembers.
    My testimony today discusses what VA is doing to support veterans 
and servicemembers and their caregivers, and what assistance and 
support services VA will provide under the new law. I will begin by 
briefly summarizing the law; describing VA's comprehensive efforts to 
develop the programs required by this law and draft the Plan; detailing 
VA's existing programs for supporting caregivers; providing VA's 
recommendation for benefits and enhancements to these programs; and 
then present a path forward for full implementation.
About the Law
    The Caregivers and Veterans Omnibus Health Services Act of 2010 
(the Act) was signed into law by President Obama on May 5, 2010. Title 
I of the Act authorizes VA to provide specified new benefits to the 
approved primary and family caregivers of eligible veterans who 
incurred or aggravated a serious injury in the line of duty on or after 
September 11, 2001. VA distinguishes between three categories of 
caregivers who may receive assistance and support under the new law:

    1.  General Caregiver: Any person who provides personal care 
services to an enrolled Veteran, regardless of era or injury, under the 
program of support services for caregivers of covered veterans.
    2.  Family Caregiver: A person designated by the eligible veteran 
who is approved as a provider of personal care services for an eligible 
veteran who supports the primary family caregiver in meeting the 
veteran's daily needs, under the program of comprehensive assistance 
for family caregivers. This person can be a family member or someone 
who lives with the eligible veteran full time.
    3.  Primary Family Caregiver: This person is designated by the 
eligible veteran and is designated by VA as the primary provider of 
personal care services for an eligible Veteran. This will be the person 
primarily responsible for the veteran's daily care and assistance, 
under the program of comprehensive assistance for family caregivers. 
This person can be a family member or someone who lives with the 
eligible Veteran full time.

    Caregivers of qualifying veterans will receive educational sessions 
made available in person and online; access to telehealth services and 
other available technologies; techniques, strategies and skills for 
caring for a disabled veteran; counseling, training and other services 
necessary for the veteran's treatment; respite care that is medically 
and age appropriate for the veteran; and referral services to community 
and other support programs. It is important to emphasize that these are 
programs and services currently available within VA, but these are 
being expanded as a result of the Act.
    Approved family caregivers of eligible veterans may receive 
tailored instruction and training for the veteran's care; travel, 
lodging and per diem while undergoing training; respite care for the 
veteran while the caregiver receives training; lodging and subsistence 
during travel to and from, and for the duration of medical 
examinations, treatments or care for the veteran; ongoing technical 
support; and counseling.
    Designated primary family caregivers may receive a monthly stipend 
paid directly to the caregiver; health care coverage under the Civilian 
Health and Medical Program of VA (CHAMPVA), if the caregiver is not 
already entitled to care or services under a health plan contract; 
mental health services; and at least 30 days of respite care per year, 
which can include in-home care. Stipend amounts will be based on the 
amount and degree of personal care services provided. Under the 
Implementation Plan submitted to the Committee in February, VA would 
ensure that stipend amounts are comparable to the earnings of a Home 
Health Aide in the veteran's local community. The actual amounts and 
other details of the stipend will be defined through regulations and 
are still in development.
    Primary and family caregivers will be chosen by the veteran through 
a joint application process with the assistance of a local VA caregiver 
support coordinator. VA will assess the eligibility of the veteran for 
the family caregiver program and the capacity for the veteran's 
selected caregiver(s) to provide the personal care services required by 
the veteran.
Implementation Plan
    Even before the Act was signed by the President, VA had begun work 
to identify resources and develop plans to put these enhancements and 
new benefits in place. VA established a Steering Committee to oversee 
the implementation process. The Committee reviewed the law, recommended 
staff resources necessary for full implementation, and established four 
Workgroups that analyzed and developed recommendations for different 
aspects of the Caregiver Support Program: benefits, clinical issues, 
eligibility and information technology. The Committee consisted of more 
than 50 subject matter experts from across the country with expertise 
in polytrauma care, care management, mental health, administration, 
law, business processes, information technology, contracts, and other 
specialties. The Department of Defense also participated in these 
sessions. The Workgroups conducted face-to-face meetings and held 
regular conference calls to address issues associated with 
implementation, answer questions critical for VA's Implementation Plan 
and develop effective processes that could be put in place across the 
system.
    VA held a Caregiver Conference in Washington, D.C. in July 2010 and 
conducted a series of meetings and round table discussions with 
veterans, caregivers, national non-governmental organizations (NGO) 
with expertise in caregiving, and Veterans Service Organizations (VSO) 
to solicit their input and identify concerns. VA staff met with VSOs on 
October 5, 2010 and October 13, 2010. These meetings included 
representatives from the American Legion, AMVETS, Blinded Veterans 
Association, Disabled American Veterans, Iraq and Afghanistan Veterans 
of America, Military Officers Association of America, National Military 
Family Association, Paralyzed Veterans of America, Veterans of Foreign 
Wars, Veterans of Modern Warfare, and Wounded Warrior Project. On 
October 7, 2010, VA met with NGOs possessing expertise in caregiving, 
including American Red Cross, Easter Seals, National Alliance for 
Caregiving, National Family Caregivers Association, Family Caregiver 
Alliance, Rosalynn Carter Institute for Caregiving, National 
Association of Area Agencies on Aging, National Council on Independent 
Living, and ARCH National Respite Network and Resource Center.
    The Implementation Plan was delivered and briefed to staff of the 
House and Senate Veterans' Affairs Committees on February 9, 2011. This 
Plan can be accessed electronically on VA's Caregiver Web site at: 
http://www.caregiver.va.gov/docs/Caregivers_part1.pdf. It is important 
to note that the Plan comprises VA's recommendations; the final word on 
eligibility criteria, as well as the other details of implementation, 
will come only after completion of the rulemaking process, which 
includes Office of Management and Budget (OMB) review and a period for 
public comment, which can also result in adjustments to the rules 
governing the program.
Existing Services Available to Caregivers and Veterans through VA
    As noted earlier, VA has offered support and benefits to the 
caregivers of veterans since before World War II. VA has provided aid 
and attendance benefits for decades as part of certain veterans' direct 
benefits, and depending upon the nature of disability. VA can provide 
up to $4,977 per month in special monthly compensation (in addition to 
the $2,673 in disability compensation for 100 percent service-connected 
condition) for eligible veterans in need of aid and attendance to allow 
them to pay caregivers. The amount varies depending on the level of aid 
and attendance needed.
    For example, VA routinely offers in-person educational support for 
caregivers of veterans undergoing discharge from an inpatient stay at a 
VA facility and teaches techniques, strategies, and skills for caring 
for a disabled veteran. This includes instruction and specialized 
training in specialty areas such as traumatic brain injury (TBI), 
spinal cord injury/disorders, and blind rehabilitation. VA has a 
caregiver assistance healthy living center on My HealtheVet 
(www.myhealth.va.gov) and hosts a caregiver Web site 
(www.caregiver.va.gov). Both of these sites include information on VA 
and community resources and caregiver health and wellness.
    VA offers a number of programs and services to support veteran care 
at home. VA purchases personal care services to assist veterans in 
their homes with activities of daily living. These benefits are 
available to veterans who, without these services, would require 
nursing home or other institutional placement and are provided using 
public and private agencies. VA also offers purchased skilled home care 
through contract agencies for veterans who are homebound and in need of 
skilled services such as nursing, social services, or physical, 
occupational or speech therapy. Home-based primary care is a unique 
program that provides comprehensive long-term primary care through an 
interdisciplinary team that visits the homes of veterans with complex, 
chronic disabling diseases or injuries for which routine clinic-based 
care is ineffective.
    The Veteran-Directed Home and Community-Based Care program provides 
veterans of all eras the opportunity to receive services in a veteran-
centered manner that allows them to avoid institutional placement while 
continuing to live in their homes and communities. VA operates this 
program in collaboration with the Administration on Aging under the 
Department of Health and Human Services. In-home hospice care is also 
available for veterans who are in the advanced stages of incurable 
disease. Care includes comfort-oriented and supportive services that 
are provided by an interdisciplinary team of providers and volunteers. 
Community Home Hospice services are available 24 hours a day, 7 days a 
week. Veterans and their caregivers who are in need of close monitoring 
of vital signs or frequent communication with a health care team can 
benefit from home telehealth services. Telehealth offers the 
possibility of treating chronic conditions cost effectively while 
contributing to patient satisfaction.
    Specialty care services, such as for blind rehabilitation, 
polytrauma, spinal cord injury, and a range of modifications or 
adaptations are also provided to Veterans and caregivers in need. 
Family training programs at Blind Rehabilitation Centers provide family 
members and caregivers with education about blindness in general, and 
specific information about their family member's vision loss. In VA's 
Polytrauma System of Care, caregiver and family education and training 
are provided as part of the rehabilitation process through meetings 
with the care team, written and web-based information, and other 
forums. This education includes rehabilitation techniques to facilitate 
adaptation, safe and effective use of prosthetic or other devices, 
skill development to meet the needs of the veteran, behavioral 
management training, and information on how to access community 
resources. Specialized information on TBI is also available if the 
Veteran has this condition. During initial rehabilitation of a veteran 
with a new spinal cord injury, VA trains the veteran to guide a 
caregiver in meeting the veteran's personal care needs. Caregiver 
support is also provided directly by VA staff and through referral to 
community support services where needed. Home care services for bowel 
and bladder care are also available, and VA can pay for these services 
through a professional home health agency. VA provides patient lifts to 
help caregivers move veterans with limited mobility, ramps to 
facilitate ingress and egress from a home, vehicular and home 
modifications and adaptations, attendant controls on any power 
wheelchair, and specially adaptive housing modifications to provide a 
barrier-free, wheelchair accessible living environment for the veteran 
and the caregiver.
    VA offers a range of family support initiatives. Family counseling, 
spiritual and pastoral care, and temporary lodging at Fisher Houses are 
all currently available. Counseling for family members under 38 United 
States Code (U.S.C.) 1782 may also be available. Respite care, either 
at home or in an institutional setting, provides the caregivers of 
Veterans with a needed break to relieve the demands of caring for a 
chronically ill, injured, or disabled family member and to prevent 
caregiver burnout. Adult Day Health Care Centers also provides respite 
care in a safe environment with constant supervision.
    VA launched a Caregiver Support Line (1-855-260-3274) that is 
providing counsel on issues related to non-institutional care, 
benefits, the law, and other questions. Since its activation on 
February 1, 2011, the line received more than 3,000 calls. This Support 
Line, staffed by clinical social workers, provides immediate and highly 
responsive access to information for caregivers. Each VA medical center 
has designated a Caregiver Support Point of Contact to coordinate 
caregiver activities and serve as a resource expert for Veterans, their 
families and VA providers to assist them in locating and accessing non-
VA resources.
VA's Plan for Benefits and Enhancements to Caregivers
    The Plan outlines VA's proposal for providing enhanced benefits for 
family caregivers of eligible veterans and servicemembers. The Plan 
includes recommendations concerning eligibility, application, training, 
monitoring and implementation, stipend amounts, health care benefit 
coverage, mental health services, and travel, lodging and per diem. As 
noted above, the recommendations that comprise the plan are just that--
recommendations--and there are steps remaining in the rulemaking review 
process (including a period for public comment) that provide an 
opportunity for adjustments in the rules and processes that will be 
followed by VA in carrying out the provisions of the Act.
    Following are some of the areas that received concentrated 
attention and discussion in the Implementation Plan. They are treated 
in full detail in the Plan, but we would like to highlight some of the 
prominent areas here.
Eligibility for Family Caregiver Program
    VA's Implementation Plan outlines proposed clinical eligibility 
criteria that would be used by VA clinical providers to determine a 
Veteran's eligibility to participate in the family caregiver program 
(i.e. whether family caregiver(s) of the Veteran may be approved and/or 
designated to receive support under the family caregiver program), and 
to help determine the amount and level of the stipend the primary 
family caregiver would receive. These clinical eligibility criteria 
would be applied, along with other eligibly criteria (such as whether 
the Servicemember is ``undergoing medical discharge,'' and whether the 
serious injury was incurred or aggravated on or after September 11, 
2001) to determine which veterans and servicemembers are eligible to 
participate in the family caregiver program.
    The clinical eligibility assessment would consist of two parts. The 
first part would include evaluation based on clear clinical criteria to 
determine the appropriateness of the Veteran for the program, and VA's 
proposal for those standards can be found at pages 13 and 14 of the 
Plan. This has proven to be the most challenging aspect of VA's 
implementation planning--to ensure that VA can put forward eligibility 
standards that fulfill the aims of the law, while setting out criteria 
that can be applied consistently by clinicians and understood by 
veterans and their families.
    The second part of the proposed assessment would determine the base 
level of the stipend to be provided to the primary family caregiver, 
based upon the complexity of the Veteran's functional limitations and 
the assistance required, as defined by activities of daily living (ADL) 
and required hours of care. Pages 16 and 17 of the Plan provide greater 
detail of how this assessment would be conducted.
    The Act defines ``family member'' as a member of the family of the 
Veteran (parent, spouse, child, step-family member, or extended family 
member) or someone who lives with the Veteran but is not a family 
member. The definition establishes eligibility requirements for family 
caregivers seeking to participate in the program. In the Plan at page 
18, VA proposes standards aimed at ensuring the caregiver meets minimum 
competency requirements, and that VA performs its due diligence to 
prevent, whenever possible, potentially abusive situations.
The Application for Family Caregivers
    The Act provides that Veterans and caregivers seeking participation 
in the program will submit a joint application to VA. VA proposes an 
application process that would be managed nationally to take advantage 
of VA's existing infrastructure and ensure a quick and accurate review. 
The application would be based on existing elements of the CHAMPVA 
application, VA's Geriatric and Extended Care Referral Form, and newly 
developed portions in response to the Act.
    VA clinicians will be trained in the specific program eligibly 
criteria to assess the needs of the Veteran and confirm his or her need 
for caregiver support. VA clinical providers will determine whether the 
care the veteran needs can be provided at home and whether a family 
member(s) on the application will be capable of providing such care. VA 
will evaluate the family member(s) to determine the amount of 
instruction, preparation and training the family member requires to 
provide the personal care service the veteran needs.
    VA aimed in the Plan to design the application process to be as 
simple as possible for the Veteran, the proposed family caregivers, and 
VA staff. VA will also incorporate the application into the Veteran's 
electronic health record. We will offer a paper application and an 
online version of the application as well. The Caregiver Support 
Coordinator or designated case manager at each VA medical center will 
work with the Veteran and the proposed family caregiver to determine 
the appropriateness of each caregiver and the educational needs of each 
participating family member.
Education and Training
    Education and training for family caregivers would include two 
parts under VA's Plan: first, a basic caregiver curriculum that will be 
available in standard classrooms or self study through books, DVD, or 
online media. It will include training on the standard information 
applicable to all caregivers and Veterans and will allow the family 
caregivers to choose the mode of training that is most convenient for 
them. It will cover material every family caregiver must understand and 
will include ten core competencies: medication management, vital signs 
and pain control, infection control, nutrition, functional activities, 
activities of daily living, communication and cognition skills, 
behavior management skills, skin care, and caregiver self-care.
    The second part of the training will be specific to the individual 
Veteran's care needs. It will emphasize care related to the Veteran's 
condition, such as traumatic brain injury, post-traumatic stress 
disorder, impulse control, suicide risk and prevention, substance use 
disorders, dementia, depression and anger.
    Both parts of the training would require that the caregiver 
demonstrate their competence to provide personal care services to the 
veteran in the home. This is an important factor because VA has heard 
from caregivers about the difficulty they have experienced in 
transferring skills learned in a clinical setting to the home 
environment. VA proposes to conduct home visits in a supportive manner 
to provide additional onsite training, to facilitate successful 
completion of the training, to validate the family caregivers' 
competence, and to provide additional support or problem solving as 
necessary. Appendix B of the Implementation Plan includes a standard 
assessment tool VA proposes to use during the home visit to ensure a 
consistent approach across the country.
    Under VA's Plan, within 10 business days of the family caregivers' 
completion of education and training, VA would conduct a home visit to 
assess the family caregivers' understanding and competence in providing 
the care needed by the veteran. During the initial visit, VA will 
review core competencies and the family caregiver will be required to 
demonstrate their understanding of these competencies and those related 
to the veteran's specific care needs. Our goal is to support and 
provide additional training as necessary to ensure the caregiver and 
veteran have what they need.
    VA heard from NGOs and others regarding the training and education 
requirements established in the Act. The NGOs recommended that VA use 
training materials based on a nationally recognized program that could 
be modified slightly to address the needs of veterans and 
servicemembers eligible to participate in the family caregiver program. 
We support this concept and are looking for partners to develop this 
material. Some VSOs and caregivers recommended that family members with 
experience in caregiving should be exempt from the required training, 
but VA in its Plan recognized the importance of establishing clinically 
demonstrated competency to provide care, which is a requirement of the 
Act.
    Training would extend beyond just care delivery for the veteran to 
include segments on self-care and stress management, important skills 
which caregivers may not have learned before. Moreover, training 
sessions provide opportunities for caregivers to connect with one 
another, to develop peer support networks and to exchange ideas that 
can benefit caregivers and veterans alike.
Monitoring and Implementation
    The Act is very clear that VA ``. . . shall monitor the well-being 
of each eligible veteran receiving personal care services under the 
program . . .'' (38 U.S.C. 1720G(a)(9)(A)). VA monitoring as outlined 
in the Plan would include evaluation of the Veteran and caregiver's 
physical and emotional state, including any signs of abuse and neglect, 
the adequacy of care and supervision being provided by the family 
caregivers, the veteran and family caregivers overall adjustment to 
care at home, and signs of caregiver stress. Home visits would be 
completed with a supportive and educational approach to ensure the 
caregiver is equipped to succeed in their role. VA would focus on the 
veteran or legal guardian and caregiver's perception of the optimal 
social, emotional, and physical state of welfare in a safe and 
nurturing environment.
    In addition to the in-home competence review after the caregiver 
has completed training, VA in its Plan proposes follow-up well-being 
checks at least once each quarter, and more often if there are 
significant changes in the Veteran's condition or in home dynamics as 
noted by the Patient Aligned Care Team (PACT) or primary care team. VA 
saw annual in-home full reassessment of the primary family caregiver's 
competence as necessary for continued receipt of the stipend and other 
benefits. The initial assessment and the quarterly follow-up checks 
would be conducted by a member of the interdisciplinary health team, 
such as a registered nurse, social worker, physical therapist, or 
others. Ongoing monitoring would be provided by VA staff through 
programs such as Home-Based Primary Care, Community Health, Spinal Cord 
Injury and Disorders Home Care, or Mental Health Intensive Case 
Management. The Caregiver Support Coordinator or designated case 
manager would be responsible for ensuring the ongoing monitoring of 
primary and family caregiver competencies.
    Changes in the level of care noted during home evaluation visits 
would be reported back to the facility Caregiver Support Coordinator or 
designated case manager and the PACT or primary care team. If there are 
concerns about caregiver competence that do not pose an immediate 
safety concern for the veteran, VA would conduct an assessment to 
determine what additional training the caregiver requires, and VA would 
make the necessary arrangements for the caregiver to receive this 
training in a timely manner. If, during the initial assessment or 
follow-up home visits, there is evidence of abuse or neglect (or other 
immediate concerns for the safety of the veteran), VA will make 
immediate arrangements for alternate care. Suspected abuse or neglect 
must be reported in compliance with law and VA policy.
    VA has heard the concerns raised by VSOs, NGOs, veterans and 
caregivers alike that, while monitoring is essential to ensuring the 
well-being of the veteran, it must be done in a supportive manner. VA 
agrees with this principle entirely and in its Plan noted it would 
train those conducting in-home visits and assessments to provide 
support compassionately to the Veteran and caregiver's specific 
situation and needs.
    The veteran or legal guardian or the primary family caregiver can 
request that the designation of primary family caregiver be revoked. VA 
can initiate revocation for cause or due to the permanent 
institutionalization or death of the veteran. Further information about 
VA's proposed revocation process can be found on pages 29-31 of VA's 
Implementation Plan.
Stipend
    VA will issue stipends directly to the designated primary family 
caregiver under this program. The stipend is made in recognition of the 
sacrifices that families make when caring for a seriously injured 
eligible veteran, and is based on the amount and degree of personal 
care services provided. As specifically provided in the Act, this 
stipend is not an entitlement. The stipend is not intended to replace 
career earnings, and a primary family caregiver does not become a VA 
employee based on receipt of the monthly caregiver stipend. Details of 
VA's proposal for implementing the stipend payments can be found at 
page 23 of the Plan.
    The stipend payments to primary family caregivers constitute 
``payments [of benefits] made to, or on account of, a beneficiary'' 
that are exempt from taxation under 38 U.S.C. 5301(a)(1).
Health Care Benefit Coverage 
    Primary family caregivers of eligible veterans may receive medical 
care under the Civilian Health and Medical Program of the Department of 
Veterans Affairs (CHAMPVA) if they are not entitled to care or services 
under a health plan contract (including Medicare, Medicaid, worker's 
compensation, insurance policies or contracts, etc.). CHAMPVA is a 
comprehensive health care benefit program in which VA shares the cost 
of certain health care services with eligible beneficiaries.
Mental Health Services
    VA recognizes that caregivers can experience stress that may result 
in depression, anger, interpersonal conflict, anxiety, substance use, 
sleep disturbance, social isolation, or other conditions. Caregiving 
can also place stress upon the marital or family relationship as well. 
VA has heard from caregivers that they need and want access to mental 
health services. As a result, VA's Plan would include mental health and 
counseling services to ensure that the primary family caregiver can 
access support and services to alleviate stress, burnout, and other 
complications.
    In accordance with 38 U.S.C. 1782, general caregivers, as well as 
family caregivers, would have access to consultation, professional 
counseling, marriage and family counseling, training and mental health 
services as necessary in connection with the treatment of the Veteran.
    VA would offer mental health and counseling services needed by 
family caregivers but unrelated to the treatment of the Veteran by 
providing individual and group therapy and counseling and peer support 
groups. Under the proposal outlined in the Plan, VA would not provide 
medication or other medical procedures related to mental health 
treatment or inpatient psychiatric care. If a primary family caregiver 
has CHAMPVA or other coverage, such care could be provided by those 
plans, subject to the health plan's particular terms.
Travel, Lodging and Per Diem
    Travel, lodging and per diem expenses would be provided to family 
caregivers when family caregivers are undergoing needed training. In 
addition, family caregivers may be provided the expenses of travel, 
including lodging and subsistence, when the eligible veteran is 
traveling to and from, and throughout the duration of, a medical 
examination, treatment or care episode.
Respite Care
    Caregiving, as noted earlier, places significant demands on those 
who provide personal care services for a seriously injured eligible 
veteran. Respite care is designed to offer family caregivers temporary 
relief from the demands of daily care, thereby supporting the veteran's 
desire to remain in his or her home. VA may provide respite care for 
the veteran during the family caregivers' training if needed. Respite 
care for the primary family caregiver will be available for at least 30 
days annually under the Act, and VA proposes including 24-hour care 
commensurate with the care provided by the family caregiver. The VA 
Caregiver Support Coordinator or designated case manager, in 
collaboration with the Patient Aligned Care Team (PACT) or primary care 
team would assess the veteran and caregiver for appropriate respite 
services. VA is committed to delivering clinically and age appropriate 
respite care services through VA and non-VA programs.
VA's Path Forward for Implementation
    The Act is a tremendous step forward for this country in supporting 
those who have made significant sacrifices on its behalf. It represents 
the hard work and efforts of Congress, Veterans Service Organizations, 
VA, and most importantly, our seriously injured veterans and their 
caregivers. We understand the frustration many have experienced with 
the pace of implementation, and we share that frustration. We regret 
the delay in transmitting the Implementation Plan to the Committee. The 
Act also identified January 30, 2011 as the date on which caregiver 
benefits would commence. Given the complexity of these programs, the 
need for stakeholder input, and the need for regulations, VA was not 
able to meet that date.
    But let me assure our veterans, their families, and the Committee 
that we have been working tirelessly to implement this program and 
begin delivering the benefits established in law. On February 28, 2011, 
VA transmitted a draft Interim Final Rule to the Office of Management 
and Budget. We believe this measure will expedite the rulemaking 
process and set the path to begin delivering caregiver benefits as 
early as this summer.
    VA has been active on a myriad of other fronts that do not require 
the publication of regulations to accomplish other implementation 
milestones. We released a request for proposals in January to assist 
the Department in creating a national program of caregiver training. 
This curriculum will serve as the basis for establishing the 
competencies of family caregivers participating in the program and will 
promote effective care for our seriously injured veterans. We launched 
a new Caregiver Support Line on February 1, 2011 out of awareness of 
the urgent need to provide information and additional support to 
caregivers. We are planning to hire at least one full time Caregiver 
Support Coordinator at every VA medical center by the end of April 
2011. We are working now on a new, state-of-the-art Web site that will 
be launched in May 2011. We are already planning to add additional 
staff on a temporary basis to manage the creation of these programs and 
to handle the initial wave of applications from veterans and 
caregivers.
    VA will also employ a comprehensive outreach program so that 
veterans and their caregivers are aware of these services and can 
easily apply. Our Caregiver Support Coordinators will assist them in 
this process and will make every effort to expedite our review and the 
delivery of benefits.
    VA understands the concerns that have been expressed on the scope 
of the benefit, as outlined in our Plan. The Secretary appreciates that 
VA has an important obligation to get this benefit right. That means 
making sure those clinicians can consistently apply--and Veterans and 
their families can understand--our eligibility criteria, as we evaluate 
the myriad types and combinations of circumstances that injured 
Veterans and their families face.
Conclusion
    There is no higher priority than delivering world class health care 
services and benefits to our seriously injured veterans and 
servicemembers and their caregivers. We again appreciate the efforts of 
Congress, the Veterans Service Organizations, and all of our 
stakeholders in making this Act a reality. It is important for VA as it 
moves ahead in implementing all parts of the caregiver provisions of 
the Act to keep the Committee apprised and to hear and respond to your 
concerns. Thank you for inviting me here to testify today to do that. 
My colleagues and I are prepared to answer your questions at this time.

                                 
             Statement of the Paralyzed Veterans of America
    Chairwoman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank 
you for the opportunity to submit our views on the implementation of 
the caregiver provisions of P.L. 111-163, the ``Caregivers and Veterans 
Omnibus Health Services Act.'' The Subcommittee proposes to answer the 
question, ``Are we getting it right?'' Simply put, the VA is not 
getting it right, and we hope that the Administration will review the 
steps it has taken so far and revise them appropriately. Likewise, we 
urge Congress to continue to conduct oversight of the VA's 
implementation plan to ensure that its full intent is being met.
    PVA and its partners worked extremely hard to get comprehensive 
caregiver legislation enacted during the 111th Congress. Fortunately, 
on May 5, 2010, the President signed into law P.L. 111-163, the 
``Caregivers and Veterans Omnibus Health Services Act.'' This 
legislation created an innovative new caregiver program to be 
administered by the Department of Veterans Affairs (VA). The law called 
for the VA to begin implementation of this important new program within 
270 days of enactment of the bill. This placed the deadline for 
implementation of this legislation in February of this year. However, 
the VA's efforts have fallen flat, to say the least.
    As you know, the VA recently published its interim final rules 
regarding the implementation of the caregiver provisions of P.L. 111-
163. PVA was very disappointed to see that the VA tailored its 
eligibility criteria very narrowly to provide for services for a much 
smaller number of veterans than Congress intended. The VA essentially 
explained that it will base eligibility for the new caregiver 
provisions on whether or not the veteran being cared for would 
otherwise be kept in an institutional setting. This simply ignores the 
call for more home and community-based care settings, particularly for 
the newest generation of veterans. Moreover, it ensures the narrowest 
scope of eligibility for the caregiver benefits. This is totally 
unacceptable.
    We were already concerned about the fact that the original 
legislation divided the levels of services provided between Pre-9/11 
and Post-9/11 service-connected disabled veterans. And yet, we 
ultimately supported the final legislation because it will do a great 
deal of good for the newest generation of severely disabled veterans 
while allowing for the VA to expand the broad range of caregiver 
services to Pre-9/11 veterans in the future.
    PVA is also seriously concerned about the VA's lack of commitment 
in its FY 2012 budget request and FY 2013 advance appropriation 
estimate. For FY 2012, the VA requested approximately $65.9 million for 
the implementation of the caregiver provisions of P.L. 111-163 and an 
additional $70.6 million for FY 2013. This is especially troublesome in 
light of the fact that during consideration of the legislation, the 
costs were estimated to be approximately $1.6 billion between FY 2010 
and FY 2015. This included approximately $60 million identified for FY 
2010 and approximately $1.54 billion between FY 2011 and FY 2015. 
However, no funding was provided in FY 2010 or FY 2011 to address this 
need. Moreover, Secretary Shinseki clearly identified a shortfall in 
funding for the provisions of P.L. 111-163 in a letter he sent to 
Congress on July 30, 2010. As a result, the VA will have an even 
greater need for funding to support P.L. 111-163 between FY 2012 and FY 
2015 in order to fully implement the provisions of the law based on the 
full intent of Congress. With this in mind, The Independent Budget for 
FY 2012--co-authored by AMVETS, Disabled American Veterans, PVA, and 
the Veterans of Foreign Wars--included a recommendation of 
approximately $385 to fund the caregiver provisions of P.L. 111-163.
    PVA has over 60 years of experience understanding the complex needs 
of spouses, family members, friends, and personal care attendants that 
love and care for veterans with life-long medical conditions. The 
aspects of personal independence and quality care are of particular 
importance to veterans with spinal cord injury/dysfunction. As a result 
of today's technological and medical advances, veterans are 
withstanding combat injuries and returning home in need of medical care 
on a consistent basis. Such advances are also prolonging and enhancing 
the lives and physical capabilities of injured veterans from previous 
conflicts. No matter the progress of modern science, these veterans 
need the health-care expertise and care from a health team comprised of 
medical professionals, mental health professionals, and caregivers. As 
a part of the health care team, caregivers must receive ongoing support 
to provide quality care to the veteran. It is for this reason, that we 
strongly urge VA to develop support and educational programs by 
conducting caregiver assessments that identify the needs and problems 
of caregivers currently caring for veterans.
    PVA members have more direct interaction with caregivers than any 
other individual group of disabled veterans. As such, PVA has developed 
educational materials over the years to benefit the disabled veteran, 
his or her family, and the caregiver on the best practices for dealing 
with the myriad of challenges they will face. I would like to highlight 
two publications in particular that PVA developed that address these 
challenges and issues.
    One very important publication that PVA developed many years ago is 
``Yes, You Can! A Guide to Self-Care for Persons with Spinal Cord 
Injury.'' The fourth edition of this book is available through PVA's 
Web site. The book serves as a self-help resource for severely disabled 
veterans, their families and their caregivers, as well as all people 
with disabilities, with a focus on individuals who have incurred a 
spinal cord injury or disorder. The book is written expressly for new 
spinal cord injured individuals providing them with a lifelong 
reference guide.
    For over two decades, ``Yes, You Can!'' has been compiled and 
edited by Dr. Stephen P. Burns, a practicing VA SCI physician, and Dr. 
Margaret C. Hammond, Chief Consultant for VA's SCI Service, as well as 
more than 40 experts from the Seattle VA Health Care System. Having 
answers to the myriad of challenges that SCI veterans and their 
families might face is central to personal care and independence for 
people who have SCI. Additionally, ``Yes, You Can!'' includes a list of 
print, online and community resources for obtaining additional 
information. The book equips people with disabilities with essential 
information on how they can lead healthy, productive lives and 
reintegrate fully into the community.
    The second publication that PVA developed is a consumer guide 
called ``Managing Personal Assistants.'' This important book provides 
critical information on how to best determine your personal assistant 
or caregiver needs. It offers advice on how to recruit, hire, properly 
train and retain, and when necessary, fire, a personal assistant or 
caregiver. It allows a severely disabled veteran and his or her family 
to be well-informed when making the caregiving decisions that are best 
for him or her.
    Our experience has shown that when the veteran's family unit is 
left out of the treatment plan the veteran suffers with long 
reoccurring medical and social problems. However, when family is 
included in the health plan through services such as VA counseling and 
education services, veterans are more apt to become healthy, 
independent, and productive members of society.
    With regard to family caregiver services, we ask that VA continue 
its effort to enhance the support and educational services provided to 
family members caring for veterans. Moreover, as the VA begins full 
implementation of the caregiver provisions of P.L. 111-163, we believe 
that it will be essential to incorporate medical professionals or 
clinicians into the training. Due to the unique health care challenges 
often associated with the catastrophic disabilities of those veterans 
who need caregiver support services, only clinicians can provide the 
broadest scope of medical care support in training.
    As the veteran community is aware, family caregivers also provide 
mental health support for veterans dealing with the emotional, 
psychological, and physical effects of combat. Many PVA members with 
spinal cord injury also have a range of co-morbid mental illnesses, 
therefore, we know that family counseling, and condition specific 
education is fundamental to the successful reintegration of the veteran 
into society. Combat exposure coupled with long and frequent 
deployments are associated with an increased risk for post-traumatic 
stress disorder and other forms of mental illness. In fact, the VA 
reports that Operation Enduring Freedom and Operation Iraqi Freedom 
(OEF/OIF) veterans have sought care for a wide array of possible co-
morbid medical and psychological conditions.
    We believe that Vet Centers should increase coordination with VA 
medical centers to accept referrals for family counseling; increase 
distribution of outreach materials to family members with tips on how 
to better manage the dislocation; improve reintegration of combat 
veterans who are returning from deployment; and provide information on 
identifying warning signs of suicidal ideation so veterans and their 
families can seek help with readjustment issues. PVA believes that an 
effective mental illness family counseling and education program can 
improve treatment outcomes for veterans, facilitate family 
communication, increase understanding of mental illness, and increase 
the use of effective problem solving and reduce family tension.
    There are approximately 44 million individuals across the United 
States that serve as caregivers on a daily basis. The contributions of 
caregivers in today's society are invaluable economically as they 
obviate the rising costs of traditional institutional care.
    PVA would like to thank this Subcommittee for the opportunity to 
express our views relating to the implementation of the VA's new 
caregiver program. We hope that the Subcommittee and Congress will take 
an active role to ensure that the VA is actually implementing the 
provisions of P.L. 111-163 as intended. Failure to comply with the 
intent of Congress is simply not an option in this case. The most 
severely disabled veterans and their families are depending on the VA 
to get it right.
    We look forward to working with the Subcommittee as it continues 
addressing these issues. We will gladly respond to any questions. Thank 
you.

                                 
         Statement of Heather L. Ansley, Esq., MSW, Director of
   Veterans Policy, VetsFirst, a Program of United Spinal Association
    Chairwoman Buerkle, Ranking Member Michaud, and other distinguished 
Members of the Committee, thank you for the opportunity to submit for 
the record our concerns about the Department of Veterans Affairs' (VA) 
implementation of the caregiver assistance program established in Title 
I of Public Law 111-163.
    VetsFirst represents the culmination of 60 years of service to 
veterans and their families. United Spinal Association, through its 
veterans service program, VetsFirst, maintains a nationwide network of 
veterans service officers who provide representation for veterans, 
their dependents and survivors in their pursuit of VA benefits and 
health care before the VA and in the Federal courts. Today, United 
Spinal Association is not only a VA-recognized national veterans 
service organization, but is also the leader in advocacy for all people 
with disabilities.
    VetsFirst fully supports the caregiver services that were included 
in the Caregivers and Veterans Omnibus Health Services Act of 2010 
(Public Law 111-163). VetsFirst believes that caregivers are vital to 
ensuring that veterans with disabilities are able to be independent. 
Under Public Law 111-163, caregivers for all eligible veterans who are 
enrolled in the VA's health care system will have access to education 
sessions, support services, counseling, mental health services, and 
respite care. The law also provides certain caregivers of veterans who 
have a serious injury, such as a traumatic brain injury, that was 
incurred or aggravated in the line of duty on or after September 11, 
2001, with a monthly stipend and access to medical care.
    For the family members of veterans with disabilities, the battle to 
ensure that their loved ones receive the support and services that they 
need to reintegrate into their families and communities never ends. In 
order to ensure that veterans with disabilities are able to receive the 
care they need, VetsFirst believes that our Nation must fully support 
the dedicated caregivers of our Nation's veterans.
    Many families of veterans with disabilities play a crucial role in 
providing needed services and supports that allow veterans to return 
to, and remain in, their homes. The sacrifice of family caregivers not 
only supports veterans, but also supports the VA in its mission. These 
individuals often endure significant life changes as they seek to 
assist their husbands, wives, and adult children in their efforts to 
rehabilitate and reintegrate into their communities.
    In the aftermath of a veteran receiving a severe injury and 
resulting long-term disability, many family caregivers are forced to 
either quit their jobs or seek flexible employment in order to care for 
their loved ones. As a result, many caregivers must balance the strains 
of caregiving for someone who has significant disabilities with lost 
income and cancellation of employer-provided health care coverage and 
other benefits. The longer-term impacts on leaving the traditional 
workforce include the loss of retirement benefits, which may lead to 
financial shortfalls as the caregiver ages.
    Although the commitment of the caregivers of our Nation's veterans 
has been evident for many decades, a study released in November 2010 by 
the National Alliance for Caregiving provides statistical evidence 
supporting the depth of the commitment that these caregivers have made 
to our veterans. For instance, the study report titled, ``Caregivers of 
Veterans--Serving on the Homefront,'' noted that 70 percent of 
caregivers for our Nation's veterans are spouses. For all populations, 
only 6 percent of caregivers are spouses. Clearly, immediate family 
members have an important role in caregiving for our Nation's veterans.
    An even higher number of caregivers, 80 percent, live with the 
veteran for whom they are providing care. Nationwide, only 23 percent 
of caregivers of all adults live with the care receiver. Consequently, 
68 percent of caregivers of veterans report a high level of emotional 
stress due to caregiving which is more than double the level of stress 
endured by caregivers of all adults.
    The lifelong commitment made by caregivers of our Nation's veterans 
is clearly represented by the 26 percent of parents who are providing 
care for their sons and daughters who are veterans of Operation Iraqi 
Freedom or Operation Enduring Freedom (Afghanistan). The long-term 
caregiving relationship of our Nation's veterans with disabilities and 
their caregivers exceeds that of other caregiving relationships. 
According to the National Alliance for Caregiving, 30 percent of 
caregivers of veterans from all eras give care for 10 years or longer, 
as opposed to only 15 percent of caregivers nationwide.
    Intensive caregiving provides many challenges for caregivers. Some 
of the challenges identified by the study include lack of awareness 
about helpful VA services, lack of information about how to receive 
financial assistance, and lack of knowledge regarding the medical 
aspects of the veteran's disability. Of note, the resource for most 
caregivers for the services and supports available to them as 
caregivers was through ``word of mouth.''
    To address some of the identified issues, the report makes seven 
specific recommendations. Those recommendations included the following: 
harnessing the ``word of mouth'' by providing caregivers with avenues 
to learn from each other, assisting caregivers with finding needed 
respite services, and making training and information about conditions 
such as post-traumatic stress disorder more accessible to caregivers.
    The expansive services provided through Title I of Public Law 111-
163 provided hope for many caregivers who as the National Alliance for 
Caregiving study demonstrates provide care for a longer period of time 
and have a higher stress level than other types of caregivers. As 
established by Congress, the caregiver programs discussed in Title I 
directly address some of the key areas of concern for many caregivers. 
The law provides caregivers for all eligible veterans enrolled in the 
VA's health care system with general supports. The law also includes a 
more comprehensive program of assistance for family caregivers of 
veterans who have a serious injury, such as a traumatic brain injury, 
that was incurred or aggravated in the line of duty on or after 
September 11, 2001.
    In order to receive assistance under the program of comprehensive 
assistance for family caregivers, a caregiver must be providing care to 
an ``eligible veteran.'' According to 38 U.S.C. Sec. 1720G(a)(1)(B)(2),

       ``an eligible veteran is any individual who (A) is a veteran or 
member of the Armed Forces undergoing medical discharge from the Armed 
Forces; (B) has a serious injury (including traumatic brain injury, 
psychological trauma, or other mental disorder) incurred or aggravated 
in the line of duty in the active military, naval, or air service on or 
after September 11, 2001; and (C) is in need of personal care services 
because of (i) an inability to perform one or more activities of daily 
living; (ii) a need for supervision or protection based on symptoms or 
residuals of neurological or other impairment or injury; or (iii) such 
other matters as the Secretary considers appropriate.''

    Under the comprehensive program, family caregivers are eligible to 
receive training, technical support, counseling, and lodging and 
subsistence. For the family caregiver who is chosen as the primary 
provider of personal care services additional benefits are available. 
These benefits include mental health services, respite care of not less 
than 30 days annually, medical care, and a monthly personal caregiver 
stipend. As identified by the National Alliance for Caregiving, these 
benefits will be extremely beneficial to the caregivers of eligible 
veterans.
    Unfortunately, the caregiver program implementation plan released 
by VA in February 2011 fails to provide the promised benefits that many 
caregivers believed would be available to them. VA's implementation 
plan, which focuses on the comprehensive caregiver program, seeks to 
place limits on eligible veterans beyond those intended by Congress. 
Specifically, VA appears to rely on 38 U.S.C. Sec. 1720G(a)(1)(B), 
which allows the Secretary to provide support ``to a family caregiver 
of an eligible veteran if the Secretary determines it is in the best 
interest of the eligible veteran to do so,'' to add seven clinical 
eligibility criteria.
    The cumulative result of these clinical criteria, however, is to 
limit the number of eligible veterans and thus family caregivers who 
can benefit from this comprehensive program beyond that intended by 
Congress. One of the clinical criterion states that, ``Without 
caregiver support providing personal care services at home in an 
ongoing manner, would require hospitalization, nursing home, or other 
institutional care.'' Another clinical criterion states that the 
veteran must ``Require continuing medical management or be at high risk 
for personal safety and cannot live independently in the community 
without caregiver support.'' Based on the ``eligible veteran'' criteria 
outlined in the law, Congress did not intend for VA to place these 
types of strictures on eligibility.
    In the proposed implementation plan, VA also imposed specific 
aspects of these clinical criteria into its definition of ``serious 
injury.'' In the law, Congress noted only certain types of injuries, 
such as traumatic brain injury, psychological trauma, or other mental 
disorder, in its explanation of this term. The VA defines serious 
injury as follows: ``Individuals with a serious injury are individuals 
who, due to their injury, psychological trauma, or mental disorder, 
require ongoing medical care, exhibit impaired ability to function 
independently in their community, are vulnerable and at high risk for 
personal safety, and for whom at least 6 months of continuous and 
approved caregiver support is required to enable them to live outside 
of an institutional care setting.'' Based on Congressional intent, 
VetsFirst believes that VA's definition of serious injury incorporates 
restrictions on eligibility beyond those intended by the law.
    If the VA is allowed to move forward with the outlined 
implementation plan, the number of eligible family caregivers providing 
needed services and supports for veterans with serious injuries due to 
their service will be limited to less than one-third the number 
Congress intended would be eligible for the program. Furthermore, 
veterans with certain types of injures that are specifically stated in 
the law may be left out due to the development of overly stringent 
criteria.
    Aside from Congressional intent, expansion of caregiver programs to 
veterans who are not eligible for an institutional level of care but 
for whom caregiving is likely to extend their ability to live in the 
community is extremely effective in the long-term. Specifically, 
delaying or preventing institutional placements through quality 
caregiving not only fulfills the desire of many individuals to remain 
in their homes but also saves money due to decreased utilization of 
institutional placements. Thus, VA must not unnecessarily limit the 
comprehensive caregiver program due to fears that the program will be 
too costly.
    In addition, VA must ensure that the process veterans with 
disabilities and their family caregivers must follow to participate in 
the comprehensive caregiver program is not overly bureaucratic. 
Instead, the process should be veteran-centered with the goal of 
helping eligible family caregivers to complete the process in a timely, 
successful manner.
    In order to ensure that the role of the family caregiver and the 
needs of the veteran are at the center of the process, VetsFirst 
believes that VA must ensure that the caregiver education and training 
outlined in the implementation plan recognizes the different skill sets 
and educational backgrounds of the caregivers. As outlined by VA, the 
caregiver education and training component will be divided into two 
sections. The first section provides general training on caregiving 
through a variety of educational methods (self-study, DVD, classroom, 
online). VetsFirst believes that this training should also include 
aspects that can speak to those who have attained knowledge through 
other caregiver training and those who have learned through the process 
of actually providing care to their loved one. If the goal of training 
is to develop the caregiving skills of family caregivers, then it must 
meet the caregiver's level of knowledge and experience.
    Although caregivers must be approved and receive adequate training, 
VetsFirst hopes that VA will make every effort to ensure that the 
process of final certification is expeditious. Many family caregivers 
have waited through great personal difficulty for the types of benefits 
available through the comprehensive caregiver program. VA must ensure 
that the certification process is conducted in a manner that encourages 
eligible veterans with disabilities and their family caregivers to 
participate in and receive the benefits of this critical program.
    Finally, VA must not limit eligibility beyond that which Congress 
intended due to fears about the consequences if the program is later 
expanded for caregivers of veterans of all eras. Based on the need 
outlined in the study by the National Alliance for Caregiving, 
VetsFirst will continue to advocate for increased services and supports 
for caregivers of veterans of all eras to make sure that these 
caregivers can continue to support our Nation's veterans with 
disabilities. Specifically, VetsFirst believes that these benefits must 
be able to not only veterans with service-connected disabilities of all 
eras but also veterans who receive VA health care services due to a 
catastrophic disability acquired outside the veteran's service. 
Otherwise, unnecessary inequality in the system of health care benefits 
may result.
    VetsFirst believes that veterans with disabilities have the right 
to receive their services and supports in the least restrictive 
environment. Most people with disabilities want to live in their homes 
and have the opportunity to be a part of their communities. Although 
funding services for caregivers requires an upfront investment, the 
long-term gains that result from assisting veterans with disabilities 
in their efforts to reintegrate into their communities are significant.
    Thank you for the opportunity to submit for the record VetsFirst's 
concerns with VA's implementation plan for the comprehensive caregiver 
program. We appreciate your leadership on behalf of our Nation's 
veterans with disabilities and their families and survivors. VetsFirst 
stands ready to work in partnership to ensure that all veterans are 
able to reintegrate in to their communities and remain valued, 
contributing members of society.

                                 
                   MATERIAL SUBMITTED FOR THE RECORD
                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                     March 17, 2011

Tom Tarantino
Senior Legislative Associate
Iraq and Afghanistan Veterans of America
777 North Capitol Street NE, Suite 403
Washington, DC 20002

Dear Tom:

    In reference to our Subcommittee on Health Committee hearing 
entitled ``Implementation of Caregiver Assistance: Are We Getting It 
Right?'' that took place on March 11, 2011. I would appreciate it if 
you could answer the enclosed hearing questions by the close of 
business on April 17, 2011.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Jian Zapata by fax at 202-225-2034. If you have any questions, please 
call 202-225-9756.

            Sincerely,

                                                 Michael H. Michaud
                                          Ranking Democratic Member
CW:jz

                               __________

                        Questions for the Record
   HVAC Hearing on ``Implementation of Caregiver Assistance: Are We 
                          Getting It Right?''
                             March 11, 2011
                       Response by Tom Tarantino
                   Senior Legislative Associate, IAVA
    Question 1: Please tell this Committee what was the extent of your 
organizations' involvement in the development of the implementation 
plan?

    Answer: Along with several other VSOs that were instrumental in 
passing the caregivers law, IAVA participated in two focus groups held 
by the VA at VA Headquarters. These meetings were held on October 5, 
2010 and October 23, 2011. Both lasted several hours. The stated goal 
of those meeting was for the VA to receive the VSO community's views 
and ideas on Eligibility, DoD to VA transition, training, benefits, and 
monitoring. While the topics were structured, the conversation was free 
form with all of the recommendations coming from the VSOs to the VA. 
The VA provided no information on where they were on any given issue. 
When asked questions by the group, the frequent response was ``What do 
you think we should do?'' While this provided a forum to address issues 
of concern from the VSO community, there was very little feedback from 
the VA. We left each meeting unsure where the VA was in the process.
    This was the extent of IAVA's involvement with the implementation 
plan. The VSOs and the Congressional offices that worked on the bill 
went to great lengths to make the legislative text as explicit as 
possible, in order to curb poor regulation. IAVA feels that despite the 
two focus groups, the VA regulated this law without effectively tapping 
the knowledge and experience of the VSO community that represents the 
veterans that they are trying to serve.

    Question 2: Traumatic Brain Injury or TBI is considered the 
signature wound of these wars. Given that, do you believe that the 
current criteria in the implementation plan would unnecessarily exclude 
many veterans who have a TBI?

    Answer: The National Military Family Association frequently says, 
``Wounded servicemembers have wounded families.'' If we are to treat 
and cure the wounds of a servicemember, we must also care for the 
wounds of the families, or in this case, the caregiver. This was 
clearly Congress' intent when crafting this law.
    We feel that the narrow eligibility criteria proposed by the VA 
will exclude many veterans and their caregivers from receiving the care 
and benefits that they need. The intent of this law was to provide 
assistance to the caregivers who have put their lives on hold to care 
for their wounded warrior. It was not meant to replace hospital care. 
TBI is the staunchest example of an injury that will be left behind by 
the VA's proposed criteria. While the most severely wounded cases of 
TBI will surely qualify, the criteria set out by the VA does not 
account for the moderate cases of TBI that may not require 
hospitalization, but still will require constant care and monitoring if 
they are to recover.
    A veteran suffering from a severe TBI who would require 
hospitalization would definitely be eligible for the caregiver program. 
However, injuries like TBI aren't that simple. There are levels of 
severity that while not requiring institutionalization, still require 
constant care to both ensure the safety of the veteran and promote a 
healthy recovery. Based on numerous accounts from our members and 
supporters, IAVA believes that the majority of those who would benefit 
from the caregivers program fall in the former category. Under current 
VA regulations, this larger group of caregivers will not be eligible 
for support. Given that this program was designed to help those 
caregivers, the VA's failure to include these caregivers shows that the 
VA is fundamentally missing the point of this program. While the 
caregiver program is meant to help facilitate the care and recovery of 
the veteran, it is designed to support the caregiver who is sacrificing 
to care for their wounded warrior.
    We understand the VA's need to establish clinical metrics in 
determining eligibility. IAVA feels that adding clinical criteria into 
the equation is necessary. However, it is not sufficient if we are to 
remedy the problem that the caregiver program is meant to solve. The VA 
must factor the needs of the caregivers who are providing a critical 
service in the veteran's care and recovery. In this respect, the VA has 
failed to meet the goals set forth by Congress.

    Question 3: Several of the testimonies raised concerns with the 
mental health services and the coverage for the caregivers in the 
implementation plan. I would like each of you to expound on your 
concerns.

    Answer: IAVA is cautiously optimistic about the mental health 
services that caregivers will be eligible for under this program. 
According to the implementation plan ``Primary family caregivers will 
be covered . . . for mental health services in connection with the 
treatment of the Veteran'' and ``mental health services needed by the 
primary family caregiver but not related to the treatment of the 
Veteran.'' While is seems that this does cover the range of mental 
health care that a caregiver would require, we are concerned about what 
the VA will determine as ``services in connection with the treatment of 
the veteran.'' Based on the VA's narrow view of criteria for the rest 
of the caregivers program, we are not confident that the VA will adopt 
an interpretation of ``connected'' that reflects the needs of the 
caregivers that this program is meant to support. Unfortunately, we 
will have to see how the VA handles this in practice to assess its 
effectiveness.

                                 

                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                     March 17, 2011

Barbara Cohoon, Ph.D., R.N.
Government Relations Deputy Director
National Military Family Association
2500 North Dorn Street, Suite 102
Alexandria, VA 22302

Dear Barbara:

    In reference to our Subcommittee on Health Committee hearing 
entitled ``Implementation of Caregiver Assistance: Are We Getting It 
Right?'' that took place on March 11, 2011, I would appreciate it if 
you could answer the enclosed hearing questions by the close of 
business on April 17, 2011.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Jian Zapata by fax at 202-225-2034. If you have any questions, please 
call 202-225-9756.

            Sincerely,

                                                 Michael H. Michaud
                                          Ranking Democratic Member
CW:jz

                               __________

                             National Military Families Association
                                                    Washington, DC.
                                                      April 8, 2011

Congressman Michael H. Michaud
Ranking Democratic Member
Subcommittee on Health
Committee on Veterans' Affairs

Dear Congressman Michaud:

    Question 1: Please tell this Committee what was the extent of your 
organization's involvement in the development of the implementation 
plan?

    Answer: The Department of Veterans Affairs extended two invitations 
to the National Military Family Association to participate in a half-
day roundtable discussion on the implementation of the caregiver 
provision in P.L. 111-163. I participated in both discussions. We were 
given plenty of opportunity to discuss our vision on how certain 
aspects of the caregiver provisions should be implemented. The four 
organizations that had worked on the drafting of the law were included 
along with a variety of other Veteran Service Organizations. The 
National Military Family Association also submitted a white paper 
outlining our Association's recommendations for implementation, which I 
have provided.

    Question 2: Traumatic Brain Injury or TBI is considered the 
signature wound of these wars. Given that, do you believe that the 
current criteria in the implementation plan would unnecessarily exclude 
many veterans who have a Traumatic Brain Injury?

    Answer: The National Military Family Association believes the 
current criteria in the implementation plan would unnecessarily exclude 
many veterans who have a Traumatic Brain Injury (TBI). There are two 
references included in the VA's implementation plan that could 
adversely affect eligibility. The inclusion of the ``need for 
`institutional' level of care without the support of a caregiver'' will 
disqualify many servicemembers and veterans with TBI. Many of our 
wounded servicemembers and veterans have mild to moderate cognitive 
impairment that require caregiver support, but they certainly do not 
need hospitalization or to be institutionalized. The criteria, 
``incapacity, physical or mental which requires care or assistance on a 
regular basis to protect the veteran from hazards or dangers incident 
to his or her daily environment,'' is concerning. The word 
``incapacity'' details the level of severity of the wound that needs to 
be met in order to qualify. Servicemembers and veterans with just mild 
or moderate TBI will most likely be disqualified under this criterion. 
There is a strong possibility that some servicemembers with multiple 
injuries, such as a mild or moderate TBI, a loss of an extremity, PTS 
or PTSD, and 10 percent burn, may not qualify for this program. 
Multiple injuries are commonly seen in our returning servicemembers 
from war. Co-morbid injuries may require the servicemember and veteran 
to need the assistance and support of a caregiver, but not seen as 
being at the level of incapacitated. Again, this was not the intent of 
the law. Both of these criteria, ``institutional'' and ``incapacity'' 
provide a level of severity that would make these servicemembers and 
veterans along with their caregivers ineligible for the caregiver 
benefits.

    Question 3: Several of the testimonies raised concerns with the 
mental health services and the coverage for the caregivers in the 
implementation plan.

    Answer: The National Military Family Association's concerns 
regarding the mental health services and the coverage for the 
caregivers in the implementation plan involve several areas.
    The first is the delay in eligibility until the servicemember is 
entering veteran status. This delay will impact the ability for the 
caregiver to obtain time sensitive needed benefits, such as access to 
mental health counseling and health care benefits. This especially 
impacts non-spouse caregivers who would greatly benefit from these 
services. As we mentioned in our testimony, the recent survey, 
``Caregivers of Veterans--Serving on the Homefront'' one in four 
respondents were parents caring for Operation Enduring Freedom and 
Operation Iraqi Freedom veterans. Also, a larger proportion of veteran 
caregivers compared to their National (civilian) counterparts reported 
mental illness, such as depression or anxiety (70 percent) or PTSD (60 
percent) compared to their National counterparts (28 percent). Veteran 
caregivers also reported their situation to be highly stressful (68 
percent versus 31 percent Nationally) and 75 percent stated it placed a 
stress on their marriage (74 percent). Also, they found there were 
widespread impacts on the caregiver's health, such as increased levels 
of stress and anxiety (77 percent) and not sleeping (77 percent), and a 
decrease in the utilization of healthy behaviors, such as seeing their 
medical provider.
    Our Association is hearing that caregivers are reaching the stage 
of burnout and many are deciding to walk away from their roles as 
caregivers. The longer the VA waits to begin benefits, the more 
opportunity there is for the caregiver's quality of life to worsen and 
for the caregiver to reach the stage of burnout. The caregiver survey 
highlighted the increased stress our veteran caregivers are under 
compared to their National counterparts. The law and Congressional 
intent were to allow the VA to provide assistance through value-added 
benefits to the caregiver early enough in the process to make a 
difference and prevent the development of physical health, mental 
health, and/or financial problems. Caregivers of our wounded, ill, and 
injured need these services now, and sooner in the recovery process 
than later.
    The second involves the decision not to provide medication for 
mental health treatment. The VA caregiver implementation plan stated, 
``Primary family caregivers will be covered . . . for mental health 
services in connection with the treatment of the Veteran'' and ``mental 
health services needed by the primary family caregiver but not related 
to the treatment of the Veteran.'' The implementation plan further 
stated, ``but not medication.'' Our Association is concerned with the 
coordination of care between the mental health provider and the health 
care provider. The VA stated they will not provide medication for 
mental health treatment. However, the caregiver's health care insurance 
program, which could be CHAMPVA, would provide the medication. Our 
Association was wondering how this would be coordinated to ensure the 
caregiver received the mental health benefit entitled in the caregiver 
law from the VA and the medication needed to effectively treat the 
mental health condition from the caregiver's health care plan. We 
recommend VA provide coordination of VA mental health services and the 
appropriate type and dosage of medication is provided by the 
caregiver's primary health care provider to ensure the caregiver is 
receiving a holistic approach to mental health care.
    Finally, our Association requests the VA to clarify what they meant 
by providing expanded ``counseling'' services to caregivers under the 
law. We would appreciate if the VA would provide a definition of what 
these expanded counseling services for family caregivers will include.

                               __________

                   Caregiver Compensation Discussion
    Deborah, Per your request, I have taken a look at the slides and 
have some suggestions.
Eligibility:
    Definition

    The definition needs to be set by the VA, but not so different from 
the DoD and the various Services to allow for the Services' Recovery 
Care Coordinators to be able to recognize the caregiver's eligibility 
for the VA Caregiver provisions. There will need to be several 
mechanisms in place to assure these families are recognized as 
qualifying for this important benefit. It should be encouraged for all 
who think they qualify to be recommended to apply, similar to the FRC 
program. Better to err on the side of receiving more requests than for 
the Service case managers to not even bring up the potential 
qualification for the program. Also, this will allow for those already 
medically discharged and receiving care in the community to be 
identified by the various Service's case managers.
    Start time

    The different provisions could start at separate times. For 
example, educational material should be readily available to access 
even though you have not qualified for the program. Access to Web site 
and pamphlet material at the earliest phase of recovery will also be 
important. Access to mental health services should be started prior to 
the eligibility being finalized. Access to mental health information 
(i.e. self assessment exams online, PTS and TBI assessment exams 
online), and available resources, (i.e. Military OneSource, TRICARE 
face to face or TRIAP, Vet Centers, etc.), will be very important to 
start this as soon as possible. The caregiver could either self 
identify or providers could recommend these services. Access should not 
be restricted to only those who have already been determined eligible 
because of the time from identifying the caregiver eligibility and 
determination of qualification. The need for formal training or 
behavioral health services may be the trigger that helps identify the 
caregiver as potential candidates for this program.
    There has been some discussion that the program's benefits should 
start immediately upon the injury/illness. As mentioned earlier, some 
of the provisions should be allowed to start earlier in the process and 
not wait for a formal determination of eligibility. Our Association 
would support the entire benefit starting around the time frame of the 
MEB process, once the Services have determined the servicemember will 
be evaluated for fit-for-duty. Wounded, ill, and injured servicemembers 
are usually triaged to determine their acuity level and they are 
assigned to a RCC accordingly. A discussion with the various Services 
to ensure caregivers are then vectored to the VA for evaluation for the 
caregiver provision during this same time period will need to take 
place by the VA. The evaluation could be done similar to the DES 
process using key factors related to the caregiver's role/
responsibilities in their care with the wounded/ill/injured 
servicemembers/veterans. As we have discussed, there will need to be 
continued evaluation as the need for the caregiver provisions may 
change over time. Health care provision may not be needed initially, 
but arise later on.
Training:
    There should be formal and informal training. Some caregivers will 
need to learn more of the hands on medical care needed to care for the 
veteran (i.e. drawing up medications, changing dressings, 
dissimpactions, etc.). Paying for them to attend Medical Assistant 
training or a higher level (LPN/RN) could be allowed depending on the 
desire of the caregiver to become an expert at that level of care. 
Again, if this is identified earlier, they may qualify for DoD's MyCAA 
that provides money for training. VA could maybe start a similar 
program for these caregivers. As intended certain level of social work 
training so they may be better able to handle stress in the family and 
the servicemember/veteran. Any training that requires the caregiver to 
be away from the servicemember/veteran, care will still needed to be 
provided. The VA should provide all those services during that time 
frame.
    Informal training would involve advocating for your servicemember/
veteran, how to care for yourself, benefits and resources available to 
you and your family, what it is like to be a caregiver, and making 
doctor's appointments. This can be done in many different forms, such 
as internet, pamphlets, and actual face to face training.
Financial compensation:
    Compensation Type A

    It is for services rendered nonmedical care. Only the primary 
caregiver would qualify. It would be on a sliding scale with a minimum 
and maximum amount allowed under this provision. The payment would 
reflect the amount of services the caregiver was providing, such as 
traveling to appointments, making appointments, etc. The amount would 
increase as the demand for services increased, such as following a 
surgery; and decrease as the need dissipated after recovery. This need 
would have to be assessed quickly without any or little time delay in 
order to provide the correct amount of compensation. You could start 
out with the level determined during the initial evaluation with the 
ability for this to increase, not decrease until the servicemember 
enters veteran status and is permanently located. Amount should be the 
same no matter where you reside during the determination phase through 
entering veteran status and permanent residence is established. If you 
were looking at the rate being tied to a geographical location, this 
would be applied only after permanent residence was established after 
becoming receiving veteran status.

    Compensation Type B

    It is for actual home health, hands on care provided to the 
servicemember/veteran by the caregiver. The payment would be hourly, 
reflect the region's payment scale, and geared toward the level of care 
provided. The caregiver will be provided training by either the VA or a 
pre-accredited civilian program. The caregiver will be certified after 
completing the training program. This certification must be recognized 
and transferable to the civilian sector. The training and certification 
will be paid for by the VA. This will be offered to no more than two 
caregivers. This would allow for more than one person to provide hands 
on care, such as mom and dad to share the physical care responsibility. 
Caregivers will be provided continued training opportunities paid for 
by the VA. A system needs to be in place to assure quality care is 
being provided by the caregiver. The caregiver is paid directly for 
their services.
Competence:
    This should be done by someone the caregiver and servicemember/
veteran trust. This can be accomplished by someone they already know, 
or trust could be built by the evaluation team set up by the VA. Same 
as a DES board, but on a much friendlier compassionate basis, so as not 
to create the feeling as though you are just going through ``the 
process of determination.'' Since you are looking for continuity in 
determination of eligibility, it would be best to set up teams with 
special training on how to deal with this delicate determination. 
Competence would be assessed during the eligibility time. Competence 
must also be evaluated on a regular basis. If they are seeing health 
care providers on a regular basis, this will be easier, then if they 
are using non-VA health care providers or no longer using health care 
providers. This population will most likely be assigned a FRC. It will 
be this person who will stay attached overseeing holistic care until 
death of the veteran. Evaluation for competence will need to be part of 
the ``care plan'' for the veteran and the family. There will be a need 
for an appeal process if the caregiver is found not competent.
Mental Health:
    All providers must be familiar with military culture, not just 
mental health providers. Access to therapy should be through telemental 
health, online chat, and face to face individual, family, and group 
sessions. As mentioned earlier, access needs to be available as soon as 
possible. Knowing how to self assess and identify resources to 
available behavioral health support will be key in addressing the issue 
early enough in the process to make effective change. The VA needs make 
sure these services are available in Military Treatment Facilities, on 
military installations that are housing wounded, ill, and injured 
servicemembers and their families in order to start these important 
services ``upstream,'' while still on active duty status. They should 
also have access in the community through Vet Centers regardless of 
meeting the ``combat'' criteria for services, at the various VA 
facilities and community-based outpatient clinics (CBOCs), and 
purchased provider services if behavioral health support is not 
available through other means.
Monitoring:
    Competence and eligibility for the various support services and 
programs must be evaluated on a regular basis. If they are seeing 
health care providers on a regular basis, this will be easier, then if 
they are using non-VA health care providers or no longer using health 
care providers. This population will most likely be assigned a FRC. It 
will be this person who will stay attached overseeing holistic care 
until death of the veteran. Evaluation for competence and the 
requirement for support services will need to be part of the ``care 
plan'' for the veteran and the family. The caregiver may not recognize 
their need for health care services, respite care, or mental health 
counseling. Having regular interaction either by phone or in person, 
should help the FRC evaluate how the caregiver is fairing. Asking 
questions, like when was the last time they went to the dentist, had a 
physical, took time off, and visited a relative. They should also be 
monitoring the family for how well they are coping. And, recommend 
support programs and services to the family as well.
Suspension of Stipend/Provisions:
    There must be a provision for transition for the caregiver. If the 
caregiver's services are no longer needed, chooses to no longer 
participate, or is asked by the veteran to no longer provide services. 
The caregiver will still be able to maintain health care for 1 year. 
The Stipend could be changed to reflect the sliding scale of non-
medical services Compensation A as discussed earlier, to reflect the 
amount of care they are still providing while the veteran is 
hospitalized. Compensation B would stop if the caregiver was no longer 
providing hands on medical care while hospitalized. Medicare ties their 
reimbursement to the 100-day rule. TRICARE for Life begins their 
evaluation for eligibility for reimbursement at the 80-day time frame 
with a determination made prior to the 100-day mark. The VA could use a 
similar rule of starting an evaluation process. Depending on the VA's 
definition of eligible veteran, they may be using Medicare already. 
Compensation would discontinue following the end of all services/care 
provided by the caregiver determined by the VA.
Investment opportunities:
    All caregivers would be TSP eligible.
Final Question:
    Don't wait too long to start these Caregiver support services and 
programs. Allow them to be flexible enough to allow the caregiver to 
initiate well upstream (while the servicemember is on active duty) in 
order to make a difference in their quality of life.

                                 

                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                     March 17, 2011

The Honorable Robert A. Petzel, M.D.
Under Secretary for Health
Veterans Health Administration
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Dr. Petzel:

    In reference to our Subcommittee on Health Committee hearing 
entitled ``Implementation of Caregiver Assistance: Are We Getting It 
Right?'' that took place on March 11, 2011. I would appreciate it if 
you could answer the enclosed hearing questions by the close of 
business on April 17, 2011.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Jian Zapata by fax at 202-225-2034. If you have any questions, please 
call 202-225-9756.

            Sincerely,

                                                 Michael H. Michaud
                                          Ranking Democratic Member
CW:jz

                               __________

                        Questions for the Record
                     Ranking Member Michael Michaud
                  House Committee on Veterans' Affairs
                         Subcommittee on Health
  ``Implementation of Caregiver Assistance: Are We Getting It Right?''
                             March 11, 2011
    Question 1: In their testimony, the Wounded Warrior Project states 
that they were ``given no inkling of the contents of the VA 
implementation plan prior to its submission to the House and Senate 
Committees''. Did you engage the VSOs in meaningful dialogue during the 
process of putting together the implementation plan that you eventually 
submitted to the Committee? If you did, when in the process did you do 
this and were their suggestions given due consideration?

    Response: The Department of Veterans Affairs (VA) met with 
representatives from several of the Veterans Service Organizations 
(VSO) on October 5 and October 13, 2010. These meetings included 
representatives from American Legion, AMVETS, Blinded Veterans 
Association, Disabled American Veterans, Iraq and Afghanistan Veterans 
of America, Military Officers Association of America, National Military 
Family Association, Paralyzed Veterans of America, Veterans of Foreign 
Wars, Veterans of Modern Warfare, and Wounded Warrior Project.
    In addition to these formal sessions, VA maintained regular contact 
with our VSO colleagues since the law was enacted. During the meetings 
in October, VA listened to the concerns raised by the VSOs on a number 
of issues including eligibility, the primary family caregiver stipend, 
education and training requirements for family caregivers, and regular 
in-home monitoring of the Veteran and the caregiver. VA adopted many of 
the recommendations offered by the VSOs, including the need for 
multiple methods of application to the program, and the importance of 
integrating the new programs into existing systems and services. 
Further information about these discussions, the recommendations put 
forward by the VSOs, and VA's response to the proposals that were not 
included in the Implementation Plan can be found on pages 34-37 of VA's 
Implementation Plan, available online at http://www.caregiver.va.gov/
docs/Caregivers_part1.pdf.
    The VSO meetings were held in early October to allow enough time 
for robust discussion and to cover all relevant topics. Potential 
aspects of eligibility criteria were discussed at least in concept. VA, 
however, did not have a formal position on the elements of the 
Implementation Plan in October, and it was premature to have provided, 
in technical detail, specific language that was still being 
deliberated. VA felt that a series of listening sessions would allow 
Department officials to hear the concerns and recommendations of the 
VSOs in an environment that would allow VA to then incorporate those 
recommendations into the larger plan.

    Question 2: Is there anything that the first panel testified on 
that you would like to address?

    Response: Some of the VSOs seemed to suggest that Veterans with 
traumatic brain injuries (TBI) would not be covered under the 
eligibility criteria outlined in VA's Implementation Plan. VA disagreed 
with that assessment in exchanges at the March 11 hearing, and is 
confident Veterans with TBI would qualify under the standards put forth 
in the Implementation Plan. Many of the clinical criteria describe 
functional impairments that are associated with TBI, including 
``incapacity, physical or mental, which requires care or assistance on 
a regular basis to protect the Veteran from hazards or dangers incident 
to his or her daily environment.''
    When VA experts were drafting the eligibility criteria, 
professionals with expertise in the Federal Recovery Coordination 
Program, our Polytrauma programs, and TBI programs were consulted for 
input. There was significant recognition of the challenges that are 
faced by family members caring for individuals with TBI, and it is VA's 
intention that those individuals be included and be eligible if the 
Veteran requires supervision to remain at home. VA anticipates that 
significant numbers of severely injured TBI patients will be eligible 
for this program.
Budget
    Question 1: Concern has been raised to this Committee on the 
adequacy of the budget resources for implementation of the Caregivers 
legislation. Could you give us some detail as to the amounts of the 
requests for FY 2011, 2012, and 2013 and what that request reflects? 
Please start with the budget for FY 2011. It is my understanding that 
the Secretary submitted a letter in July of 2010 requesting an 
additional $166 million for P.L. 111-163. I would also like to know if 
you believe these requests are adequate to adequately implement the 
plan.

    Response: VA cannot finalize the cost estimates while the Interim 
Final Rule is pending. VA will continue to keep the Committee informed, 
including providing our final estimate, once the process is completed.
    In response to your concern about the July 2010 letter, VA 
submitted to the House and Senate Committees on Appropriations and 
Veterans Affairs a report on the sufficiency of funds in FY 2011 on 
July 30, 2010. The FY 2011 budget was presented in February 2010, but 
Public Law 111-163 was not signed into law until May 5, 2010. As a 
result, the July letter only states that the 2011 budget did not 
include funds for these programs because these programs did not exist 
at the time the budget was proposed. VA has identified resources to 
support these initiatives in FY 2011 and has included in its 2012 and 
2013 request additional support.
Eligibility
    Question 1: Many of the VSOs take issue with the eligibility 
criteria contained in the implementation plan and subsequently in the 
regulations. Would you explain to the Committee why VA decided to 
``narrow the pool of eligible caregivers'' with the addition of the 
criteria-clearly this was not the intent of the law.

    Response: VA does not believe it is an accurate characterization to 
say that the eligibility criteria identified in the Implementation Plan 
were designed to ``narrow the pool of eligible caregivers.'' The 
clinical experts consulted in developing these criteria are dedicated 
to helping injured Veterans and were exercising their professional 
judgment in developing criteria that would define those Veterans and 
caregivers in greatest need so as to be able to provide them with the 
additional support they require. It is important that VA has clear 
clinical guidelines to be consistently applied by clinicians across the 
country. We know that many Members of Congress and Veterans' advocates 
disagree with the criteria outlined in the Plan. VA and the 
Administration take these concerns seriously, and they are being 
considered during the subsequent deliberations on the content of the 
pending Interim Final Rule.

    Question 2: Why was it necessary for the VA to establish clinical 
eligibility criteria beyond those in the law?

    Response: Several key terms in the law were undefined, including 
``serious injury'' and others. VA cannot implement the program without 
defining clear criteria that can be consistently applied by clinicians 
across the country. The criteria in the Plan attempts to provide that 
consistency. VA and the Administration are taking the criticism of the 
policy issue of eligibility and other aspects of the program very 
seriously.

    Question 3: Wounded Warrior Project testified that the VA plan 
defines the term ``personal care services'' in a manner inconsistent 
with the law. Would you agree with that?

    Response: VA does not agree that the Implementation Plan defines 
the term ``personal care services'' in a manner inconsistent with the 
law. The rationale for applicable program definitions, including the 
definition of the term ``personal care services,'' will be included in 
the Interim Final Regulations.
Mental Health
    Question 1: In the case of a Veteran injured after 9/11, the law 
directs VA to provide mental health services needed by the primary 
caregiver. But the VA plan imposes restrictions not required by law. 
Under VA's plan, if the caregiver needed mental health care for anxiety 
or depression due to the stresses of caregiving (rather than care 
related to the Veteran's treatment) but was not eligible for CHAMPVA, 
VA would apparently not provide any mental health services. Under those 
circumstances, a caregiver might have to rely on other coverage that 
might have very limited mental health benefits. Why is that a good 
policy, given the goal of maintaining the caregiver's mental and 
emotional health?

    Response: VA recognizes that caregivers can experience stress that 
may result in depression, anger, interpersonal conflict, anxiety, 
substance use, sleep disturbance, social isolation, or other 
conditions. Caregiving can also place stress upon the marital or family 
relationship as well. In these circumstances, in accordance with 38 
United States Code (U.S.C.) 1782, general caregivers, as well as family 
caregivers, would have access to consultation, professional counseling, 
marriage and family counseling, training, and mental health services as 
necessary in the connection with the treatment of the Veteran.
    VA would offer mental health and counseling services needed by 
family caregivers but unrelated to the treatment of the Veteran by 
providing individual and group therapy and counseling and peer support 
groups. This provision in Public Law 111-163 (as it is proposed in the 
Implementation Plan) would ensure that mental health services would be 
provided to primary family caregivers whether the care is related to 
the treatment of the Veteran (where care could be provided under 38 
U.S.C. 1782) or whether they were unrelated (where care could be 
provided under 38 U.S.C. 1720G(a)(3)(A)(ii)(II). This would cover most 
mental health needs of primary family caregivers.
    VA's Implementation Plan stated that VA would not provide 
medication or other medical procedures related to mental health 
treatment or provide inpatient psychiatric care. This provision was 
included because VA believed that caregivers requiring this type of 
intensive treatment should seek it within the context of a 
comprehensive treatment setting that addresses all elements of the 
caregiver's well-being, not just his or her mental health care. This 
philosophy underlies VA's approach to care, which is to treat all of 
the Veteran's health care needs, because mental or physical health 
conditions can create complications beyond the immediate diagnosis.
    In the event that a caregiver needed care in the private sector, 
the law provides access to health care under the Civilian Health and 
Medical Program of the Department of Veterans Affairs (CHAMPVA) for 
certain primary family caregivers who are not otherwise entitled to 
care or services under a health-plan or contract. In addition, the 
local VA facility's Caregiver Support Coordinator would assist him or 
her in locating a provider and ensuring that care and services meet the 
caregiver's needs.

                                 
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