```

[Senate Report 113-107]
[From the U.S. Government Publishing Office]

                                                       Calendar No. 186
113th Congress                                                   Report
                                 SENATE
 1st Session                                                    113-107

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

 
                 CAREGIVERS EXPANSION AND IMPROVEMENT 
                              ACT OF 2013

                                _______
                                

               September 17, 2013.--Ordered to be printed

                                _______
                                

         Mr. Sanders, from the Committee on Veterans' Affairs,
                        submitted the following

                              R E P O R T

                             together with

                             MINORITY VIEWS

                         [To accompany S. 851]

    The Committee on Veterans' Affairs (hereinafter, ``the 
Committee''), to which was referred the bill (S. 851), to 
extend to all veterans with a serious service-connected injury 
eligibility to participate in the family caregiver services 
program, having considered the same, reports favorably thereon 
without amendment, and recommends that the bill do pass.

                              Introduction

    On April 25, 2013, Chairman Sanders introduced S. 851, the 
proposed ``Caregivers Expansion and Improvement Act of 2013.'' 
S. 851 would expand a national program for the caregivers of 
seriously injured veterans to provide them with a tax-free 
monthly stipend, reimbursement for travel expenses, health 
insurance, mental health services, counseling, training, and 
respite care.

                           Committee Hearing

    On May 9, 2013, the Committee held a hearing on pending 
health care legislation, which included discussion of S. 851. 
Testimony on S. 851 was offered by: Robert L. Jesse, MD, PhD, 
Principal Deputy Under Secretary for Health, Department of 
Veterans Affairs; Rick Weidman, Executive Director for Policy 
and Government Affairs, Vietnam Veterans of America; and 
Heather Ansley, Esq., MSW, Vice President for Veterans Policy, 
VetsFirst.

                           Committee Meeting

    After carefully reviewing the testimony from the foregoing 
hearing, the Committee met in open session on July 24, 2013, to 
consider, among other legislation, S. 851. The Committee voted, 
by voice vote, to report favorably S. 851 to the Senate.

                     Summary of S. 851 as Reported

    S. 851 (hereinafter, ``the Committee bill'') would expand 
the program of support for caregivers of seriously injured 
veterans to caregivers of veterans of all eras.

                       Background and Discussion

    In 2006, then-Ranking Member Daniel K. Akaka introduced S. 
2753, to improve caregiver assistance services for veterans. 
During the May 11, 2006, hearing on this legislation, Senator 
Akaka stated, ``Ensuring caregivers have the support and tools 
they need to care for their family members makes economic 
sense, and more importantly, makes policy sense.'' Senator 
Akaka's bill was included as part of legislation Congress 
passed and the President signed into law--Public Law 
(hereinafter, ``P.L.'') 109-461, the ``Veterans Benefits, 
Health Care, and Information Technology Act of 2006.'' The law 
authorized $5 million for each of the fiscal years 2007 and 
2008 for the Department of Veterans Affairs (hereinafter, 
``VA'') to carry out pilot caregiver assistance programs. VA 
began 8 caregiver assistance pilot programs in October 2007.
    The pilot programs provided a number of lessons learned, 
including the need for a multi-modality approach, effective 
communication, and caregiver education and support. According 
to the report from VA to Congress required by P.L. 109-461, 
``[r]espite is a key component of programs that reduced 
caregiver stress and burden.'' The report also states many 
``elements of the caregiver pilots can easily serve rural and 
difficult to access populations,'' citing that ``caregiver 
education, training, and support services do not require face-
to-face contact'' but can be provided through ``[w]eb based 
training and resource information, telephone support groups, 
and telehealth equipment.'' Overall, the pilots were found to 
``result in a healthier caregiver, improved care for the 
veteran and a better quality of life for both.''
    In 2008, a 1-year extension of authority for these pilot 
programs was approved in P.L. 110-387, the ``Veterans' Mental 
Health and Other Care Improvements Act of 2008.'' Additionally, 
the Senate approved S. 1963, the ``Caregivers and Veterans 
Omnibus Health Services Act of 2009.'' At the time S. 1963 was 
debated on the Senate floor, then-Chairman Akaka addressed 
those Senators concerned about the cost of the legislation, 
stating that ``we cannot renege on the obligation to care for 
those who honorably serve our country. When we as a nation vote 
to send American troops to war, we are promising to care for 
them when they return. The cost of health care is a true cost 
of war and must be treated as such.'' He went on to say, ``To 
assert that this legislation requires excessive spending is 
simply wrong. This spending is critical when taking into 
account the sacrifices these men and women have made for the 
nation.''
    S. 1963 later became P.L. 111-163, the Caregivers and 
Veterans Omnibus Health Services Act of 2010 (hereinafter, 
``the Caregivers law''), on May 5, 2010. The law reduced the 
burden faced by family caregivers of post-9/11 veterans by 
providing them with a tax-free monthly stipend, reimbursement 
for travel expenses, health insurance, mental health services 
and counseling, training, and respite care. Since its inception 
through July 2013, the law has helped more than 10,600 veteran 
caregivers and their families.
    The passage of the Caregivers law served as an important 
step in ensuring the caregivers of our newest generation of 
veterans received the resources necessary to provide the best 
possible care for their loved ones. However, these benefits and 
services were not made available to all veterans. Limiting 
eligibility for the program to caregivers of post-9/11 veterans 
created an inequity between caregivers of the newest generation 
of veterans and the tens of thousands of hardworking, dedicated 
caregivers who provide care to all other veterans. In September 
2013, VA submitted to Congress the Expansion of Family 
Caregiver Assistance Report, as required by the Caregivers law. 
In this report, VA stated:

        Expansion of the Program of Comprehensive Assistance 
        for Family Caregivers would remedy the inequity created 
        by the current statutory requirements, and would 
        further recognize the sacrifice of our Veterans from 
        all eras and the needs of their family caregivers. VA 
        believes, apart from resource issues that are discussed 
        below, such an expansion is operationally feasible.

The Congressional Budget Office estimates that approximately 
70,000 caregivers of pre-9/11 veterans could be eligible for 
the expanded program.
    The caregivers of veterans from other eras have spent 
years, sometimes decades, caring for severely injured veterans. 
While data related to the loss of income for veteran caregivers 
is limited, studies highlighted by the Military Caregivers 
report published by RAND in 2013 indicated approximately two-
thirds of caregivers with jobs reported missing work.\1\ The 
other third are said to have reduced their hours due to their 
caregiving responsibilities. These caregivers deserve the same 
access to resources and services provided to caregivers of the 
veterans from our country's most recent conflicts.
---------------------------------------------------------------------------
    \1\Tanielian, Terri, Rajeev Ramchand, Michael P. Fisher, Carra S. 
Sims, Racine Harris, and Margaret C. Harrell. Military Caregivers: 
Cornerstones of Support for Our Nation's Wounded, Ill, and Injured 
Veterans. RAND Corporation, 2013.
---------------------------------------------------------------------------
    Paralyzed Veterans of America submitted a statement for the 
record for the May 9, 2013, hearing on pending health 
legislation noting:

        No reasonable justification (other than cost 
        considerations) can be provided for why pre-9/11 
        veterans with a service-connected injury or illness 
        should be excluded from the comprehensive caregiver 
        program. Catastrophically disabled veterans needs are 
        not different simply because they may have been injured 
        prior to the selected date.

    At the same hearing, Rick Weidman of Vietnam Veterans of 
America observed:

        Many Vietnam veterans are alive today because their 
        wives, or sisters, or other relatives have been taking 
        care of them for decades. Heretofore there was never 
        any recognition of the fact that these veterans would 
        either have had to enter into long term care or would 
        have been on the street if not for the extraordinary 
        efforts of these family caregivers. Either way the 
        additional cost to American society would have been 
        extremely large, whether in fiscal cost or the societal 
        cost of having many additional veterans among the 
        homeless.

    The statements above attest to the importance of VA's 
caregiver program and the value this program will have for 
caregivers of pre-9/11 veterans. These statements also 
highlight that access to the program should be determined based 
on need, rather than the period of time the veteran served in 
the Armed Forces.
    Fully supporting caregiving activities not only ensures 
equity of services and benefits available to the caregivers of 
our most seriously injured veterans, it may also generate 
future cost savings. Supporting caregiving activities now may 
further enable veterans to remain at home rather than admitting 
them to a more expensive institutional setting, such as a 
nursing home. As described below, the cost of providing care in 
an institutional setting can be significantly greater than the 
cost of providing care in the home.
    VA is obligated to provide nursing home care for veterans 
who need such care and meet 1 of the following criteria: a 
service-connected disability rating of seventy percent or more; 
a need for nursing home care for a service-connected 
disability; or a rating of sixty percent when either 
unemployable or permanently and totally disabled. The 
Department's fiscal year 2014 budget request included 
$4,928,496,000 for long-term institutional care for the care of 
an estimated 42,465 veterans per day. This amounts to an 
average cost of $116,060 per veteran a year.
    Receiving long-term care in the private sector, which is an 
option for eligible veterans, is costly as well. According to a 
survey conducted in 2012 by MetLife's Mature Market Institute, 
the average cost of a private room in a nursing home in the 
United States was $90,520 per year. In contrast, as of July 
2013, the cost of the annual stipend of the Caregiver program, 
the most expensive aspect of the program, is approximately 
$18,203 per caregiver, nearly one-tenth the cost of 
institutional long-term care.
    Many family members are eager to give their veterans the 
opportunity to receive care at home by serving as caregivers. A 
study by the National Alliance for Caregivers (hereinafter, 
``NAC'') in 2010 found seventy-eight percent of veteran 
caregivers find their role fulfilling. However, the financial, 
physical, and mental toll on these caregivers can be 
substantial. According to a 2012 report by the Pew Research 
Center, thirty percent of adults in the United States serve as 
caregivers. A 2010 MetLife study, entitled ``Working Caregivers 
and Employer Health Care Costs,'' found there is an 8-percent 
difference in increased health care costs between caregiving 
and non-caregiving employees. This same study also found 
because stress can be an issue for caregivers, ``wellness 
programs that offer stress-management seminars and stress-
reduction programs * * * can be helpful.'' The findings of this 
report underscore the value of important services offered to 
caregivers of post-9/11 veterans through VA's caregiver 
program, which include training, counseling and respite--all of 
which are important mechanisms to reduce stress--and health 
care services, which can improve overall wellness.
    The financial burdens on caregivers who leave the workforce 
without financial assistance, such as a caregiver stipend, may 
impact the ability of caregivers to obtain health insurance. 
The report released by the NAC in 2010 noted caregivers of 
veterans in households with incomes less than $50,000 have had 
their retirement plans disproportionately impacted compared to 
those with higher household incomes.
    This point was emphasized in testimony submitted to the 
Committee with respect to its May 9, 2013, hearing by the 
Disabled American Veterans:

        The critical care [caregivers] provide amounts to 
        significant personal sacrifice resulting in lost 
        professional opportunities and reduction in income. 
        Caregiving exacts a tremendous toll on that caregiver's 
        health and well-being.

    Mental health concerns are often prevalent in the caregiver 
population as well, because many do not have access to 
supportive services. The NAC report also observed sixty-eight 
percent of veteran caregivers describe being highly-stressed, 
while another forty percent rate their physical strain as high 
due to the demands of their job. The same report also indicated 
caregivers of veterans in highly rural areas experience 
episodes of depression more frequently than those in more urban 
settings.
    The Caregivers law has been both popular and successful. As 
of July 2013, more than 10,600 caregivers have been approved 
for the program. According to VA, approximately 500 new family 
caregivers are being approved each month. These caregivers 
received an average monthly stipend between $575 and $2,254. 
Ninety-two percent of the approved caregivers are female, 
seventy-four percent of them are spouses and fifteen percent 
are parents. In addition, the majority of approved caregivers 
are between the ages of 26 and 40.
    Caregivers approved for the program have taken advantage of 
many of the services available through VA. For example, the 
National Caregiver Support Line, created through the Caregivers 
law, received more than 85,000 calls, averaging over 150 calls 
per day as of July 8, 2013. Additionally, as of that same date, 
more than 125 caregivers had participated in the Peer Support 
Mentoring Program. This program offers new caregivers the 
opportunity to be paired with experienced caregivers in order 
to share knowledge and skills and act as a support system.
    Finally, in VA's report to Congress regarding the expansion 
of family caregiver assistance services, VA acknowledged the 
positive impact the program had on family caregivers and 
veterans alike. The report noted,

        Preliminary program outcomes for a small sample of 
        program participants suggest a statistically 
        significant decrease in the level of burden reported by 
        approved family caregivers three months after the 
        initial home visit. An initial review has also shown a 
        statistically significant decrease in average monthly 
        inpatient utilization by eligible Veterans 
        participating in the Program of Comprehensive 
        Assistance for Family Caregivers.

    Based on its own assessment of the program, VA concluded:

        Expanding the Program of Comprehensive Assistance for 
        Family Caregivers would allow equitable access to 
        seriously injured Veterans from all eras (who otherwise 
        meet the program's eligibility criteria) and their 
        approved family caregivers. In reality, countless 
        families across every generation have been caregivers. 
        Without compensation and with little support, these 
        caregivers have sacrificed much for their Veteran and 
        this Nation.

    Committee Bill. The Committee bill would amend section 
1720G of title 38, United States Code, by striking ``on or 
after September 11, 2001,'' thus making the services and 
benefits available to caregivers of veterans of all eras.
    Removing this limitation would allow VA to waive the cost 
of furnishing hospital care or medical services for caregivers 
of veterans of all eras in emergency cases; authorize VA to pay 
for the caregivers' lodging and subsistence, as well as the 
expenses of travel to and from a treatment facility and 
expenses for the duration of the veteran's treatment episode at 
that facility; authorize VA to provide a tax-free monthly 
stipend; and ensure caregivers of veterans of all eras will be 
included in a national survey of family caregivers conducted in 
collaboration between VA and the Department of Defense.

                      Committee Bill Cost Estimate

    In compliance with paragraph 11(a) of rule XXVI of the 
Standing Rules of the Senate, the Committee, based on 
information supplied by the Congressional Budget Office 
(hereinafter, ``CBO''), estimates that enactment of the 
Committee bill would, relative to current law, increase 
discretionary spending by $510 million in fiscal year 2014 and 
by $9.5 billion over the 2014-2018 period, but would not affect 
direct spending or revenues. Enactment of the Committee bill 
would not affect the budgets of state, local, or tribal 
governments.
    The cost estimate provided by CBO, setting forth a detailed 
breakdown of costs, follows:

                               Congressional Budget Office,
                                   Washington, DC, August 15, 2013.
Hon. Bernard Sanders,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 851, the Caregivers 
Expansion and Improvement Act of 2013.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Ann E. 
Futrell.
            Sincerely,
                                      Douglas W. Elmendorf,
                                                          Director.

  Enclosure.

S. 851--Caregivers Expansion and Improvement Act of 2013

    Summary: S. 851 would expand eligibility for the Family 
Caregivers program administered by the Department of Veterans 
Affairs (VA). CBO estimates that implementing the bill would 
cost $9.5 billion over the 2014-2018 period, assuming 
appropriation of the estimated amounts. Enacting S. 851 would 
not affect direct spending or revenues; therefore, pay-as-you 
go procedures do not apply.
    S. 851 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
    Estimated cost to the Federal Government: The estimated 
budgetary impact of S. 851 is shown in the following table. The 
costs of this legislation fall within budget function 700 
(veterans benefits and services).

----------------------------------------------------------------------------------------------------------------
                                                                     By fiscal year, in millions of dollars--
                                                                ------------------------------------------------
                                                                 2014   2015    2016    2017    2018   2014-2018
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION

Estimated Authorization Level..................................   571   1,436   2,502   2,610   2,720     9,839
Estimated Outlays..............................................   510   1,337   2,375   2,577   2,693     9,492
----------------------------------------------------------------------------------------------------------------

    Basis of estimate: For this estimate, CBO assumes that the 
legislation will be enacted near the start of fiscal year 2014, 
that the necessary amounts will be appropriated for each year, 
and that outlays will follow historical spending patterns for 
similar and existing programs.
    Under the Family Caregiver program, VA provides several 
benefits (a stipend, health care, training, and respite care) 
to caregivers of eligible veterans. Veterans who have a 
service-connected disability incurred on or after September 11, 
2001, and are in need of personal care services are eligible 
for that program. S. 851 would expand the Family Caregiver 
program to provide those same benefits to caregivers of all 
such veterans, regardless of when they served.
    Based on information from VA on the current level of 
participation in the program, CBO estimates that under the bill 
about 70,000 additional caregivers would become eligible for 
the program. CBO further estimates that the expanded program 
would be implemented gradually, with 17,000 caregivers 
receiving stipends in 2014, growing to the full 70,000 by 2016.
    Under the Family Caregiver program, a stipend is provided 
to the veteran's primary caregiver. That stipend amount varies 
based on the amount and the degree of care needed. For the 
current program, benefits per primary caregiver total $25,000, 
on average. CBO expects that this bill would open up the 
caregiver program to an older population with greater need for 
home assistance. As a result, CBO estimates higher average 
costs of roughly $33,000 in 2014 (those costs would be adjusted 
for inflation throughout the projection period). Thus, CBO 
estimates that implementing S. 851 would cost $510 million in 
2014 and $9.5 billion over the 2014-2018 period, assuming 
appropriations of the necessary amounts.
    Pay-As-You-Go Considerations: None.
    Intergovernmental and private-sector impact: S. 851 
contains no intergovernmental or private-sector mandates as 
defined in UMRA and would not affect the budgets of state, 
local, or tribal governments.
    Estimate prepared by: Federal Costs: Ann E. Futrell; Impact 
on State, Local, and Tribal Governments: Lisa Ramirez-Branum; 
Impact on the Private Sector: Elizabeth Bass.
    Estimate approved by: Theresa Gullo, Deputy Assistant 
Director for Budget Analysis.

                      Regulatory Impact Statement

    In compliance with paragraph 11(b) of rule XXVI of the 
Standing Rules of the Senate, the Committee has made an 
evaluation of the regulatory impact that would be incurred in 
carrying out S. 851. The Committee finds that S. 851 would not 
entail any regulation of individuals or businesses or result in 
any impact on the personal privacy of any individuals and that 
the paperwork resulting from enactment would be minimal.

                 Tabulation of Votes Cast in Committee

    In compliance with paragraph 7(b) of rule XXVI of the 
Standing Rules of the Senate, the following is a tabulation of 
votes cast in person or by proxy by members of the Committee on 
Veterans' Affairs at its July 24, 2013, meeting. On that date, 
the Committee voted by voice vote to order reported S. 851, a 
bill to extend to all veterans with a serious service-connected 
injury eligibility to participate in the family caregiver 
services program.

                             Agency Report

    On September 11, 2013, Eric K. Shinseki, Secretary, U.S. 
Department of Veterans Affairs, provided views on S. 851, among 
other issues. An excerpt from the Department views is reprinted 
below:

                               Enclosure
VA Views

           *       *       *       *       *       *       *

        S. 851, CAREGIVERS EXPANSION AND IMPROVEMENT ACT OF 2013

    The Caregivers and Veterans Omnibus Health Services Act of 
2010, Public Law (P.L.) 111-163 (the Act), signed into law on 
May 5, 2010, provided expanded support and benefits for 
caregivers of eligible and covered Veterans. While the law 
authorized certain support services for caregivers of covered 
Veterans of all eras, other benefits under the Act were 
authorized only for qualified family caregivers of eligible 
Veterans who incurred or aggravated a serious injury in the 
line of duty on or after September 11, 2001. These new benefits 
for approved family caregivers, provided under the Program of 
Comprehensive Assistance for Family Caregivers, include a 
monthly stipend paid directly to designated primary family 
caregivers and medical care under CHAMPVA for designated 
primary family caregivers who are not eligible for TRICARE and 
not entitled to care or services under a health-plan contract.
    S. 851, the Caregivers Expansion and Improvement Act of 
2013, would remove ``on or after September 11, 2001'' from the 
statutory eligibility criteria for the Program of Comprehensive 
Assistance for Family Caregivers, and thereby expand 
eligibility under such program to Veterans of all eras who 
otherwise meet the applicable eligibility criteria.
    Recently, VA sent a report to the Committees on Veterans' 
Affairs of the Senate and House of Representatives (House) 
(required by Section 101(d) of the Act) on the feasibility and 
advisability of such an expansion, as would be effected by S. 
851. In that report, VA noted that expanding the Program of 
Comprehensive Assistance for Family Caregivers would allow 
equitable access to seriously injured Veterans from all eras 
(who otherwise meet the program's eligibility criteria) and 
their approved family caregivers. VA also noted that families 
across every generation have been caregivers who have 
sacrificed much for their Veteran and this Nation.
    In the report, VA noted difficulties with making reliable 
projections of the cost impact of opening the Program of 
Comprehensive Assistance for Family Caregivers to eligible 
Veterans of all eras, but estimated a range of $1.8 billion to 
$3.8 billion in FY 2014.
    VA cannot responsibly provide a position in support of 
expanding the Program of Comprehensive Assistance for Family 
Caregivers without a realistic consideration of the resources 
necessary to carry out such an expansion, including an analysis 
of the future resources that must be available to fund other 
core direct-to-Veteran health care services. This is especially 
true as VA presses to buttress mental health services and 
ensure the fullest possible access to care in rural areas. VA 
is also mindful as we look ahead to the allocations for the 
Veterans Benefits and Services functions in the Senate-passed 
and House-passed FY 2014 budget resolutions (S. Con. Res. 8 and 
H. Con. Res. 25, respectively).
    We wish to make it very clear that VA believes an expansion 
of those benefits that are limited by era of service would 
result in equitable access to the Program of Comprehensive 
Assistance for Family Caregivers for long-deserving caregivers 
of those who have sacrificed greatly for our Nation. However, 
VA cannot endorse this measure before further engaging with 
Congress on these top-line fiscal constraints, within the 
context of all of VA health care programs. VA welcomes further 
discussion of these issues with the Committee.

           *       *       *       *       *       *       *

                   MINORITY VIEWS OF RANKING MEMBER 
                           HON. RICHARD BURR

    I agree with my colleagues, in principal, on expanding the 
Comprehensive Assistance for Family Caregivers Program; 
however, this bill would cost $9.5 billion over five years and 
the Majority has not identified an offset to pay for it. I 
firmly believe that legislation we report out of the Committee 
should include offsets but, more importantly, I believe we 
should only expand programs that are fully implemented and 
follow the intent of the law creating that program. In 
addition, we need to make sure a program expansion will not 
divert resources away from the Veterans Health Administration's 
(VHA) principal duty--to provide health care to veterans.
    The Caregivers Program, crafted by this Committee with 
significant opposition from the Department of Veterans Affairs 
(VA), was intentionally limited to veterans of the most recent 
conflicts in Iraq and Afghanistan. As then-Chairman Akaka noted 
during consideration of S. 1963 in the Senate, these benefits 
and services were not made available to all veterans for three 
reasons: ``[O]ne, the needs and circumstances of the newest 
veterans in terms of the injuries are different--different--
from those of veterans from earlier eras; two, the family 
situation of the younger veterans is different from that of 
older veterans; and three, by targeting this initiative on a 
specific group of veterans, the likelihood of a successful 
undertaking is enhanced.'' I believe the most important of 
those reasons was the belief that VA would not be able to 
implement a program of this magnitude covering veterans from 
all eras. Subsequently, VA has demonstrated that they have had 
trouble implementing even the limited program. Their rollout 
and management of the program has been flawed in several areas.
    On May 5, 2011, VA published in the Federal Register an 
Interim Final Rule for the Caregivers Program with comments due 
to VA by July 5, 2011. However, more than two years after the 
comment period has closed, VA has yet to publish a Final Rule 
or formally address the comments received. Since the start of 
the program two years ago, several problems have been brought 
to my attention. Some examples of these problems are: decisions 
determining eligibility for the program are inconsistent across 
the country; VA has no quality assurance program to monitor the 
quality, consistency, and timeliness of those decisions; and 
there is no formal process to appeal the decisions of 
eligibility for caregiver assistance.
    Our responsibility to the taxpayer is to ensure the laws 
enacted are implemented correctly, are working as Congress 
envisioned, and will not divert resources away from VA's core 
mission. As VA states in the Expansion of Family Caregivers 
Assistance Program Report, submitted to Congress in 
September 2013:

        VA cannot responsibly advise the Congress on expansion 
        of the Program of Comprehensive Assistance for Family 
        Caregivers without a realistic consideration of the 
        resources necessary to carry out that expansion, a 
        forward-looking analysis of resources that must be 
        available to fund core, direct-to-Veteran health care 
        services, and the ability to provide Veterans with 
        adequate access to those services.

    The report also points out:

        [E]ven using the lower of the range of projections for 
        the cost of expansion discussed above, VA believes that 
        under either the House-passed or Senate-passed budget 
        framework, expansion of the Program of Comprehensive 
        Assistance for Family Caregivers poses the risk of 
        compromising resources needed for its core Veteran 
        health care mission.

    Before spending $9.5 billion to expand this program to 
veterans of all eras, we need to ensure that VA is fulfilling 
the intent of Congress in how they are administering the 
current Caregivers Program. Expanding a flawed program now will 
not only exacerbate the problems currently facing the program, 
but could also draw financial resources away from other VHA 
programs.

                        Changes in Existing Law

    In compliance with paragraph 12 of Rule XXVI of the 
Standing Rules of the Senate, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, existing law in which no change is 
proposed is shown in roman).

Title 38. Veterans' Benefits

           *       *       *       *       *       *       *

Part II. General Benefits

           *       *       *       *       *       *       *

Chapter 17. Hospital, Nursing Home, Domiciliary, and Medical Care

           *       *       *       *       *       *       *

Subchapter II. Hospital, Nursing Home, or Domiciliary Care and Medical 
Treatment

           *       *       *       *       *       *       *

SEC. 1720G. ASSISTANCE AND SUPPORT SERVICES FOR CAREGIVERS.

    (a) Program of comprehensive assistance for family 
caregivers.
          (1)(A) The Secretary shall establish a program of 
        comprehensive assistance for family caregivers of 
        eligible veterans.
          (B) The Secretary shall only provide support under 
        the program required by subparagraph (A) 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.
          (2) For purposes of this subsection, 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

           *       *       *       *       *       *       *

                                  

```