VA Enhanced Monthly Benefits: Recipient Population Is Changing, and Awareness Could Be Improved
Published: 2011-12-14T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Department of Veterans Affairs (VA) offers Aid and Attendance (A&A) benefits to individuals who need regular assistance and the attendance of another person or Housebound benefits to individuals who are substantially confined to their homes. These benefits, which increase recipients monthly disability compensation or pension payments, are called enhanced compensation or enhanced pension, respectivelycollectively referred to as enhanced monthly benefits. This report describes (1) characteristics of enhanced monthly benefit recipients; (2) how the benefits help veterans obtain needed services, and the associated difficulties they face in obtaining these services; and (3) VAs efforts to educate veterans and their family members about the availability of the benefits. GAOs work included analyzing VA case-level demographic data from fiscal years 2000 to 2010 on enhanced monthly benefit recipients, conducting facilitated focus groups with veterans and their family representatives, and interviewing VA headquarters and regional officials on VAs outreach efforts for enhanced monthly benefits, as well as reviewing relevant federal laws and regulations.
section_title: What GAO Found
paragraphs: According to VA data during fiscal years 2000 to 2010, most enhanced monthly benefit recipients were veterans, over age 65, and receiving the A&A enhancement as part of their pension benefit. The recipient population is changing, however. In particular, the percentage of enhanced monthly benefit recipients age 65 or younger increased from 18 percent to 24 percent over the decade. Also, the percentage of recipients paid benefits under the disability compensation program increased from 15 percent to 26 percent. The cost of enhanced monthly benefits has increased from $124 million in fiscal year 2000 to $409 million in fiscal year 2010; however, VA does not know what portion of these costs was paid specifically for A&A and Housebound benefits. VA maintains data on enhanced monthly benefit recipients total payments but does not separately identify the amount awarded as an A&A or Housebound benefit. VA officials stated that under its current system, separately tracking the costs of these benefits would be complicated and difficult.
Enhanced monthly benefits helped veterans obtain services to perform everyday living activities in different ways, but high service costs and limited service availability in some areas can make it difficult to acquire the services. Benefit recipients GAO spoke with said that they used their benefits to pay for in-home services by private providers, offset lost income from family members who provided care for them, or defray the costs of an assisted living facility. However, obtaining services from private providers can still pose difficulties for some recipients because of the generally higher cost of services in large urban areas or the limited availability of services in rural areas.
VA conducts a number of outreach activities to educate veterans and their family members about available benefits; however, a large number of elderly veterans may not be aware of their potential eligibility for enhanced monthly benefits. A VA study found that of pension recipientswho are mainly elderly veterans62 percent might be eligible for enhanced monthly benefits but only 22 percent received them, which the study primarily attributed to lack of awareness about the benefits. VAs outreach efforts may not be sufficient to inform elderly veterans about enhanced monthly benefits because outreach activities do not typically focus on these benefits, some printed material lacks information on eligibility and application requirements for these benefits, and the extent to which regional offices conduct elderly outreach varies, among other reasons.
section_title: What GAO Recommends
paragraphs: GAO recommends that VA conduct more focused outreach to better educate potential recipients about enhanced monthly benefits. VA agreed with the recommendation and described a number of actions it would take or explore to address it, such as including more detailed information in its printed material on enhanced monthly benefits.

section_title: Letter
paragraphs: Every day, thousands of veterans and their family members who are  disabled from illnesses, injuries, or aging must rely on others to help them  perform basic functions of everyday life such as bathing, feeding, and  dressing themselves or to assist them with other needs such as  transportation. As an enhancement of basic disability compensation and  pension benefits, the Department of Veterans Affairs (VA) offers Aid and  Attendance (A&A) and Housebound benefits, which help these individuals  obtain needed services. A&A benefits are paid to severely disabled  individuals who require regular aid and attendance of another person.  Housebound benefits, which are generally smaller than A&A benefits, are  paid to disabled individuals who are substantially confined to their homes.  Depending on whether the veteran is receiving disability compensation or  pension benefits, the combined payment is called an enhanced disability  compensation or enhanced pension, which we collectively refer to as  enhanced monthly benefits. Provided as a single monthly payment in  combination with the disability compensation or pension benefit,  enhanced monthly benefits can help defray the cost of obtaining needed  daily living support services. Enhanced monthly benefits are  administered by VA’s Veterans Benefits Administration (VBA). Recipients  of these benefits have generally been among the oldest and most  severely disabled veterans. Although enhanced monthly benefits have  existed for decades, there are questions about whether those who may  be eligible for and need the benefits are aware of them.
As requested, this report examines (1) characteristics of enhanced  monthly benefit recipients; (2) how the benefits help veterans obtain  needed services, and the associated difficulties they face obtaining these  services; and (3) VA’s efforts to educate veterans and their family  members about the availability of the benefits. To conduct our work, we  analyzed VA data from fiscal years 2000 to 2010 on the characteristics of  recipients of enhanced monthly benefits, such as age and disabling  conditions. We also conducted focus group discussions with veterans and  their family representatives to obtain their views on how enhanced  monthly benefits helped them obtain needed assistance. We conducted  phone interviews with veterans or their family representatives who could  not attend a focus group discussion. We held focus group discussions in  San Antonio, Texas; St. Petersburg, Florida; and Norfolk, Virginia. We  selected these locations because they had high concentrations of  veterans who were receiving enhanced monthly benefits. We randomly  selected 33 focus group participants based on VA data on veterans  receiving these benefits during fiscal year 2009. We also gathered data  from MetLife and Genworth on the cost of providing services to assist  individuals with disabilities. We interviewed officials from VA’s Veterans  Health Administration (VHA) about other benefits and services VA  provides to help veterans perform everyday activities. In addition, we  reviewed relevant federal laws and regulations, as well as prior GAO and  other reports that addressed outreach efforts and best practices. We  interviewed veterans and their family members regarding their  experiences in learning about and applying for enhanced monthly  benefits, the effectiveness of VA’s outreach efforts, and possible  improvements to such efforts. We also interviewed VA officials in 10 VBA  regional offices to discuss their outreach activities. These offices were  selected based on several factors, including their size and geographic  location. In addition, we gathered data from VBA on elderly outreach  activities by regional offices during fiscal year 2010.
We conducted this performance audit from December 2009 through  December 2011 in accordance with generally accepted government  auditing standards. These standards require that we plan and perform the  audit to obtain sufficient, appropriate evidence to provide a reasonable  basis for our findings and conclusions based on our audit objectives. We  believe that the evidence obtained provides a reasonable basis for our  findings and conclusions based on our audit objectives. Additional  information on our scope and methodology is provided in appendix I.
subsections: section_title: Background
paragraphs: Various disabilities prevent many veterans from independently performing  everyday living activities (see fig. 1).
VA offers enhanced monthly benefits that help such individuals obtain  needed services. These services can be provided at home, in an assisted  living facility, or a nursing home and can be provided by private providers,  family and friends, and VHA. VA is required to ensure that potential  recipients are informed about available benefits and to the maximum  extent possible are offered assistance applying for them. VBA  administers enhanced monthly benefits as well as other monetary and  nonmonetary benefits, and conducts outreach through its 57 regional  offices and Benefits Assistance Service and other VA offices.
Veterans may be eligible for A&A benefits if they establish a factual need for A&A, when considering many factors,  including an ability to perform everyday personal functions such as  bathing, dressing, eating, adjusting prosthetic devices, and protecting  themselves from hazards or dangers in their daily environment; are a patient in a nursing home; are bedridden; or are blind or nearly blind.
Veterans may be eligible for Housebound benefits if they have a disability rated at 100 percent and, as a result, are permanently or  substantially confined to their homes, or a disability rated at 100 percent, and at least one other disability rated  at 60 percent or more—although these individuals are legally  classified as Housebound, they may be able to leave their homes.
A&A and Housebound benefits both offer assistance that helps veterans  function more independently, but A&A benefits are only for those who are  in need of regular aid and attendance of another person, whereas  Housebound benefits are for those who may be substantially confined to  their homes. In addition to individual requirements specific to A&A and  Housebound benefits, individuals have to meet the eligibility requirements  for basic disability compensation or pension benefits.
subsections: section_title: Enhanced Disability Compensation
paragraphs: When A&A or Housebound benefits are received as part of disability  compensation benefits, the combined payment is called enhanced  disability compensation. To qualify for disability compensation benefits,  veterans must have disabling injuries or illnesses that occurred or were  made worse by their active military service. Such veterans must also  have received a discharge or release under conditions other than  dishonorable. Per VA’s policy manual, VA is supposed to automatically  consider the need for the A&A or Housebound benefit when awarding  veterans a disability rating of 100 percent and may grant the benefit when  there is sufficient medical evidence to support the individual’s need for aid  and attendance.
The total monthly enhanced disability compensation benefit amount for  A&A varies based on the veteran’s level of disability and family  composition, whereas the amount of the Housebound benefit varies  based only on the veteran’s family composition. For example, depending  upon a veteran’s level of disability, the total monthly enhanced disability  compensation payment for a single veteran receiving A&A benefits can  range from approximately $3,300 to approximately $7,700 while the  monthly payment for a veteran with a spouse and one child can range  from approximately $3,600 to approximately $7,900. In contrast, the total  monthly payment with Housebound benefits is approximately $3,000 for a  single veteran and approximately $3,300 for a veteran with a spouse and  child. For veterans receiving either A&A or Housebound benefits, the  monthly amount is increased by $136 if the spouse requires A&A, by $75  for each child in excess of one, and by $240 for each school child over  the age of 18.
section_title: Enhanced Pension
paragraphs: When veterans receive A&A or Housebound benefits as part of a VA  pension, the combined payment is called an enhanced pension. Veterans  who served during a period of war and meet other service requirements  may receive a VA pension if they are 65 or older, or at any age if they  have disabilities unrelated to their military service that render them  permanently and totally disabled, among other requirements.
Because  VA pension benefits are offered to help veterans or their surviving  spouses of limited means, potential recipients must not exceed certain  income and asset thresholds. Table 1 shows the differences in the  maximum annual pension benefit limits for 2010 based on family  composition for a VA pension recipient without enhanced benefits, with  the A&A benefit, and with the Housebound benefit.
Veterans may have other sources of income, such as Social Security  disability and retirement benefits, Medicaid, and private insurance, some  of which may be counted in determining whether a veteran meets income  eligibility requirements for a pension. For example, Social Security  retirement benefits are counted as part of a veteran’s income, whereas  public assistance benefits such as Social Security’s Supplemental  Security Income is not. In addition to income, VA considers the net worth  of individuals, excluding the value of the person’s home and vehicle. The  standard that VA uses to determine eligibility for these benefits is whether  the individuals’ resources are sufficient to meet their basic needs without  assistance from VA. While there is no specified limit on the amount of  resources individuals may have, if they have assets of $80,000 or more,  per VA’s policy manual, VA is supposed to conduct an assessment to  determine if their assets are sufficient to meet their basic needs. Assets  counted toward the “sufficient means” figure of $80,000 include bank  accounts, certificates of deposit, money market accounts, investment  accounts, annuities, retirement accounts, and life insurance cash  surrender values. To assess ongoing eligibility and benefit levels, VA  requires pensioners who have income other than Social Security to file an  annual income report.
subsections: section_title: Other Available Benefits and Services
paragraphs: In addition to enhanced monthly benefits, VA provides other benefits to  help veterans perform daily living activities. For example, VBA provides  benefits to help veterans purchase or convert an automobile to  accommodate their disability. VHA offers other services, including the  Home-Based Primary Care program, adult medical foster care, and adult  day health care.
section_title: Enhanced Monthly Benefit Population Is Changing and Costs Are Growing
paragraphs: VA data at the end of fiscal year 2010 showed that for the overall enhanced  monthly benefit population (including veterans and survivors), most  recipients were veterans, over age 65, receiving the benefit as part of their  monthly pension benefit, and receiving the A&A supplement, but the  composition and characteristics of the recipient population is changing (see  fig. 2). According to VA’s data, more than 271,000 veterans and survivors  received enhanced monthly benefits at the end of fiscal year 2010—a 52  percent increase since the end of fiscal year 2000. While veterans over age  65 comprised the majority of the overall enhanced monthly benefit  population from fiscal years 2000 to 2010, there was an increased share of  survivors, recipients age 65 or younger, those receiving the benefits under  the disability compensation program, and those receiving the Housebound  benefit enhancement. These changes were primarily driven by veterans  age 65 or younger receiving these benefits—particularly those ages 46 to  65—-as well as younger veterans receiving enhanced compensation  benefits that included the Housebound enhancement.
Changes in the characteristics of the overall population of veterans and  survivors who received enhanced monthly benefits were also mirrored in  the population of veteran recipients. For example, the data showed that  younger veterans are an increasing share of the veteran enhanced monthly  benefit population. Although veterans over age 65 continued to comprise  the majority of enhanced monthly benefit recipients at the end of fiscal year  2010, their share of the veteran enhanced monthly benefit population has  decreased steadily. Specifically, at the end of fiscal year 2010, veterans  over age 65 who received enhanced monthly benefits accounted for a 64  percent share of all veterans receiving these benefits compared with a 76  percent share in fiscal year 2000. Meanwhile the share of veteran  enhanced monthly benefit recipients age 65 or younger increased from 24  percent to 36 percent over this time period (see fig. 3). While this increase  was primarily driven by veterans ages 46 to 65, there was also a  substantial increase in the percentage of veterans ages 18 to 45.
Also for veterans who received enhanced monthly benefits, VA data  showed that most received enhanced pension benefits that included the  A&A benefit. This was particularly true for veteran recipients over age 65,  although their share of these benefits declined from 62 percent in fiscal  year 2000 to 50 percent in fiscal year 2010. For veterans age 65 and  under receiving enhanced pension benefits with the A&A benefit, their  share remained about the same—14 percent in fiscal year 2000  compared with 13 percent in fiscal year 2010 (see fig. 4). By the end of  fiscal year 2010, the percentage of veteran recipients age 65 or younger  who received enhanced disability compensation benefits that included the  Housebound benefit almost tripled from 6 percent in fiscal year 2000 to  17 percent in fiscal year 2010.
VA’s data also showed that most veterans receiving enhanced monthly  benefits served during earlier war periods, but the number of recipients  from more recent war periods is growing. The majority of recipients  served during World War II, the Korean Conflict, and the Vietnam War  (see fig. 5). Although Persian Gulf War (Gulf War) veterans comprised a  relatively small proportion of veteran recipients, their numbers increased  at a greater rate during fiscal years 2000 to 2010 (from less than 1,300 to  nearly 11,000—more than a sevenfold increase) than veterans from any  other period of service. Appendix II provides more information on the  periods of service that qualify veterans for enhanced monthly pension  benefits.
In addition to analyzing the overall characteristics of veterans who  received enhanced monthly benefits, we specifically analyzed the  disabling conditions of Gulf War veterans. Consistently, the most  common categories of disabling conditions during that time period were  skeletal conditions, neurological conditions and convulsive disorders, and  mental and eating disorders. However, there were significant changes  among other disabling conditions and categories of disabling conditions.  For example, ear conditions increased from ninth most common in 2000  to fourth most common in fiscal year 2010, while cardiovascular  conditions went from sixth most common in fiscal year 2000 to eighth  most common in fiscal year 2010. In addition, the proportion of Gulf War  veteran enhanced monthly benefit recipients reporting diagnoses of Post  Traumatic Stress Disorder grew dramatically from 8 percent at the end of  fiscal year 2000 to 28 percent at the end of fiscal year 2010. Additionally,  7 percent of veteran enhanced monthly benefit recipients from the Gulf  War reported diagnoses of traumatic brain injuries at the end of fiscal  year 2010.
Similar to the veteran population who received enhanced monthly  benefits, the characteristics of survivors who received these benefits have  also changed between the end of fiscal years 2000 and 2010. Over this  period, most survivor recipients of enhanced monthly benefits were over  age 65, and there was a slight decrease—from 6 percent to 3 percent—in  the share of survivors age 65 or younger. Survivors primarily received  enhanced pension benefits, and the share of such recipients increased  from 77 percent in fiscal year 2000 to 84 percent in fiscal year 2010. Also,  the percentage of survivor recipients of enhanced monthly benefits that  included A&A benefits increased from 91 percent to 96 percent from fiscal  years 2000 to 2010. Figure 6 shows the characteristics of survivor  recipients at the end of each fiscal year from 2000 to 2010.
For fiscal years 2000 to 2010, the total VA paid for enhanced benefits  increased from approximately $124 million to $409 million; however, VA  does not know the portion of enhanced benefit costs paid specifically for  A&A and Housebound benefits. VA stated that it does not separately  compile and monitor costs specifically attributable to A&A and  Housebound benefits because they are not “stand-alone” benefits. The  agency also stated that it would be complicated and difficult to track these  costs separately in the agency’s current system and that it would take a  considerable amount of resources to determine the costs and benefits of  tracking this type of data.
section_title: Enhanced Monthly Benefits Help Veterans Obtain Needed Services, but High Service Costs and Limited Availability of Services in Some Locations Can Pose Difficulties
paragraphs: Veterans and family members who participated in our focus groups and  one-on-one interviews said that enhanced monthly benefits help them  obtain needed assistance in different ways. For example, these benefits  helped them pay for in-home services by private providers, offset lost  income of family members who provide care, or defray the costs of an  assisted living facility. One veteran told us that enhanced monthly  benefits help him afford the home-based care that enables him and his  wife to remain in their home. Another veteran told us that these benefits  help replace some of the family income that was lost when his wife retired  early from her job to care for him, rather than having him stay in a nursing  home. Among the veterans we contacted, the activities they most  frequently reported needing help with were bathing, dressing, and  toileting (see fig. 7).
In addition, 12 of the veterans we contacted said that enhanced monthly  benefits also help them obtain other services, including transportation,  doing laundry, preparing meals, and managing medications.
The veterans we spoke with also used their enhanced monthly benefits to  obtain services from one or more of three sources—private providers,  family members or friends, and VHA. They obtained services from each  of these sources with similar frequency (see fig. 8).
About half of the veterans we spoke with (16 of 33) obtained home-based  services from VHA. VHA offers various home-care services, including its  Home-Based Primary Care Program, adult day health care, and adult  medical foster care. The Home-Based Primary Care Program provides  services such as rehabilitation and coordination of care to veterans who  need assistance with daily living activities, among other health-care  needs. One veteran we contacted said that the Home-Based Primary  Care Program provided all needed services to help him meet his in-home  health care needs. However, as we have noted in prior work, these  services were not available in certain areas—especially rural locations,  where approximately 40 percent of the veteran population enrolled in the  VA health care system lives, according to VA. These gaps could make it  difficult for some veterans to access VHA home-based care. VHA officials  said that as of July 2010, there were still a limited number of home-based  care service providers to contract with in some rural areas. However,  according to VHA officials, one step the agency has taken to address this  problem is to collaborate with local area agencies on aging to help  arrange for needed services. Also, VA is planning to expand its Home- Based Primary Care Program, which currently operates in 15 VA medical  centers.
Some veterans may need to purchase services from private providers to  assist them in performing daily living activities, which could make it  difficult for veterans living in higher-cost regions of the country to obtain  services. Private providers may offer a variety of services, such as  housekeeping provided by home care aides and administration of oral  medication by home health aides. The cost of these services varies  among and within states. Nationally, our analysis of MetLife and  Genworth data showed that the hourly cost for obtaining services from  home care aides ranges from $9 to $38, and the national median hourly   Generally, service costs are lowest in Southern states.  cost is $18.25. The median hourly cost of obtaining services from home health aides was  less than the national median for all but one Southern state. Figure 9  shows regional and state differences in service costs. The cost of care  also varies within states. For example, the median hourly cost of  obtaining services from a home care aide in California ranges from  $18.86 in Los Angeles to $24.38 in San Francisco, or about a 29 percent  cost difference. Also, services are less available in some rural areas,  which can limit recipients’ ability to obtain them. In addition, according to  a study by the National Association for Home Care and Hospice,  providers nationwide are finding it difficult to hire and retain a sufficient  number of home health aides and home care aides to provide assistance  to individuals needing them.
Family members and friends are also called upon to help veterans  perform daily activities but can face difficulties in doing so. About half of  the veterans we contacted (17 of 33) relied on family members or friends  to help them, and in some cases these individuals were their sole source  of care. For example, the spouse of one veteran said that she had to  attend to him 24 hours a day—including bathing and dressing him, and  taking him to dialysis treatment—which prevented her from getting a job.  An August 2009 study of veterans who received assistance from family  caregivers found that persons with disabilities who had more restrictions  in performing daily living activities and more health care needs were less  likely than people with fewer restrictions to obtain home-based care,  placing additional stress on their caregivers. According to a November  2010 study, some of the major difficulties family members and others face  in providing caregiver support for veterans include a lack of knowledge  about the veterans’ medical condition as well as a lack of skills to help  caregivers perform various activities. Some of the caregivers we  contacted said they were unable to provide all of the assistance needed  to perform everyday living activities. For example, one veteran relied on  his spouse for assistance, but she was not always able to perform certain  tasks. The veteran relies on a device to lift him, but when he falls, he told  us that his spouse has to call the fire department to lift him.
Last year, Congress passed the Caregivers and Veterans Omnibus  Health Services Act of 2010 in part to provide assistance to family  caregivers of veterans. The legislation directs VA to provide specified  benefits and services to the caregivers of certain Post 9/11 veterans who  have serious service-connected injuries and are in need of personal care  services. As required by the new legislation, VA developed an  implementation plan to guide its provision of benefits and services to  caregivers of eligible veterans. Additionally, VA has begun to offer  additional caregiver services to the families of seriously injured Post 9/11  veterans, such as monthly stipends, training, medical-related travel cost  reimbursements, and respite care. The legislation also requires VA to  report to Congress on the feasibility of expanding the family caregiver  benefits to veterans whose injuries were incurred before 9/11.
section_title: Many Elderly Veterans May Be Unaware of Enhanced Monthly Benefits Despite VA’s Outreach Efforts
subsections: section_title: Many Elderly Veterans Reportedly Lack Awareness of Enhanced Monthly Benefits
paragraphs: VA’s data for fiscal years 2000 to 2010 indicate that elderly veterans and  their surviving family members are the primary recipients of enhanced  monthly benefits, although many other potentially eligible elderly veterans  likely are unaware of these benefits. VA has previously acknowledged  that enhanced pensions, whose primary recipients are elderly veterans,  are underused and that not all potential recipients are aware of these  benefits. Also, a 2004 VA study found that while 62 percent of pension  recipients might be eligible for these benefits, only about 22 percent  received them.925,000 veterans and between 940,000 and 1.38 million surviving family  members would be eligible for, but would not be receiving, VA pension  benefits. A portion of these veterans and surviving family members were  expected to also qualify for enhanced monthly benefits. The study found,  however, that the lack of awareness about the VA pension is the primary  reason eligible veterans and their surviving family members may not be  applying for enhanced monthly benefits. Some VA officials and Veterans  Service Organizations (VSO) representatives we spoke with also said that   This study estimated that, in 2010, between 565,000 and  many elderly veterans are unaware of VA benefits for which they may be  eligible, including enhanced monthly benefits. According to one VA  official, this lack of awareness exists because many elderly veterans were  never informed about VA benefits after they left the service.
If elderly veterans do not learn about enhanced monthly benefits from VA  or other reliable sources such as VSOs, there is a risk they will be  misinformed or become victims of predatory financial practices. According  to some VA officials, as well as representatives from an elderly advocacy  organization, VSOs, state and local government officials, and elder law  attorneys we spoke with, some elderly veterans learn about enhanced  monthly benefits from financial planners and attorneys who may charge  for services that VA and VSOs provide for free. These officials said that  some attorneys and financial planners may convince elderly veterans,  who ordinarily would be ineligible for a VA pension because of excess  assets, to reduce these assets by transferring them into annuities or  irrevocable trusts. We also observed websites where organizations  market asset transfer services to help elderly veterans qualify for VA  pension and enhanced monthly benefits. Representatives from an elderly  advocacy organization noted that financial planners may be charging  significant fees for each senior citizen they assist in transferring assets to  qualify for a VA pension. Once established, these investments could  severely limit veterans’ access to their assets or prevent them from  obtaining Medicaid benefits in the future. For example, one elder law  attorney told us that some elderly veterans may need nursing home care,  but transferring assets to qualify for VA pension benefits may cause them  to be ineligible for Medicaid benefits that would pay for this care.
section_title: VA’s Outreach Approach May Not Be Sufficient to Inform Elderly Veterans about Enhanced Monthly Benefits
paragraphs: VA provides outreach to both the general veteran population and to  specific veteran population groups identified as warranting additional  attention, such as seriously disabled (Post 9/11), homeless, and elderly  veterans. VA’s general outreach activities tend to focus on benefits such  as health care, disability compensation, education, and home loans.  However, certain benefits like enhanced monthly benefits are more likely  to be highlighted during outreach activities for specific veteran population  groups based on their potential eligibility. For example, VA officials told us  that there is an increased emphasis on enhanced monthly benefits during  outreach to seriously disabled Post 9/11 veterans, as well as elderly  veterans, who comprise major segments of the eligible population for  these benefits.
VA provides personalized outreach to seriously injured Post 9/11  veterans, which gives them several opportunities to learn about enhanced  monthly benefits. For example, VA assigns staff to military treatment  facilities to provide these veterans with tailored benefits information and  to initiate the claims process. Also, these veterans are assigned a case  manager and have access to VHA social workers who may inform them  about enhanced monthly benefits and help them apply for these benefits.  In addition, for the disability compensation program, VA requests  information on disabling conditions of all applicants. Under VA’s policy  manual, the agency is to use this information to consider eligibility for  enhanced monthly benefits for veterans with a disability rating of 100  percent, and, seriously injured Post-9/11 veterans may qualify for these  benefits as part of their disability compensation.
VA’s outreach to elderly veterans provides them with fewer opportunities  to learn about enhanced monthly benefits. VA conducts outreach  activities in locations where the elderly reside or congregate, such as  assisted living facilities and senior centers, and at events sponsored by or  in collaboration with organizations that serve the elderly. However, some  elderly veterans who may qualify for enhanced monthly benefits may  have disabilities that prevent them from attending such events or do not  interact with the organizations that VA collaborates with. According to VA  officials, the agency does not have outreach designed to specifically  target elderly veterans who may be confined to their home. In contrast to  the compensation program, for pension applicants age 65 and older, VA  only requests information on disabling conditions of those applicants who  indicate they are housebound or in need of regular assistance of another  person to consider eligibility for enhanced monthly benefits. Therefore,  VA would not have information needed to consider eligibility for enhanced  monthly benefits for all pension applicants.
VA has collaborated on elderly outreach with national organizations that  serve the elderly. For example, at the national level, VA has partnered with  the Assisted Living Federation of America to develop informational material  on enhanced monthly benefits and has staffed benefits booths during  conferences held by this and other organizations that serve the elderly.  Agency officials told us that such efforts may increase in the future as VBA  identifies more organizations to partner with for outreach initiatives. VBA  has also participated in an advisory group of the Center for Benefits  Outreach and Enrollment to identify best practices for elderly outreach.
VA also provides informational material on its benefits, but the content  may not provide enough details about eligibility and application  requirements for enhanced monthly benefits. For example, VA’s 2011  benefits handbook informs readers that enhanced monthly benefits are  available, although it does not elaborate on the specific limitations with  everyday living activities or transportation that a veteran must have in  order to be eligible for these benefits. VA benefits pamphlets, a handout  on pension benefits, as well as presentations used during outreach  activities that we assessed also lacked such information. Additionally,  enhanced monthly benefits are mentioned in the attachments VA includes  with award letters sent to veterans when they are granted pension  benefits. However, they do not discuss eligibility requirements. Also, the  eligibility verification form that some pension recipients annually complete  does not include information about enhanced monthly benefits, although  some pension recipients may qualify for these benefits, but are not  receiving them.
In addition to printed material, VA provides online information about  enhanced monthly benefits, but this information may be difficult to find.  For example, the home page on VA’s website does not provide direct  links to access information on these benefits, which could make it difficult  for users to locate information about them. The home page does contain  a link for the pension program that provides information on eligibility and  application requirements for A&A and Housebound benefits; however,  because it is not apparent that this link would provide such information,  users may not be inclined to follow it. Also, VA and the Department of  Defense recently developed the eBenefits web portal to provide veterans  with customized information on, and how to apply for, VA benefits and  assistance, but it does not include a direct link to information on  enhanced monthly benefits. A few of our focus group participants  commented that they had difficulty finding information about enhanced  monthly benefits on VA’s website. Website guidelines recommend that  navigation procedures to access online information be simple and that  links be properly labeled to help users obtain desired results.
Finally, VA provides information on enhanced monthly benefits through its  nine call centers, including a call center that exclusively responds to  inquiries related to the VA pension. These centers handle inquiries from  the 800 number that VA directs veterans to call for information about  benefits. In response to a VA Office of Inspector General study that found  that veterans had difficulty getting through to call agents and obtaining  correct information, VBA implemented a new call routing system in March  2011 to improve callers’ access to call agents, and is working to develop  national performance standards for call agents to improve the quality of  services provided.
section_title: VA Guidance to VBA Regional Offices on Elderly Outreach Is Broad, and the Extent to Which Regional Offices Conduct These Activities Varies
paragraphs: Most outreach activities for VA’s benefits are conducted at the VBA  regional office level, and VBA provides broad guidance on conducting  outreach to its regional offices. In its procedures manual, VA requires  each VBA regional office to designate an elderly outreach coordinator and  provides suggestions on collaborating with agencies or organizations that  serve the elderly. However, besides these suggestions, this manual does  not define the specific duties of the coordinator or identify other types of  elderly outreach activities that should be conducted. We contacted 10 of  VBA’s 57 regional offices and of these 10 offices, only 4 collaborated with  local agencies that serve the elderly, despite suggestions in the manual to  do so. Also, the extent to which VBA regional offices coordinated and  collaborated on outreach with local VHA facilities varied among the 10  regional offices we contacted. For example, while staff in all of these  offices said that they coordinate with VHA, only six indicated that they  provide training to social workers and other VHA employees to enable  them to provide information on available VBA benefits to potential  recipients. Staff in all of the regional offices we contacted told us they  collaborate with VSOs on outreach, but the extent and nature of this  collaboration differed. The collaboration included such things as training  VSO staff on available benefits and working with VSO staff to conduct  outreach in remote areas or to provide application assistance to veterans  who are physically unable to visit the regional office. Some offices may  have worked with VSOs in one or a combination of these ways.
Similarly, the extent to which regional offices identified locations to  conduct elderly outreach also varied among the 10 regional offices we  contacted. Staff in 5 offices told us they proactively identify locations to  disseminate information on VA benefits as well as identify potential  recipients. During these elderly outreach activities, regional office staff  may have one-on-one conversations with attendees and provide  information on enhanced monthly benefits to those who indicate they  need assistance to perform everyday living activities. However, staff in  the other five offices said that they did not conduct elderly outreach  activities at all, or only did so in response to invitations from other  organizations.
Agencywide, the amount of time VBA regional offices spent conducting  elderly outreach activities varied considerably. VA’s fiscal year 2010 data  show that the total number of hours regional offices reported spending on  elderly outreach ranged from 0 to over 100. For example, 2 regional  offices reported spending over 100 hours, 12 reported less than 10 hours,  and 9 offices either reported they did not conduct any elderly outreach or  did not report this information. There may be several reasons for this wide  variance. Although staff in most regional offices we contacted said that  limited staff, funding, and other resources minimize their capacity to  conduct outreach, some offices had staff with full-time responsibilities for  outreach, including elderly outreach. In contrast, other offices conducted  outreach as part of ancillary duties or on a voluntary basis. VA is currently  prioritizing outreach to the homeless as well as Post 9/11 veterans and  staff in some offices we contacted told us they focus their outreach on  those veteran groups rather than the elderly. Also, VA has acknowledged  that the number of elderly veterans is increasing but has yet to establish  detailed plans or performance goals for its elderly outreach efforts. For  example, VA’s strategic plan for fiscal years 2011 to 2015 includes  outreach initiatives for different veteran population groups but none that  specifically target elderly veterans. In addition, for elderly outreach, VA is  currently using the total number of hours devoted annually to these types  of activities as a performance indicator, but this does not provide the  information needed to assess the outcomes and effectiveness of the  agency’s efforts. VBA officials told us the agency is in the process of  identifying appropriate performance goals and measures for all of its  outreach efforts.
VA’s broad guidance posed some challenges for regional offices in  conducting elderly outreach, and VA has begun to take steps to address  this issue. For example, staff in one office said they conducted minimal  elderly outreach, in part, due to a lack of guidance from VA’s central  office, while staff in another office told us that more specific guidelines on  conducting elderly outreach are needed. Recently, VA has taken some  steps to enhance guidance to regional offices. For example, in May 2010,  VA’s central office reinstituted bimonthly conference calls with regional  elderly outreach coordinators to facilitate information sharing among  participants. Also, VA’s central office requires regional offices to submit  weekly reports on their outreach activities through a web-based reporting  tool. The reports include information on the type of outreach activity  conducted, the number of hours devoted to each targeted veteran  population group, and the number of attendees at an outreach event.  According to VBA officials, the reporting tool is currently being enhanced  to enable VA’s central office to conduct a more in-depth analysis of the  information reported, which may in turn allow for more tailored guidance  to each regional office.
Many of the staff at regional offices and the veterans we spoke with  provided suggestions on how VA might increase awareness about  enhanced monthly benefits. Staff at several VBA regional offices  suggested VA increase awareness by using local or national media to  disseminate information targeted to elderly veterans. Suggestions by  veterans included mailing information on eligibility and application  requirements to potential recipients. Some of the veterans we spoke with  also said that VHA was their first source of information about enhanced  monthly benefits and that VHA employees should play a primary role in  providing this information.
section_title: Conclusions
paragraphs: Enhanced monthly benefits can play a critical role in helping aging and  disabled veterans obtain the services they need to perform everyday  living activities and, in many cases, allow them to stay in their homes or  other noninstitutional settings. Demand for these benefits will likely grow  as life expectancy increases and more younger service members return  home with injuries from global conflicts. Although enhanced monthly  benefits have existed for decades, many within certain populations, such  as elderly veterans, are unaware of them and are, therefore, forgoing  valuable benefits. While VA conducts a number of outreach efforts and  provides information to educate veterans and their families about  available benefits, there are opportunities for VA to improve its efforts to  ensure that potential recipients, particularly the elderly and those who are  not connected to VA’s health care system, are aware of all benefits for  which they may be eligible. Without specific performance goals and  metrics to improve outreach to elderly veterans, more detailed guidance  to better instruct regional offices on how to conduct elderly outreach, and  improved information on application and eligibility requirements for  enhanced monthly benefits that is easy to access, many elderly veterans  and their family members may fail to receive assistance that could  improve their quality of life. It will be important for VA to address these  issues to ensure that veterans are aware of all available benefits for  which they may qualify. Taking steps to better inform elderly veterans  about enhanced monthly benefits will not only ensure that they receive  benefits that could help them obtain needed services to perform daily  living activities, but also ensure that younger veterans are aware of the  benefits as they age and possibly develop a need to access these  benefits.
section_title: Recommendation for Executive Action
paragraphs: To enable VA to improve its efforts to educate veterans and their family  members about enhanced monthly benefits, we recommend that the  Secretary of VA direct the Undersecretary for Benefits to take steps to  conduct more focused outreach to potential recipients, which could entail  the following:  Improving communication of and accessibility to information about  enhanced monthly benefits. Such efforts could include (1) providing  more information in the VA benefits handbook and other informational  material on VA benefits, (2) increasing the visibility of links on VA’s  website to information about these benefits, and (3) using local or  national broadcast and print media to disseminate information about  these benefits.
Continuing efforts to establish specific performance goals and metrics  for increasing outreach to elderly veterans.
Providing more detailed guidance to regional offices on how elderly  outreach should be conducted and on the specific duties of outreach  coordinators.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to VA for review and comment. In its  written comments (see app. III), VA concurred with our recommendation  and provided information on a number of actions the agency planned to  take or explore to address it.
For example, VA stated that it would include more detailed language  about enhanced monthly benefits in its 2012 Federal Benefits for  Veterans, Dependents and Survivors handbook as well as post  information about these benefits on VA’s website, the joint  VA/Department of Defense eBenefits portal, and VA social media  directories such as Facebook and Twitter.
VA also stated that it would explore the feasibility of targeted direct  mailings to veteran and survivor pension recipients to inform them of the  eligibility requirements for enhanced benefits and the application process.  As part of its efforts to establish specific performance goals and metrics,  VA stated that it plans to analyze available data related to its current  outreach efforts to clarify expectations and address measures and  standards of outreach to elderly veterans and survivors. Additionally, VA  stated that VBA would provide guidance to regional offices on how to  conduct elderly outreach through such means as regular conference calls  and national awareness training for outreach coordinators.
As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to relevant congressional  committees, the Department of Veterans Affairs, and other interested  parties. In addition, the report will be available at no charge on the GAO  website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7215 or bertonid@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix IV.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: The objectives of our review were to determine (1) characteristics of  enhanced monthly benefit recipients, (2) how enhanced monthly benefits  help veterans obtain needed services, and the associated difficulties they  face in obtaining these services, and (3) the Department of Veterans  Affairs’ (VA) efforts in educating veterans and their family members about  the availability of the benefits.
For our first objective, we obtained and analyzed case-level demographic  data about individuals who received enhanced monthly benefits at the  end of each fiscal year from 2000 to 2010, or whose benefits had been  terminated. The data included recipients’ age, disabling conditions, period  of service, state of residence, type of benefit received, and where  applicable, the reason for termination of benefits. We also obtained  information on the total enhanced monthly benefit payment. These data  were retrieved from VA’s Benefits Delivery Network and Veterans  Services Network. Data obtained included any veterans and qualified  surviving spouses or parents who received Aid & Attendance (A&A) or  Housebound benefits as an enhancement to monthly compensation or  pension benefits during this time period. Since these data are not  publicly available, VA compiled data extracts for our use. We reviewed  relevant federal laws and regulations. We also reviewed VA policies and  other documents, and interviewed officials in the VA’s Veterans Benefits  Administration (VBA) Compensation and Pension Services to identify  requirements for receiving enhanced monthly benefits, and how benefit  amounts are determined. In our analysis of information about periods of  service, we excluded veterans who fought in World War I or during the  Mexican Border Period because they comprised a very small number of  cases at the end of fiscal year 2000 (a total of 123, or less than 0.11  percent of all veteran recipients) and none by the end of fiscal year 2010.  Also, we removed duplicate entries in the diagnostic code fields in VA’s  data. Our assessment of the reliability of VA’s data is discussed  separately in this appendix.
For our second objective, we reviewed studies and reports by GAO and  others to obtain information on the services that recipients of enhanced  monthly benefits may need to perform everyday living activities, the  different sources of this help, and difficulties veterans may face in obtaining  these services. We also interviewed two national and two local  organizations that provide services and support to the elderly, individuals  with disabilities, and their caregivers. In addition, we analyzed information  on the cost of acquiring these services to show how costs can vary across  all 50 states and the District of Columbia. We also examined provisions of  the Caregivers and Veterans Omnibus Health Services Act of 2010 to  determine how it would help caregivers. A more detailed discussion of our  analysis of cost data is provided separately in this appendix.
For our third objective, we reviewed relevant federal laws and regulations  to identify VA’s outreach responsibilities. To evaluate outreach to  potential recipients by VA’s central office, we interviewed officials from  central office who were familiar with its efforts. We also identified VA’s  past and present outreach activities, as well as its outreach plans. In addition, we reviewed the outreach guidance that VBA central office  provides to VBA regional offices. To evaluate VBA regional office  outreach efforts targeted to potential recipients, we contacted officials  from 10 regional offices. These regional offices were judgmentally  selected to represent the different characteristics of VA’s regional offices.  In addition, we examined fiscal year 2010 data on regional office elderly  outreach activities. We assessed VA’s print and online informational  materials for clarity and the extent to which they provide complete  information on eligibility and application requirements for enhanced  monthly benefits. We also analyzed VA’s website and eBenefits portal for  ease of accessing information about eligibility and application  requirements. In addition, we reviewed studies about Internet usage  among elderly and disabled populations. To enhance our evaluation of  VA’s outreach efforts, we interviewed representatives of veterans service  organizations (VSO) to obtain their views on VA’s outreach efforts. We  also interviewed representatives of organizations that represent and  interact with elderly populations and individuals with disabilities, some of  whom have collaborated with VA on outreach. In addition, we used key  outreach best practices identified in GAO and other reports as criteria to  assess VA’s outreach efforts. The criteria included outlining of strategic goals for the campaign and determination of a  identification and researching of the target audience to understand  some of its key characteristics, such as size of population; establishment of strategic partnerships with other entities that are  stakeholders in the issue to get help with planning and implementing  the outreach campaign;  targeting of the outreach message with audience specific, culturally  sensitive content and use of media and languages that are the most  appropriate for the audience;  reinforcement of the message with repetition and different media,  especially when targeting people who may be challenging to serve;  and development and implementation of performance measures for  evaluating the effectiveness of the outreach campaign.
As part of our audit work for objectives two and three, we conducted a  series of focus groups and one-on-one interviews with veterans who  receive enhanced monthly benefits or a family member they chose to  represent their views. A detailed discussion of the methodology used to  plan, conduct, and analyze the results of these focus groups, and one-on- one interviews, is provided separately in this appendix.
We conducted this performance audit from December 2009 through  December 2011 in accordance with generally accepted government  auditing standards. Those standards require that we plan and perform the  audit to obtain sufficient, appropriate evidence to provide a reasonable  basis for our findings and conclusions based on our audit objectives. We  believe that the evidence obtained provides a reasonable basis for our  findings and conclusions based on our audit objectives.
subsections: section_title: Reliability Assessment of VA Data on Enhanced Monthly Benefit Recipients
paragraphs: To assess the reliability of these data, we (1) reviewed documentation for  data extracts, (2) conducted electronic testing for obvious errors in  accuracy and completeness, and (3) worked closely with agency officials to  identify any data problems. When we found discrepancies (such as missing  or invalid values), we brought them to VBA’s attention and worked with  agency program and data specialists to correct the discrepancies before  conducting our analyses. In some cases, we opted to limit our analysis to  avoid using unreliable information. For example, because of persistent  problems with data on terminated cases, we narrowed our scope to include  only cases that were active as of the end of each fiscal year. In addition,  because the data for fiscal years 2007 to 2010 lacked information on the  disabling conditions for a large number of veterans from earlier periods of  service, we limited our analysis of this information to veterans from the Gulf  War period. Based on our assessment and steps taken to limit our use of  problematic information, we determined the data were sufficiently reliable  for the purposes of our report.
section_title: Analysis of Information on the Cost of Obtaining Services
paragraphs: We obtained summary-level data on the cost of noninstitutional care in all  50 states and the District of Columbia from the MetLife Mature Market  Institute’s 2010 Market Survey of Long-Term Care Costs and Genworth  Financial’s 2010 Cost of Care Survey. Both studies report costs for each  type of service provider at the state level and for some localities within  each state. We limited our analysis to the three types of noninstitutional  care reported in these studies: home care aides (or homemaker  services), home health aides, and assisted living facilities. For home care  aides and home health aides, we reported hourly rates. For assisted  living facilities, we reported monthly rates.
To assess the reliability of the data reported in these studies, we  reviewed methodological documentation for both studies. We also  interviewed knowledgeable individuals from each organization who were  involved in the design and execution of the survey and analysis of the  survey data. As a result of our work, we determined that the data were  sufficiently reliable for our purposes.
To demonstrate how costs of obtaining services vary across the county,  we reported the median cost for the three types of service providers in all  50 states and the District of Columbia. While the Cost of Care Survey  reported median costs for each type of service, we calculated the median  costs using record-level data from the Market Survey of Long-Term Care  Costs. We report the midpoint between the two median costs from each  study. There was a small and methodologically immaterial difference in  data we reported about the median hourly cost of home care aides in Los  Angeles; the MetLife data represented Los Angeles and the Genworth  data represented Los Angeles County.
section_title: Focus Groups and One-on- One Interviews with Recipients of Enhanced Monthly Benefits
paragraphs: To help assess the role played by enhanced monthly benefits in helping  veterans obtain needed services and the impact of VA outreach activities,  we obtained views from veteran recipients or their designated family  representatives through a series of six focus groups we conducted in  September 2010. We conducted two focus groups in each of three  locations—San Antonio, Texas; Saint Petersburg, Florida; and Norfolk,  Virginia. These locations were selected because each provided a large  pool of veterans who likely were receiving enhanced monthly benefits as  part of their compensation or pension payments from which to draw focus  group volunteers. To obtain information from focus group participants, we  established a standard protocol to facilitate the discussions. We pretested  the protocol to identify any needed changes before conducting the focus  groups and one-on-one interviews.
We randomly selected enhanced monthly benefit recipients to participate  in our focus groups using VA fiscal year 2009 data on recipients who lived  in or around our three focus group locations. We obtained information  from 33 veterans or their designated family representatives. To increase  the number of responses from veterans or their representatives, we  conducted phone interviews with veterans who could not attend a focus  group. During these interviews, we covered the same topics discussed  during our focus groups. In addition to the focus groups and one-on-one  interviews, one veteran chose to provide written responses.
The characteristics of focus group participants varied widely. The age of  participants ranged from 39 to 96 years of age, with an average age of 73  years. Also, the veterans we contacted served in various war periods,  including World War II, the Korean Conflict, Vietnam War, and the Gulf  War. In addition, participants reported a variety of disabling conditions.  Some focus group participants received enhanced monthly benefits as  part of their pension and others as part of their compensation benefit  payment. Table 2 summarizes characteristics of veterans we contacted.
Each focus group covered several major topics, including VA outreach  activities, processes for filing a claim for enhanced monthly benefits,  services obtained as a benefit recipient, and recommendations for  improving VA outreach practices, as well as veteran experiences in  obtaining these benefits. A GAO facilitator led each discussion to keep  participants focused on the specified issues within discussion time  frames. With the consent of all focus group participants, we recorded  each discussion and had each recording professionally transcribed.focus group discussion protocol was also used to guide one-on-one  interviews. We summarized the information collected and identified  common themes. While we identified a number of common themes  across the six focus groups, our results cannot be generalized to the  universe of veterans receiving enhanced monthly benefits.
section_title: Appendix II: Qualifying Periods of War for VA’s Pension Program
paragraphs: Indian wars. January 1, 1817, through December 31, 1898. Service must  have been rendered with the United States military forces against Indian  tribes or nations.
Spanish-American War. April 21, 1898, through July 4, 1902. If veterans  served with the United States military forces engaged in hostilities in the  Moro Province, the ending date is July 15, 1903. The Philippine  Insurrection and the Boxer Rebellion are included.
Mexican border period. May 9, 1916, through April 5, 1917, in the case  of veterans who served in Mexico, on the borders thereof, or in the waters  adjacent thereto.
World War I. April 6, 1917, through November 11, 1918. If veterans served  with the United States military forces in Russia, the ending date is April 1,  1920. Service after November 11, 1918, and before July 2, 1921, is  considered World War I service if the veterans served in the active military,  naval, or air service after April 5, 1917, and before November 12, 1918.
World War II. December 7, 1941, through December 31, 1946. If the  veterans were in service on December 31, 1946, continuous service  before July 26, 1947, is considered World War II service.
Korean Conflict. June 27, 1950, through January 31, 1955.
Vietnam Era. The period beginning on February 28, 1961, and ending on  May 7, 1975, in the case of veterans who served in the Republic of  Vietnam during that period. The period beginning on August 5, 1964, and  ending on May 7, 1975, in all other cases.
Persian Gulf War. August 2, 1990, through date to be prescribed by  Presidential proclamation or law.
Future dates. The period beginning on the date of any future declaration  of war by Congress and ending on a date prescribed by Presidential  proclamation or concurrent resolution of Congress.
section_title: Appendix III: Comments from the Department of Veterans Affairs
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
paragraphs: Daniel Bertoni, (202) 512-7215 or bertonid@gao.gov.
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, individuals making key  contributions to this report were Shelia Drake, Assistant Director; James  Bennett; Melinda Cordero; Mary Crenshaw; Alex Galuten; Isabella  Johnson; Nelson Olhero; Kate Van Gelder; Walter Vance; and Mark Ward.
section_title: Related GAO Products
paragraphs: VA’s Fiduciary Program: VA Plans to Improve Program Compliance and  Policies, but Sustained Management Attention is Needed. GAO-10-635T.  Washington, D.C.: April 22, 2010.
VA’s Fiduciary Program: Improved Compliance and Policies Could Better  Safeguard Veterans’ Benefits. GAO-10-241. Washington, D.C.: February  26, 2010.
VA Health Care: Long-Term Care Strategic Planning and Budgeting Need  Improvement. GAO-09-145. Washington, D.C.: January 23, 2009.
Veterans’ Benefits: Improved Management Would Enhance VA’s Pension  Program. GAO-08-112. Washington, D.C.: February 14, 2008.
VA Long-Term Care: Service Gaps and Facility Restrictions Limit  Veterans’ Access to Noninstitutional Care. GAO-03-487. Washington,  D.C.: May 9, 2003.
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