Department of Veterans Affairs’ Potential Role in Addressing the COVID-19 Outbreak
Released: 2020-03-20T00:00:00

Introduction

The Department of Veterans Affairs (VA) provides a range of benefits and services to veterans who meet certain eligibility criteria. These benefits and services include, among other things, hospital and medical ca re; disability compensation and pensions; education; vocational rehabilitation and employment services; assistance to homeless veterans; home loan guarantees; administration of life insurance, as well as traumatic injury protection insurance for servicemembers; and death benefits that cover burial expenses.

The department carries out its programs nationwide through three administrations and the Board of Veterans' Appeals (BVA). The Veterans Health Administration (VHA) is responsible for health care services and medical and prosthetic research programs. The Veterans Benefits Administration (VBA) is responsible for, among other things, providing disability compensation, pensions, and education assistance. The National Cemetery Administration (NCA) is responsible for maintaining national veterans cemeteries; providing grants to states for establishing, expanding, or improving state veterans cemeteries; and providing headstones and markers for the graves of eligible persons, among other things.

In addition to providing health care services to veterans and certain eligible dependents, the VHA is statutorily required to serve as a contingency backup to the Department of Defense (DOD) medical system during a national security emergency and to provide support to the National Disaster Medical System and the Department of Health and Human Services (HHS) as necessary in response to national crises. The department is also required to take appropriate actions to ensure VA medical centers are prepared to protect veteran patients and staff during a public health emergency.

Novel Coronavirus (COVID-19)13

On December 31, 2019, the World Health Organization (WHO) was informed of a cluster of pneumonia cases in Wuhan City, Hubei Province of China. Illnesses have since been linked to a disease caused by a previously unidentified strain of coronavirus, designated Coronavirus Disease 2019, or COVID-19. On January 30, 2020, an Emergency Committee convened by the WHO Director-General declared the COVID-19 outbreak to be a Public Health Emergency of International Concern (PHEIC). On January 31, the Secretary of Health and Human Services (HHS) declared a public health emergency under Section 319 of the Public Health Service Act (42 U.S.C. 247d). On March 11, 2020, the WHO characterized the COVID-19 outbreak as a pandemic. Two days later, on March 13, the President declared the COVID-19 outbreak a national emergency, beginning March 1, 2020.

The VHA plays a significant role in the domestic response to a pandemic. It is one of the largest integrated direct health care delivery systems in the nation, caring for more than 7.1 million patients in FY2020 and providing 123.8 million outpatient visits at approximately 1,450 VA sites of care. The VHA employs a workforce of 337,908 full-time equivalent employees (FTEs), largely composed of health care professionals. In addition, the VHA has a statutory mission to contribute to the overall federal emergency response capabilities.

Scope and Limitations

This report provides an overview of VA's response thus far to this rapidly evolving COVID-19 pandemic. It does not provide an exhaustive description of all of the department's activities, and it is based on very limited publicly available information from VA. It is organized as follows: first, it provides details on VHA's, VBA's, and NCA's response activities; second, it provides details on VA's emergency preparedness ("Fourth Mission") activities to provide support to the overall federal emergency response; and lastly, it briefly describes congressional activity as it pertains to VA and veterans. The Appendix provides a summary of VHA's emergency authorities.

Medical Care for Veterans During the COVID-19Â Outbreak

VHA's provision of medical care to veterans in response to the COVID-19 outbreak includes implementing mitigation strategies at VHA facilities, as well as testing and treating veterans diagnosed with or suspected of having COVID-19. (A general description of medical care to veterans is provided in other CRS reports. )

In late February 2020, VA provided information to congressional oversight committees on the number of positive and presumptive positive cases of COVID-19. On March 13, 2020, the department began publishing this information publicly on its website, which it updates on a regular basis. The number of positive diagnoses is likely to grow as testing for COVID-19 becomes more widespread.

VA has reported on the measures it has taken to contain and mitigate further exposure. It has issued guidance for patients, implemented mitigation strategies at VHA facilities, and begun testing patients who present symptoms consistent with COVID-19.

Guidance for Patients

VA is advising veterans who may be sick or who are exhibiting flu-like symptoms not to come to a VA facility. Instead, patients are advised to call their health care providers, even if they already have a scheduled appointment. Alternatively, patients can send a secure message through the VHA online portal, My HealtheVet, or schedule a telehealth appointment.

In addition, VA is advising patients to budget additional time for appointments due to enhanced screening measures at VA facilities. These enhanced screening measures, as well as other mitigation strategies at VHA facilities, are described below.

Mitigation at VHA Facilities

On March 10, 2020, VA announced safeguards to protect nursing home residents and spinal cord injury patients. As of that date, no visitors are allowed at either VA nursing homes or spinal cord injury/disorder (SCI/D) centers. The only exception to this policy is if a veteran is in the last stages of life, in which case VA allows visitors in the veteran's room only. VA is not accepting any new admissions to nursing homes and is limiting new admissions to SCI/D centers.

VA began implementing enhanced screening procedures at all sites of care to screen for respiratory illness and COVID-19 exposure. Enhanced screening procedures are determined at the local level, so they vary at each facility. However, VA has designed standardized screening questions for each facility.

Each VA medical center is implementing a two-tiered system to mitigate the potential for spread of the virus, creating a zone for active COVID-19 cases and a passive zone for care unrelated to COVID-19. VA has canceled all elective surgeries and limited routine appointments.

COVID-19 Testing and Treatment30

This section describes the current VA policy on testing patients for COVID-19 and treatment following a COVID-19 diagnosis.

COVID-19 Diagnostic Testing

On March 13, 2020, the department began publishing the number of positive cases of COVID-19, and the number of tests conducted, on its public website, which it updates on a regular basis. Individual medical centers have discretion on where to send samples for testing. Samples can be tested at the Palo Alto VA Medical Center, state public health labs, or private labs.

Individual providers decide whether to test for COVID-19 on a patient-by-patient basis. However, VA has advised providers that patients must be exhibiting respiratory symptoms and have another factor, such as recent travel or known exposure to someone who tested positive.

Generally, diagnostic testing is a covered service under VA's standard medical benefits package, which is available to all veterans enrolled in the VA health care system. Some veterans are required to pay copayments for care that is not related to a service-connected disability. However, routine lab tests are exempt from copayments. VA has not announced whether cost-sharing for the COVID-19 diagnostic test is included under the exemption for routine lab tests.

The Families First Coronavirus Response Act ( P.L. 116-127 ), enacted on March 18, 2020, allows VA to waive any copayment or other cost-sharing requirements charged to veterans for COVID-19 testing or medical visits during any period of this public health emergency. VA has not publicly announced whether cost-sharing for the COVID-19 diagnostic test will be waived for all veterans who are subject to cost-sharing. (For a discussion of P.L. 116-127 , see the " Congressional Response " section of this report.)

COVID-19 Treatment

VA has not indicated whether it has developed a treatment plan for patients diagnosed with COVID-19. Treatment depends largely on the severity of symptoms that each patient experiences.

VA is handling coverage and cost of treatment for COVID-19 as it would for any other treatment for a condition that is not service-connected. Treatment for COVID-19 is a covered benefit under the VA standard medical benefits package. However, some veterans may have to pay copayments for both outpatient and inpatient care.

Normal coverage rules apply for veterans who report to urgent care or walk-in clinics. To be eligible, a veteran must be enrolled in the VA health care system and must have received VA care in the past 24 months preceding the episode of urgent or walk-in care. Eligible veterans needing urgent care must obtain care through facilities that are part of VA's contracted network of community providers. These facilities typically post information indicating that they are part of VA's contracted network. If an eligible veteran receives urgent care from a noncontracted provider or receives services that are not covered under the urgent care benefit, the veteran may be required to pay the full cost of such care. Certain veterans are required to pay copayments for care obtained at a VA-contracted urgent care facility or walk-in retail health clinic.

In addition, normal rules apply for veterans who report to non-VA emergency departments. To be eligible for VA payment or reimbursement, a veteran's non-VA care must meet the following criteria:

The emergency care or services were provided in a hospital emergency department or a similar facility that provides emergency care to the public. The claim for payment or reimbursement for the initial evaluation and treatment was for a condition of such a nature that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health. A VA or other federal facility or provider was not feasibly available and an attempt to use them beforehand would not have been considered reasonable by a prudent layperson. At the time the emergency care or services were furnished, the veteran was enrolled in the VA health care system and had received medical services from the VHA within the 24-month period preceding the furnishing of such emergency treatment. The veteran was financially liable to the provider of emergency treatment for that treatment. The veteran had no coverage under a health plan contract that would fully cancel the medical liability for the emergency treatment. If the condition for which the emergency treatment was furnished was caused by an accident or work-related injury, the veteran is required pursue all claims against a third party for payment of such treatment first.

Homeless Veterans

Veterans experiencing homelessness live in conditions that could make them particularly vulnerable to COVID-19. Those who are unsheltered lack access to sanitary facilities. For those sleeping in emergency shelters, conditions may be crowded, with short distances between beds, and there may be limited facilities for washing and keeping clean.

While VA itself administers programs to assist veterans experiencing homelessness, there are several grants for nonprofit and public entities to provide housing and services to homeless veterans. These include the Homeless Providers Grant and Per Diem program (transitional housing and services), the Supportive Services for Veteran Families (short- to medium-term rental assistance and services), and Contract Residential Services (housing for veterans participating in VA's Health Care for Homeless Veterans program).

VA released guidance on March 13, 2020, for its grantees that administer programs for veterans who are homeless. The guidance suggests grantees take a number of actions:

Develop a response plan, or review an existing plan, and coordinate response planning with local entities, including health departments, local VA medical providers, and Continuums of Care. Plans should address staff health, potential staff shortages, and acquisition of food and other supplies, as well as how to assist veteran clients. Prevent infection through methods recommended by the CDC, such as frequent handwashing, wiping down surfaces, and informing clients about prevention techniques. In congregate living facilities, such as those provided through VA's Grant and Per Diem program, keep beds at least three feet apart (preferably six, if space permits), sleep head-to-toe, or place barriers between beds, if possible. Develop questions to ask clients about their health to determine their needs and how best to serve them. For new clients, interviews should occur prior to entry into a facility (such as over the phone), if possible, or in a place separate from other clients. If a client' answers to questions indicate risk of COVID-19, separate them from other program participants (have an isolation area, if possible), clean surfaces, and reach out to medical professionals. If isolation is not practical, reach out to other providers who might be able to isolate.

Veterans Benefits Administration (VBA)

On March 18, 2020, the Veterans Benefits Administration (VBA) announced via Facebook and Twitter that all regional offices will be closed to the public starting March 19. While the regional offices are to remain open to ensure the continuity of benefits, the offices are to no longer accept walk-ins for claims assistance, scheduled appointments, counseling, or other in-person services. VBA is directing veterans who have claims-specific questions or any questions to use the Inquiry Routing & Information System (IRIS) or to call 1-800-827-1000.

A March 16, 2020, Government Executive news article explained that VBA is facing "network operationality" issues after several regional offices told their employees to telework full time. VBA headquarters, in Washington, DC, then rescinded the telework directives due to the information technology issues. VBA is to continue performing tests on the network throughout the week. According to the article, a VA spokesperson said that regional office directors are to make decisions on work flexibility based on "the circumstances in their communities" but must discuss all plans with "central office leadership."

Educational Assistance

In FY2020, over 900,000 individuals are expected to receive veterans educational assistance from the GI Bills (e.g., the Post-9/11 GI Bill), Veteran Employment Through Technology Education Courses (VET TEC), Veterans Work-Study, Veterans Counseling, and VetSuccess on Campus (VSOC). As a result of COVID-19, some participants' training and education may be disrupted, and some participants may receive a lower level of or no benefits. These concerns may directly affect beneficiaries in several ways, including the following:

Some students may be required to stop out, discontinue working, or take a leave of absence as a result of their own illness. Some training establishments, educational institutions, and work-study providers may close temporarily or permanently. Some training establishments, educational institutions, and work-study providers may be required to reduce participants' hours, enrollment rate, or rate of pursuit. Some educational institutions may transition some courses to a distance learning format. Some educational institutions may require students living on campus to move off campus. Individuals receiving benefits in foreign countries may encounter any of the above circumstances while residing in a foreign country whose COVID-19 situation may differ from that in the United States, or may stop out, discontinue working, or take a leave of absence and return to the United States.

A related issue is that, in the past, GI Bill benefits could not be paid for pursuit of online courses that had not been previously approved as online courses. Given this limitation, VA requested that school-certifying officials "temporarily refrain from making any adjustments to enrollment certifications" pending subsequent VA guidance and/or legislative action.

On March 12, 2020, VA reminded GI Bill participants and school-certifying officials of its ability to continue paying benefits as participants and institutions react to the COVID-19 emergency. In particular, VA may continue to pay GI Bill benefits for up to four weeks following the temporary closure of an educational institution under an established policy based on an executive order of the President, or due to an emergency situation. Other limitations noted in the correspondence would be alleviated by recently passed legislation (see the " Congressional Response " section of this report for a discussion of S. 3503 ).

National Cemetery Administration (NCA)

The National Cemetery Administration (NCA) has provided limited information for the survivors and dependents of veterans who have passed away and are scheduled to be buried in National Cemetery. As of March 18, 2020, NCA has provided some guidance for both families and funeral directors regarding interments and services for veterans.

For f amilies and v isitors . VA National Cemeteries remain open to visitors and for interments, but visitors should follow their local communities' restrictions on visitations and travel. For families who prefer to inter now but hold the committal service at a later date, NCA says it will work to accommodate those requests. For families who prefer to have the committal service now, NCA asks them to adhere to CDC recommendations for group gatherings.

For f uneral d irectors . NCA is asking funeral directors to follow the CDC guidelines and recommendations on group gatherings for families who proceed with full committal services. In addition, NCA informed organizers that it has discouraged all cemetery personnel from handshaking and any unnecessary physical contact with family members and funeral organizers. NCA is to work with the funeral directors and families to accommodate future committal services for those who decide to postpone.

NCA has set up an "Alerts" web page for the public to check cemetery operating status and is directing the public to its Facebook and Twitter pages for the most recent operating information.

Emergency Preparedness ("Fourth Mission")

In 1982, the Department of Veterans Affairs (VA)-Department of Defense (DOD) Health Resources Sharing and Emergency Operations Act ( P.L. 97-174 ) was enacted to serve as the primary health care backup to the military health care system during and immediately following an outbreak of war or national emergency. Since then, Congress has provided additional authorities to VA to "use its vast infrastructure and resources, geographic reach, deployable assets, and health care expertise, to make significant contributions to the Federal emergency response effort in times of emergencies and disasters."

Among other authorities, VHA may care for nonveterans, as well as veterans not enrolled in the VA health care system. This applies in situations where the President has declared a major disaster or emergency under the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. Â§5121 et seq.) (the Stafford Act), or where the HHS Secretary has declared a disaster or emergency activating the National Disaster Medical System established pursuant to Section 2811(b) of the Public Health Service Act (42 U.S.C. Â§300hh-11(b)). The President's March 13, 2020, declaration of a national emergency under Section 501(b) of the Stafford Act allows VA to use this authority.

According to VA, during declared major disasters and emergencies, service-connected veterans receive the highest priority for VA care and services, followed by members of the Armed Forces receiving care under 38 U.S.C. Section 8111A, and then by individuals affected by a disaster or emergency described in 38 U.S.C. Section 1785 (i.e., individuals requiring care during a declared disaster or emergency or during activation of the National Disaster Medical System [NDMS]). In general, care is prioritized based on clinical needâthat is, urgent, life-threating medical conditions are treated before routine medical conditions (see the Appendix ).

During a disaster or emergency, VA can support HHS by providing resources to civilian health care systems. Furthermore, VA's National Acquisition Center can assist with acquisition and logistical support, such as by providing ventilators, medical equipment and supplies, and pharmaceuticals. Generally, if a state, tribal, or territorial government needs resources, they can request assistance from the federal government through their local HHS Regional Emergency Coordinator (REC). The HHS REC is to then submit a task order to the HHS Secretary's Operations Center (SOC) to be fulfilled by HHS, VA, or another federal agency. VA cannot receive direct requests for assistance from state and local governments.

Congressional Response

Funding and Cost-Sharing

On March 14, 2020, the House passed the Families First Coronavirus Response Act ( H.R. 6201 ). The Senate passed the measure on March 18, and the President signed it into law the same day as P.L. 116-127 . The act provides $30 million for VHA's medical services account to fund health services and related items pertaining to COVID-19. In addition, the act provides $30 million for VHA's medical community care account. These funds are available until September 30, 2022. Among other things, the act allows VA to waive any copayment or other cost-sharing requirements for COVID-19 testing or medical visits during any period of this public health emergency.

Education Assistance

S. 3503 , as passed by the Senate on March 16, 2020, and then passed by the House on March 19, 2020, allows VA to continue to provide GI Bill benefits from March 1, 2020, through December 21, 2020, for courses at educational institutions that are converted from in-residence to distance learning by reason of an emergency or health-related situation. S. 3503 further permits VA to pay the Post-9/11 GI Bill housing allowance as if the courses were not offered through distance learning throughout the same period. With the exception of those covered under this S. 3503 exemption, Post-9/11 GI Bill participants enrolled exclusively in distance education are eligible for no more than one-half the national average of the housing allowance.

Emergency Supplemental Appropriations Request60

On March 17, 2020, the Administration submitted to Congress a supplemental appropriations request. The Administration seeks $16.6 billion for FY2020 for VA's response to the COVID-19 outbreak. This includes $13.1 billion for the medical services account. According to the request, this additional amount would provide funding for "healthcare treatment costs, testing kits, temporary intensive care unit bed conversion and expansion, and personal protective equipment." The request also includes $2.1 billion for the medical community care account to provide three months of health care treatment provided in the community in response to COVID-19. VA assumes that about 20% of care for eligible veterans will be provided in the community, since community care facilities would be at full capacity with nonveteran patients. Furthermore, the request includes $100 million for the medical support and compliance account for the provision of 24-hour emergency management coordination overtime payments; for costs associated with travel and transport of materials; and to enable VHA' s Office of Emergency Management to manage its response to COVID-19. The emergency supplemental appropriations request also includes $175 million for the medical facilities account to upgrade VA medical facilities to respond to the virus. The request also includes $1.2 billion for the information technology systems account to upgrade telehealth and related internet technology to deliver more health care services remotely.

Appendix. VHA Emergency Powers