The United States has a long history of providing benefits to those who have served in the defense of the nation. What began as a disability compensation and pension program for veterans during the early years of the republic has grown into a comprehensive veteran benefits and services system. The federal responsibility of managing this system has been entrusted by Congress primarily to the Department of Veterans Affairs (VA). The VA carries out its veterans programs nationwide through the following three administrations and an appeals board: The Veterans Health Administration (VHA) is responsible for veteran health care programs. The Veterans Benefits Administration (VBA) is responsible for disability compensation, pension, vocational rehabilitation, education assistance, home loan guaranty, and insurance, among other benefits. The National Cemetery Administration (NCA) is responsible for providing burial space and maintaining national cemeteries, among other responsibilities. The Board of Veterans Appeals (BVA) renders final decisions on appeals regarding veteran benefits claims. The VHA, the largest and most visible operating unit, is predominantly a direct service provider of primary and specialty care, similar in many ways to a large private sector health care system. However, some aspects of the VHA are very different from a private health care system. Not only does the VHA employ health professionals to provide health care services directly, but the VHA also purchases care for certain veterans from community health providers. Further, the VHA provides social services and other supportive services—such as housing assistance, home health aide services, and adult day health care—that are rarely tied to private sector health care providers or financed by private health insurance or Medicare. Beyond the provision of health care and other support services to veterans and eligible family members, the VHA is statutorily required to conduct medical research into the special health care needs of veterans, to train health care professionals, to serve as a contingency back up 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 addition to providing inpatient, outpatient, and a range of other medical care services, the VHA has been authorized by Congress since the 1960s to provide nursing home care to eligible veterans in VA facilities, private nursing facilities contracted by the VA, and state veterans homes. Although the VHA initially provided only institutional-based long-term care, VA long-term care services have expanded to include a full range of long-term services and supports (LTSS)—both institutional and non-institutional. These services include programs of care directly provided by the VA, such as home-based primary care and geriatric evaluation, as well as services purchased by the VA, such as home health aide and home respite care. The VA typically refers to programs under this broad umbrella as Geriatrics and Extended Care (GEC) Programs (see Figure 1 and text box for terminology used in this report). These programs share a primary goal: to support veterans to remain safe in the least restrictive environment. This report provides an overview of the long-term care services offered by the VA, whether directly provided or purchased from the community. It first provides a brief history of legislation relevant to VA long-term care services. Next, it provides information on veteran eligibility for care and enrollment, to give a picture of who these programs serve. It then provides an overview of the structure of the VHA to explain how care is administered, followed by a description of the various long-term care programs that the VA offers. Finally, the report discusses potential issues of interest for Congress. Prior to the enactment of P.L. 88-450 in 1964, the VA did not have explicit statutory authority to provide nursing home care to veterans in VA facilities; however, the VA did provide a limited form of institutional care in its domiciliaries for those who no longer needed hospitalization. Toward the end of FY1964, within the scope of existing statutory authority, the VA began making plans to implement a nursing home care program with 2,000 beds in VA hospitals "for those veterans who have obtained maximum hospital benefits, [but] are too physically disabled for domiciliary care, and still have a need for nursing care which for various reasons cannot be provided in the community." In August 1964, P.L. 88-450 authorized, among other things, 4,000 beds for nursing home care. It further authorized care in private or public nursing homes for no more than six months at VA expense for VA patients who had received maximum hospital benefits but who still needed long-term nursing home care. If the veteran needed permanent nursing home care for more than six months, the veteran would be placed in a VA nursing home rather than a private nursing home. P.L. 88-450 also authorized the VA to make per diem payments to state veterans' nursing homes for the care of eligible veterans. In enacting P.L.88-450, Congress recognized the growing need for nursing home care for World War II veterans in future years, and at the same time recognized the need for VA to move patients from expensive hospitals settings (when they no longer needed hospitalization) to less expensive nursing home settings for longer-term convalescence. P.L. 91-101, enacted in 1969, amended P.L. 88-450 and eliminated the six-month limitation on care at a contracted community nursing home for veterans who were previously hospitalized in a VA hospital for a service-connected disability. For all other veterans, the six-month limitation applied, but the VA was authorized to extend the time period at its discretion. The Veterans Health Care Expansion Act of 1973 ( P.L. 93-82 ) further liberalized eligibility for contracted community nursing home care for veterans with service-connected conditions and authorized the VA to provide nursing home care to veterans in contracted community nursing homes without having to be admitted to a VA hospital first. In 1998, a Federal Advisory Committee on the Future of VA Long-Term Care found that VA's long-term care system developed incrementally in the 1970s and early 1980s. Nursing home care remains its primary emphasis, while home and community based care is underdeveloped. In addition, long-term care programs are not fully integrated into the healthcare system at many VA facilities. Despite a continuum of offerings, services are not available universally and access often is restricted. Many facilities do not have mechanisms for coordinating long-term care services, relying on episodic admissions to individual programs. Long-term care is largely viewed as an adjunct rather than an integral part of the healthcare system, VA long-term care services must be remodeled to effectively deliver needed services. Based on recommendations of the Federal Advisory Committee on the Future of VA Long-Term Care, Congress began to examine the VA's long-term care programs, which led to the enactment of the Veterans Millennium Health Care and Benefits Act ( P.L. 106-117 ) in November 1999. This act, among other things, mandated nursing home care for veterans with a service-connected condition in need of such care and for veterans with nonservice-connected conditions who are 70% or more service-connected disabled. Among other things, it also required the VA to provide non-institutional care, such as home-based care and adult day health care, to all enrolled veterans. In his signing statement, President Clinton stated: This bill is especially significant for its approach in the provision of enhanced extended care services to veterans. It firmly establishes that the Department of Veterans Affairs (VA) should accord the highest priority for nursing home care to the most severely disabled veterans and those needing care for service-connected disabilities. It will also ensure that veterans enrolled in the VA health care system receive noninstitutional, extended-care services, including geriatric evaluations and adult day health care. In general, eligibility for VA long-term care services depends on several factors, including veterans' need for the service, as determined by the VA; whether the service is institutional or non-institutional; and, for certain programs, veterans' service-connected status. However, to understand eligibility for VA long-term care services, it is important to understand eligibility for VA health care in general, the VA's enrollment process, and its enrollment priority groups. Unlike Medicare or Medicaid, VA medical care is not an entitlement program. Contrary to numerous claims made concerning promises of "free health care for life," not every veteran is automatically entitled to health care from the VA. Eligibility for VA health care is based primarily on "veteran status" resulting from military service. In general, veteran status is established by active-duty status in the military, naval, or air service and a discharge or release from active military service under "other than dishonorable" conditions (e.g., general, honorable, under honorable conditions). After veteran status has been established, the VA next places an applicant into one of two categories. The first category comprises veterans with service-connected disabilities or with incomes below an established threshold. Service-connected disability means that such disability was incurred or aggravated in the line of duty in active service. Veterans with service-connected disability or income below the threshold are regarded by the VA as "high priority" veterans and are enrolled in Priority Groups 1-6 (see Figure B-1 ). The second category of veterans comprises those who do not fall into one of the first six priority groups—primarily veterans with nonservice-connected medical conditions and with incomes above the VA-established threshold. These veterans are enrolled in Priority Group 7 or 8. As shown in Table 1 , the majority of VA-enrolled veterans (77%) fall into Priority Groups 1-6, with 23% of veterans in Priority Group 1 (those with 50% or more service-connected disability or determined by VA to be unemployable due to service-connected conditions) and 22% of veterans in Priority Group 5 (those with incomes below the threshold, receiving VA pensions, or receiving Medicaid).