[Senate Report 113-107] [From the U.S. Government Publishing Office] Calendar No. 186 113th Congress Report SENATE 1st Session 113-107 ====================================================================== CAREGIVERS EXPANSION AND IMPROVEMENT ACT OF 2013 _______ September 17, 2013.--Ordered to be printed _______ Mr. Sanders, from the Committee on Veterans' Affairs, submitted the following R E P O R T together with MINORITY VIEWS [To accompany S. 851] The Committee on Veterans' Affairs (hereinafter, ``the Committee''), to which was referred the bill (S. 851), to extend to all veterans with a serious service-connected injury eligibility to participate in the family caregiver services program, having considered the same, reports favorably thereon without amendment, and recommends that the bill do pass. Introduction On April 25, 2013, Chairman Sanders introduced S. 851, the proposed ``Caregivers Expansion and Improvement Act of 2013.'' S. 851 would expand a national program for the caregivers of seriously injured veterans to provide them with a tax-free monthly stipend, reimbursement for travel expenses, health insurance, mental health services, counseling, training, and respite care. Committee Hearing On May 9, 2013, the Committee held a hearing on pending health care legislation, which included discussion of S. 851. Testimony on S. 851 was offered by: Robert L. Jesse, MD, PhD, Principal Deputy Under Secretary for Health, Department of Veterans Affairs; Rick Weidman, Executive Director for Policy and Government Affairs, Vietnam Veterans of America; and Heather Ansley, Esq., MSW, Vice President for Veterans Policy, VetsFirst. Committee Meeting After carefully reviewing the testimony from the foregoing hearing, the Committee met in open session on July 24, 2013, to consider, among other legislation, S. 851. The Committee voted, by voice vote, to report favorably S. 851 to the Senate. Summary of S. 851 as Reported S. 851 (hereinafter, ``the Committee bill'') would expand the program of support for caregivers of seriously injured veterans to caregivers of veterans of all eras. Background and Discussion In 2006, then-Ranking Member Daniel K. Akaka introduced S. 2753, to improve caregiver assistance services for veterans. During the May 11, 2006, hearing on this legislation, Senator Akaka stated, ``Ensuring caregivers have the support and tools they need to care for their family members makes economic sense, and more importantly, makes policy sense.'' Senator Akaka's bill was included as part of legislation Congress passed and the President signed into law--Public Law (hereinafter, ``P.L.'') 109-461, the ``Veterans Benefits, Health Care, and Information Technology Act of 2006.'' The law authorized $5 million for each of the fiscal years 2007 and 2008 for the Department of Veterans Affairs (hereinafter, ``VA'') to carry out pilot caregiver assistance programs. VA began 8 caregiver assistance pilot programs in October 2007. The pilot programs provided a number of lessons learned, including the need for a multi-modality approach, effective communication, and caregiver education and support. According to the report from VA to Congress required by P.L. 109-461, ``[r]espite is a key component of programs that reduced caregiver stress and burden.'' The report also states many ``elements of the caregiver pilots can easily serve rural and difficult to access populations,'' citing that ``caregiver education, training, and support services do not require face- to-face contact'' but can be provided through ``[w]eb based training and resource information, telephone support groups, and telehealth equipment.'' Overall, the pilots were found to ``result in a healthier caregiver, improved care for the veteran and a better quality of life for both.'' In 2008, a 1-year extension of authority for these pilot programs was approved in P.L. 110-387, the ``Veterans' Mental Health and Other Care Improvements Act of 2008.'' Additionally, the Senate approved S. 1963, the ``Caregivers and Veterans Omnibus Health Services Act of 2009.'' At the time S. 1963 was debated on the Senate floor, then-Chairman Akaka addressed those Senators concerned about the cost of the legislation, stating that ``we cannot renege on the obligation to care for those who honorably serve our country. When we as a nation vote to send American troops to war, we are promising to care for them when they return. The cost of health care is a true cost of war and must be treated as such.'' He went on to say, ``To assert that this legislation requires excessive spending is simply wrong. This spending is critical when taking into account the sacrifices these men and women have made for the nation.'' S. 1963 later became P.L. 111-163, the Caregivers and Veterans Omnibus Health Services Act of 2010 (hereinafter, ``the Caregivers law''), on May 5, 2010. The law reduced the burden faced by family caregivers of post-9/11 veterans by providing them with a tax-free monthly stipend, reimbursement for travel expenses, health insurance, mental health services and counseling, training, and respite care. Since its inception through July 2013, the law has helped more than 10,600 veteran caregivers and their families. The passage of the Caregivers law served as an important step in ensuring the caregivers of our newest generation of veterans received the resources necessary to provide the best possible care for their loved ones. However, these benefits and services were not made available to all veterans. Limiting eligibility for the program to caregivers of post-9/11 veterans created an inequity between caregivers of the newest generation of veterans and the tens of thousands of hardworking, dedicated caregivers who provide care to all other veterans. In September 2013, VA submitted to Congress the Expansion of Family Caregiver Assistance Report, as required by the Caregivers law. In this report, VA stated: Expansion of the Program of Comprehensive Assistance for Family Caregivers would remedy the inequity created by the current statutory requirements, and would further recognize the sacrifice of our Veterans from all eras and the needs of their family caregivers. VA believes, apart from resource issues that are discussed below, such an expansion is operationally feasible. The Congressional Budget Office estimates that approximately 70,000 caregivers of pre-9/11 veterans could be eligible for the expanded program. The caregivers of veterans from other eras have spent years, sometimes decades, caring for severely injured veterans. While data related to the loss of income for veteran caregivers is limited, studies highlighted by the Military Caregivers report published by RAND in 2013 indicated approximately two- thirds of caregivers with jobs reported missing work.\1\ The other third are said to have reduced their hours due to their caregiving responsibilities. These caregivers deserve the same access to resources and services provided to caregivers of the veterans from our country's most recent conflicts. --------------------------------------------------------------------------- \1\Tanielian, Terri, Rajeev Ramchand, Michael P. Fisher, Carra S. Sims, Racine Harris, and Margaret C. Harrell. Military Caregivers: Cornerstones of Support for Our Nation's Wounded, Ill, and Injured Veterans. RAND Corporation, 2013. --------------------------------------------------------------------------- Paralyzed Veterans of America submitted a statement for the record for the May 9, 2013, hearing on pending health legislation noting: No reasonable justification (other than cost considerations) can be provided for why pre-9/11 veterans with a service-connected injury or illness should be excluded from the comprehensive caregiver program. Catastrophically disabled veterans needs are not different simply because they may have been injured prior to the selected date. At the same hearing, Rick Weidman of Vietnam Veterans of America observed: Many Vietnam veterans are alive today because their wives, or sisters, or other relatives have been taking care of them for decades. Heretofore there was never any recognition of the fact that these veterans would either have had to enter into long term care or would have been on the street if not for the extraordinary efforts of these family caregivers. Either way the additional cost to American society would have been extremely large, whether in fiscal cost or the societal cost of having many additional veterans among the homeless. The statements above attest to the importance of VA's caregiver program and the value this program will have for caregivers of pre-9/11 veterans. These statements also highlight that access to the program should be determined based on need, rather than the period of time the veteran served in the Armed Forces. Fully supporting caregiving activities not only ensures equity of services and benefits available to the caregivers of our most seriously injured veterans, it may also generate future cost savings. Supporting caregiving activities now may further enable veterans to remain at home rather than admitting them to a more expensive institutional setting, such as a nursing home. As described below, the cost of providing care in an institutional setting can be significantly greater than the cost of providing care in the home. VA is obligated to provide nursing home care for veterans who need such care and meet 1 of the following criteria: a service-connected disability rating of seventy percent or more; a need for nursing home care for a service-connected disability; or a rating of sixty percent when either unemployable or permanently and totally disabled. The Department's fiscal year 2014 budget request included $4,928,496,000 for long-term institutional care for the care of an estimated 42,465 veterans per day. This amounts to an average cost of $116,060 per veteran a year. Receiving long-term care in the private sector, which is an option for eligible veterans, is costly as well. According to a survey conducted in 2012 by MetLife's Mature Market Institute, the average cost of a private room in a nursing home in the United States was $90,520 per year. In contrast, as of July 2013, the cost of the annual stipend of the Caregiver program, the most expensive aspect of the program, is approximately $18,203 per caregiver, nearly one-tenth the cost of institutional long-term care. Many family members are eager to give their veterans the opportunity to receive care at home by serving as caregivers. A study by the National Alliance for Caregivers (hereinafter, ``NAC'') in 2010 found seventy-eight percent of veteran caregivers find their role fulfilling. However, the financial, physical, and mental toll on these caregivers can be substantial. According to a 2012 report by the Pew Research Center, thirty percent of adults in the United States serve as caregivers. A 2010 MetLife study, entitled ``Working Caregivers and Employer Health Care Costs,'' found there is an 8-percent difference in increased health care costs between caregiving and non-caregiving employees. This same study also found because stress can be an issue for caregivers, ``wellness programs that offer stress-management seminars and stress- reduction programs * * * can be helpful.'' The findings of this report underscore the value of important services offered to caregivers of post-9/11 veterans through VA's caregiver program, which include training, counseling and respite--all of which are important mechanisms to reduce stress--and health care services, which can improve overall wellness. The financial burdens on caregivers who leave the workforce without financial assistance, such as a caregiver stipend, may impact the ability of caregivers to obtain health insurance. The report released by the NAC in 2010 noted caregivers of veterans in households with incomes less than $50,000 have had their retirement plans disproportionately impacted compared to those with higher household incomes. This point was emphasized in testimony submitted to the Committee with respect to its May 9, 2013, hearing by the Disabled American Veterans: The critical care [caregivers] provide amounts to significant personal sacrifice resulting in lost professional opportunities and reduction in income. Caregiving exacts a tremendous toll on that caregiver's health and well-being. Mental health concerns are often prevalent in the caregiver population as well, because many do not have access to supportive services. The NAC report also observed sixty-eight percent of veteran caregivers describe being highly-stressed, while another forty percent rate their physical strain as high due to the demands of their job. The same report also indicated caregivers of veterans in highly rural areas experience episodes of depression more frequently than those in more urban settings. The Caregivers law has been both popular and successful. As of July 2013, more than 10,600 caregivers have been approved for the program. According to VA, approximately 500 new family caregivers are being approved each month. These caregivers received an average monthly stipend between $575 and $2,254. Ninety-two percent of the approved caregivers are female, seventy-four percent of them are spouses and fifteen percent are parents. In addition, the majority of approved caregivers are between the ages of 26 and 40. Caregivers approved for the program have taken advantage of many of the services available through VA. For example, the National Caregiver Support Line, created through the Caregivers law, received more than 85,000 calls, averaging over 150 calls per day as of July 8, 2013. Additionally, as of that same date, more than 125 caregivers had participated in the Peer Support Mentoring Program. This program offers new caregivers the opportunity to be paired with experienced caregivers in order to share knowledge and skills and act as a support system. Finally, in VA's report to Congress regarding the expansion of family caregiver assistance services, VA acknowledged the positive impact the program had on family caregivers and veterans alike. The report noted, Preliminary program outcomes for a small sample of program participants suggest a statistically significant decrease in the level of burden reported by approved family caregivers three months after the initial home visit. An initial review has also shown a statistically significant decrease in average monthly inpatient utilization by eligible Veterans participating in the Program of Comprehensive Assistance for Family Caregivers. Based on its own assessment of the program, VA concluded: Expanding the Program of Comprehensive Assistance for Family Caregivers would allow equitable access to seriously injured Veterans from all eras (who otherwise meet the program's eligibility criteria) and their approved family caregivers. In reality, countless families across every generation have been caregivers. Without compensation and with little support, these caregivers have sacrificed much for their Veteran and this Nation. Committee Bill. The Committee bill would amend section 1720G of title 38, United States Code, by striking ``on or after September 11, 2001,'' thus making the services and benefits available to caregivers of veterans of all eras. Removing this limitation would allow VA to waive the cost of furnishing hospital care or medical services for caregivers of veterans of all eras in emergency cases; authorize VA to pay for the caregivers' lodging and subsistence, as well as the expenses of travel to and from a treatment facility and expenses for the duration of the veteran's treatment episode at that facility; authorize VA to provide a tax-free monthly stipend; and ensure caregivers of veterans of all eras will be included in a national survey of family caregivers conducted in collaboration between VA and the Department of Defense. Committee Bill Cost Estimate In compliance with paragraph 11(a) of rule XXVI of the Standing Rules of the Senate, the Committee, based on information supplied by the Congressional Budget Office (hereinafter, ``CBO''), estimates that enactment of the Committee bill would, relative to current law, increase discretionary spending by $510 million in fiscal year 2014 and by $9.5 billion over the 2014-2018 period, but would not affect direct spending or revenues. Enactment of the Committee bill would not affect the budgets of state, local, or tribal governments. The cost estimate provided by CBO, setting forth a detailed breakdown of costs, follows: Congressional Budget Office, Washington, DC, August 15, 2013. Hon. Bernard Sanders, Chairman, Committee on Veterans' Affairs, U.S. Senate, Washington, DC. Dear Mr. Chairman: The Congressional Budget Office has prepared the enclosed cost estimate for S. 851, the Caregivers Expansion and Improvement Act of 2013. If you wish further details on this estimate, we will be pleased to provide them. The CBO staff contact is Ann E. Futrell. Sincerely, Douglas W. Elmendorf, Director. Enclosure. S. 851--Caregivers Expansion and Improvement Act of 2013 Summary: S. 851 would expand eligibility for the Family Caregivers program administered by the Department of Veterans Affairs (VA). CBO estimates that implementing the bill would cost $9.5 billion over the 2014-2018 period, assuming appropriation of the estimated amounts. Enacting S. 851 would not affect direct spending or revenues; therefore, pay-as-you go procedures do not apply. S. 851 contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act (UMRA). Estimated cost to the Federal Government: The estimated budgetary impact of S. 851 is shown in the following table. The costs of this legislation fall within budget function 700 (veterans benefits and services). ---------------------------------------------------------------------------------------------------------------- By fiscal year, in millions of dollars-- ------------------------------------------------ 2014 2015 2016 2017 2018 2014-2018 ---------------------------------------------------------------------------------------------------------------- CHANGES IN SPENDING SUBJECT TO APPROPRIATION Estimated Authorization Level.................................. 571 1,436 2,502 2,610 2,720 9,839 Estimated Outlays.............................................. 510 1,337 2,375 2,577 2,693 9,492 ---------------------------------------------------------------------------------------------------------------- Basis of estimate: For this estimate, CBO assumes that the legislation will be enacted near the start of fiscal year 2014, that the necessary amounts will be appropriated for each year, and that outlays will follow historical spending patterns for similar and existing programs. Under the Family Caregiver program, VA provides several benefits (a stipend, health care, training, and respite care) to caregivers of eligible veterans. Veterans who have a service-connected disability incurred on or after September 11, 2001, and are in need of personal care services are eligible for that program. S. 851 would expand the Family Caregiver program to provide those same benefits to caregivers of all such veterans, regardless of when they served. Based on information from VA on the current level of participation in the program, CBO estimates that under the bill about 70,000 additional caregivers would become eligible for the program. CBO further estimates that the expanded program would be implemented gradually, with 17,000 caregivers receiving stipends in 2014, growing to the full 70,000 by 2016. Under the Family Caregiver program, a stipend is provided to the veteran's primary caregiver. That stipend amount varies based on the amount and the degree of care needed. For the current program, benefits per primary caregiver total $25,000, on average. CBO expects that this bill would open up the caregiver program to an older population with greater need for home assistance. As a result, CBO estimates higher average costs of roughly $33,000 in 2014 (those costs would be adjusted for inflation throughout the projection period). Thus, CBO estimates that implementing S. 851 would cost $510 million in 2014 and $9.5 billion over the 2014-2018 period, assuming appropriations of the necessary amounts. Pay-As-You-Go Considerations: None. Intergovernmental and private-sector impact: S. 851 contains no intergovernmental or private-sector mandates as defined in UMRA and would not affect the budgets of state, local, or tribal governments. Estimate prepared by: Federal Costs: Ann E. Futrell; Impact on State, Local, and Tribal Governments: Lisa Ramirez-Branum; Impact on the Private Sector: Elizabeth Bass. Estimate approved by: Theresa Gullo, Deputy Assistant Director for Budget Analysis. Regulatory Impact Statement In compliance with paragraph 11(b) of rule XXVI of the Standing Rules of the Senate, the Committee has made an evaluation of the regulatory impact that would be incurred in carrying out S. 851. The Committee finds that S. 851 would not entail any regulation of individuals or businesses or result in any impact on the personal privacy of any individuals and that the paperwork resulting from enactment would be minimal. Tabulation of Votes Cast in Committee In compliance with paragraph 7(b) of rule XXVI of the Standing Rules of the Senate, the following is a tabulation of votes cast in person or by proxy by members of the Committee on Veterans' Affairs at its July 24, 2013, meeting. On that date, the Committee voted by voice vote to order reported S. 851, a bill to extend to all veterans with a serious service-connected injury eligibility to participate in the family caregiver services program. Agency Report On September 11, 2013, Eric K. Shinseki, Secretary, U.S. Department of Veterans Affairs, provided views on S. 851, among other issues. An excerpt from the Department views is reprinted below:Enclosure VA Views * * * * * * * S. 851, CAREGIVERS EXPANSION AND IMPROVEMENT ACT OF 2013 The Caregivers and Veterans Omnibus Health Services Act of 2010, Public Law (P.L.) 111-163 (the Act), signed into law on May 5, 2010, provided expanded support and benefits for caregivers of eligible and covered Veterans. While the law authorized certain support services for caregivers of covered Veterans of all eras, other benefits under the Act were authorized only for qualified family caregivers of eligible Veterans who incurred or aggravated a serious injury in the line of duty on or after September 11, 2001. These new benefits for approved family caregivers, provided under the Program of Comprehensive Assistance for Family Caregivers, include a monthly stipend paid directly to designated primary family caregivers and medical care under CHAMPVA for designated primary family caregivers who are not eligible for TRICARE and not entitled to care or services under a health-plan contract. S. 851, the Caregivers Expansion and Improvement Act of 2013, would remove ``on or after September 11, 2001'' from the statutory eligibility criteria for the Program of Comprehensive Assistance for Family Caregivers, and thereby expand eligibility under such program to Veterans of all eras who otherwise meet the applicable eligibility criteria. Recently, VA sent a report to the Committees on Veterans' Affairs of the Senate and House of Representatives (House) (required by Section 101(d) of the Act) on the feasibility and advisability of such an expansion, as would be effected by S. 851. In that report, VA noted that expanding the Program of Comprehensive Assistance for Family Caregivers would allow equitable access to seriously injured Veterans from all eras (who otherwise meet the program's eligibility criteria) and their approved family caregivers. VA also noted that families across every generation have been caregivers who have sacrificed much for their Veteran and this Nation. In the report, VA noted difficulties with making reliable projections of the cost impact of opening the Program of Comprehensive Assistance for Family Caregivers to eligible Veterans of all eras, but estimated a range of $1.8 billion to $3.8 billion in FY 2014. VA cannot responsibly provide a position in support of expanding the Program of Comprehensive Assistance for Family Caregivers without a realistic consideration of the resources necessary to carry out such an expansion, including an analysis of the future resources that must be available to fund other core direct-to-Veteran health care services. This is especially true as VA presses to buttress mental health services and ensure the fullest possible access to care in rural areas. VA is also mindful as we look ahead to the allocations for the Veterans Benefits and Services functions in the Senate-passed and House-passed FY 2014 budget resolutions (S. Con. Res. 8 and H. Con. Res. 25, respectively). We wish to make it very clear that VA believes an expansion of those benefits that are limited by era of service would result in equitable access to the Program of Comprehensive Assistance for Family Caregivers for long-deserving caregivers of those who have sacrificed greatly for our Nation. However, VA cannot endorse this measure before further engaging with Congress on these top-line fiscal constraints, within the context of all of VA health care programs. VA welcomes further discussion of these issues with the Committee. * * * * * * * MINORITY VIEWS OF RANKING MEMBER HON. RICHARD BURR I agree with my colleagues, in principal, on expanding the Comprehensive Assistance for Family Caregivers Program; however, this bill would cost $9.5 billion over five years and the Majority has not identified an offset to pay for it. I firmly believe that legislation we report out of the Committee should include offsets but, more importantly, I believe we should only expand programs that are fully implemented and follow the intent of the law creating that program. In addition, we need to make sure a program expansion will not divert resources away from the Veterans Health Administration's (VHA) principal duty--to provide health care to veterans. The Caregivers Program, crafted by this Committee with significant opposition from the Department of Veterans Affairs (VA), was intentionally limited to veterans of the most recent conflicts in Iraq and Afghanistan. As then-Chairman Akaka noted during consideration of S. 1963 in the Senate, these benefits and services were not made available to all veterans for three reasons: ``[O]ne, the needs and circumstances of the newest veterans in terms of the injuries are different--different-- from those of veterans from earlier eras; two, the family situation of the younger veterans is different from that of older veterans; and three, by targeting this initiative on a specific group of veterans, the likelihood of a successful undertaking is enhanced.'' I believe the most important of those reasons was the belief that VA would not be able to implement a program of this magnitude covering veterans from all eras. Subsequently, VA has demonstrated that they have had trouble implementing even the limited program. Their rollout and management of the program has been flawed in several areas. On May 5, 2011, VA published in the Federal Register an Interim Final Rule for the Caregivers Program with comments due to VA by July 5, 2011. However, more than two years after the comment period has closed, VA has yet to publish a Final Rule or formally address the comments received. Since the start of the program two years ago, several problems have been brought to my attention. Some examples of these problems are: decisions determining eligibility for the program are inconsistent across the country; VA has no quality assurance program to monitor the quality, consistency, and timeliness of those decisions; and there is no formal process to appeal the decisions of eligibility for caregiver assistance. Our responsibility to the taxpayer is to ensure the laws enacted are implemented correctly, are working as Congress envisioned, and will not divert resources away from VA's core mission. As VA states in the Expansion of Family Caregivers Assistance Program Report, submitted to Congress in September 2013: VA cannot responsibly advise the Congress on expansion of the Program of Comprehensive Assistance for Family Caregivers without a realistic consideration of the resources necessary to carry out that expansion, a forward-looking analysis of resources that must be available to fund core, direct-to-Veteran health care services, and the ability to provide Veterans with adequate access to those services. The report also points out: [E]ven using the lower of the range of projections for the cost of expansion discussed above, VA believes that under either the House-passed or Senate-passed budget framework, expansion of the Program of Comprehensive Assistance for Family Caregivers poses the risk of compromising resources needed for its core Veteran health care mission. Before spending $9.5 billion to expand this program to veterans of all eras, we need to ensure that VA is fulfilling the intent of Congress in how they are administering the current Caregivers Program. Expanding a flawed program now will not only exacerbate the problems currently facing the program, but could also draw financial resources away from other VHA programs. Changes in Existing Law In compliance with paragraph 12 of Rule XXVI of the Standing Rules of the Senate, changes in existing law made by the bill, as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italic, existing law in which no change is proposed is shown in roman). Title 38. Veterans' Benefits * * * * * * * Part II. General Benefits * * * * * * * Chapter 17. Hospital, Nursing Home, Domiciliary, and Medical Care * * * * * * * Subchapter II. Hospital, Nursing Home, or Domiciliary Care and Medical Treatment * * * * * * * SEC. 1720G. ASSISTANCE AND SUPPORT SERVICES FOR CAREGIVERS. (a) Program of comprehensive assistance for family caregivers. (1)(A) The Secretary shall establish a program of comprehensive assistance for family caregivers of eligible veterans. (B) The Secretary shall only provide support under the program required by subparagraph (A) to a family caregiver of an eligible veteran if the Secretary determines it is in the best interest of the eligible veteran to do so. (2) For purposes of this subsection, an eligible veteran is any individual who-- (A) is a veteran or member of the Armed Forces undergoing medical discharge from the Armed Forces; (B) has a serious injury (including traumatic brain injury, psychological trauma, or other mental disorder) incurred or aggravated in the line of duty in the active military, naval, or air service [on or after September 11, 2001]; and * * * * * * *