Legion submits statement on expansion of VA's caregiver program

The House Committee on Veterans’ Affairs held an open session on Feb. 6 to examine the effectiveness of the Department of Veterans Affairs (VA) caregiver support program and assess reforms that are needed to successfully expand the program to pre-9/11 veterans and caregivers. The American Legion submitted a statement for the record.

“There’s been miscommunication, confusion and frustration from veterans, caregivers and VA employees alike concerning practically every aspect of this program – from eligibility determinations to clinical appeals to revocations and more,” said Rep. Phil Roe, R-Tenn., committee chairman. “Serious issues still remain to be resolved including, as (it) seems to be the case for every VA program, long-standing and critically important (information technology) IT issues.”

Since its implementation in 2011, Roe said the caregiver program has experienced significantly high demand and unexpected setbacks. Those setbacks led to the VA initiating a 45-day public comment period. From early January to Feb. 5, VA officials solicited public input on several components of the program to help inform VA officials of any changes needed to increase consistency across the program, and to also ensure that those recommendations support veterans and their caregivers, according to the Office of the Federal Register.

“To the department’s credit, they are well aware of those issues and have taken steps in the last year to address them,” Roe said. “I support expanding the family caregiver program to pre-9/11 veterans, but I believe that before doing so, we must ensure the program is working as intended.”

VA Secretary David Shulkin said the caregiver program is important as it makes a difference in the lives of so many veterans. The department remains committed to promoting and enhancing their well-being through the provision of unprecedented services and support, according to his written testimony.

“VA leads the country in an unprecedented way in providing a program like this,” Shulkin said. “Last year, we spent about $500 million on the post-9/11 caregiver program. By expanding it to the pre-9/11 veterans, I think we can have a much bigger impact. We can do this in a cost-effective way by focusing on those that need the benefits the most.”

The American Legion has long advocated that VA’s caregiver program, which is currently available only to post-9/11 veterans and their caregivers, be expanded to include all generations of veterans. The American Legion believes that all veterans, regardless of what era they served in, deserve equality in terms of benefits including fair access. 

“The selfless devotion that it takes to be a caregiver knows no age or era,” Roe said. “What caregivers of post-9/11 veterans have been experiencing over the last 17 years is old hat to what caregivers of pre-9/11 veterans have been experiencing for, in some cases, decades.”

In 2015, veterans and their caregivers began sharing reports about them being cut from the VA’s Program of Comprehensive Assistance for Family Caregivers (PCAFC). VA officials announced two years later that it would suspend revocations of benefits initiated by VA medical centers for the PCAFC, pending a full program review. That announcement came shortly after media reports revealed that some VA medical centers had been dropping caregivers from the program at alarming rates due to budget constraints. 

Shulkin took action last April by ordering an internal review that was intended to evaluate the consistency of program revocation, and also standardize communication with veterans and caregivers nationwide. 

“It became very clear to me that we had inconsistencies in this program and that it wasn’t working the way that we thought it should,” Shulkin said. “There were rates of revocations that were in the very, very high levels (which) other programs didn’t have and that was really unacceptable.”

Shulkin said the VA’s review, which lasted three months, indicated a need for better communication between the department, caregivers and veterans about eligibility determinations, discharges and the clinical appeals process. 

“I made the decision, last April, to pause the program,” he said. “During that time, we conducted listening sessions with our veterans and their caregivers and a number of internal and external groups. As a result of that strategic pause, we made a whole bunch of decisions that we think improved the program.”

After PCAFC resumed full operation in July 2017, VA officials issued a new directive outlining staff responsibilities, veteran and caregiver eligibility requirements, available benefits and revocation procedures. Shulkin said the VA also conducted mandatory staff training on the new directive and implemented standardized communications and outreach materials to educate veterans and their caregivers about the program. 

“Our revocations dropped down from 237 a month before the pause to 192 after the pause, (which is) a 20 percent decrease,” he said. 

Last year alone, more than 400 VA staff, 350 of which included caregiver support coordinators in VA medical centers across the country, provided services and support to nearly 26,000 individual caregivers through PFAFC. About 8,000 caregivers accessed a variety of services including telephone educational support, face-to-face classes and peer support programs, according to Shulkin.

In addition, more than 2,000 caregivers participated in evidence-based clinical interventions. While those efforts have improved the experiences of veterans and caregivers, Shulkin said the VA recognizes that there is still more work to do.

“In order for us to get even more input (regarding) how we can make this program work better, we published a notice (of request for information in the Federal Register last month) with eight specific questions,” Shulkin said. “That public comment period ended (midnight on Feb. 5) so we’re now going to start reviewing all of those comments.”

One concern that has been brought to the attention of The American Legion, VA and others, is that each VA medical center director has the authority to approve or deny veterans into the PCAFC. Under current authority, Shulkin said determining eligibility is extremely complex and resource intensive, often requiring multiple treatment providers and assessments. 

The American Legion urges Congress to pass legislation requiring the VA to have a national standard that is consistent, fair and reasonable. 

“We’ve recently established a Caregiver Survivor Federal Advisory Committee which just had its first meeting last October,” he said. “VA is also going to be able to share our expertise through the (Recognize, Assist, Include, Support and Engage) RAISE Family Caregivers Act that President Trump recently signed into law. We know we have a lot more work to do and more decisions to make.”

When it comes to finding the right balance between clinical appropriateness and cost, Roe said he shares the Obama Administration’s concern that expansion of the caregiver program under the current budget framework could compromise resources that are needed to meet the VA’s core mission. 

“The current budget request does reflect all that we need to do. There was some substantial growth early on that numbers were doubling in 2015 and 2016,” VA Care Management Acting Chief Consultant Margaret Kabat said. “We’ve seen a steadying of the current need. We don’t have that huge increase that we need because about 80 percent our budget is the stipend payments that go to caregivers.”

The American Legion also recommends an independent audit of the VA’s caregiver program to determine what is working or not working, and what changes are required to improve the program.

“I expect it to take about six to eight weeks to get to the point where we can identify some specific recommendations,” Kabat said. 

Shulkin said the department’s goal is to make the eligibility criteria more streamlined and easily understood. Officials are currently focusing on how to leverage the caregiver support coordinators in the field to reduce administrative burden, allowing more interactions that focus on veteran care.

“I think that we do need additional legislative authority and appropriations to be able to expand the program,” he said. “If we have the right consistency of clinical criteria, that would allow us to take current resources and expand them to veterans who need them.”