VA, Roe tie caregiver benefit expansion to tightened eligibility

by Tom Philpott

In drafting legislation that would expand comprehensive caregiver benefits to severely injured veterans of all past wars, Rep. Phil Roe, R-Tenn., chairman of the House Veterans Affairs Committee, directed staff this month to start with the proposal announced by VA Secretary David Shulkin at a Feb. 6 committee hearing.

Shulkin said he supports extending caregiver benefits — which includes a monthly stipend, access to health care insurance, caregiver training, stress counseling and a period of paid respite away from caregiver responsibilities — to people caring for veterans catastrophically injured in wars back to World War II.

However, as a condition for making benefits available to veterans injured before the Afghanistan and Iraq wars, Shulkin wants Congress to narrow eligibility criteria. Post-9/11 veterans now qualify for the comprehensive benefits if their physical or mental injuries prevent them from performing one or more activities of daily living, whether bathing, preparing meals or dressing themselves. It’s a level caregiver need medical experts describe as Tier 1.

Shulkin proposes that Congress align the VA plan’s eligibility criteria with other caregiver programs that provide benefits only if those injured cannot perform three or more activities of daily living, a Tier 3 threshold. He described this as a “more clinically appropriate criteria” than the post-9/11 law mandated since 2011.

However, Shulkin said the 26,000 caregivers now drawing benefits under that law should be protected from the changes for as long as they meet the looser criteria. He also said the law should more clearly spell out that veterans are eligible for caregiver benefits if they suffer severe cognitive dysfunction.

“I think that’s something we could carry to the Congress and get passed,” Roe told Shulkin after he shared his proposal. No committee member disagreed.

If the VA caregiver program is expanded as Shulkin envisions, an additional 40,000 veterans would be eligible, he said. If current post-9/11 benefits were extended to older generations unchanged, 188,000 veterans would be eligible.

The Senate’s veterans affairs committee in December approved and sent to the full Senate the Caring for Our Veterans Act (S 2193), with has provisions to extend the current caregiver program to older generations of war-era veterans in two phases and at an estimated cost of $3.4 billion over five years. Shulkin’s more restricted plan presumably would cost a quarter of that total.

VA spent $500 million last year on its comprehensive caregiver program. VA and veteran service groups both contend caregiver benefits actually save the government billions of dollars because home care avoids the greater cost of sending severely injured vets into nursing facilities. A senior VA official said cost-avoidance under Shulkin’s plan could total $2.5 billion by 2030.

The preference of veteran service organizations is that Congress pass the Senate committee’s caregiver expansion, which they worked closely with Sen. Patty Murray, D-Wash., to shape and gain the support of her committee colleagues.

At the House hearing, however, Chairman Roe asked representatives of two veterans groups, and a nationwide advocacy group for caregivers, if they could support Shulkin’s call to extend benefits to older generations but also limit eligibility to veterans with Tier 3 conditions.

“We certainly won’t oppose any efforts to expand in any way,” said Sarah Dean, of Paralyzed Veterans of America, emphasizing the unmet needs of caregivers for older severely injured veterans. “And if starting with Tier 3 is what we have to do to start (benefits), we absolutely support that.” But she added, “It just won’t be the end of the conversation.”

Steven Schwab, executive director of the Elizabeth Dole Foundation, said it was “encouraging” to hear VA seriously discuss extending benefits to older generations. The foundation wants “to explore a timeline on how we move beyond Tier 3 and make sure that all pre-9/11 caregivers who need and deserve support with this benefit receive it (but) yeah, I think we’re open to that.”

Adrian Atizado with Disabled American Veterans Congress also didn’t reject Shulkin’s plan, noting that critically important benefits for veterans often start by Congress “making incremental improvements.” But lawmakers shouldn’t delay more actions to ensure every veteran “is equitably treated,” Atizado added.

The Senate committee bill with caregiver expansion language is stalled in that chamber over part of the bill that would modify and extend the Choice program for allowing veterans access to non-VA or community health care. A spokeswoman for Sen. Johnny Isakson, R-Ga., said the committee chairman continues to support his bill’s caregiver expansion plan for older generations of vets. But, said his spokeswoman, Isakson is “happy to take a look at what the House proposes.”

Murray, on the other hand, rejects Shulkin’s compromise.

“We should be working to expand support for veterans’ caregivers, not restricting it even further,” Murray said. “I absolutely oppose this … and I will fight against it any way I can in the Senate.”

Carlos Fuentes with Veterans of Foreign War said the Senate bill is the ideal and he disagreed with Shulkin that current eligibility rules are too loose.

“Frankly, it doesn’t matter how many activities of daily living a veteran isn’t able to perform. What matters is if they need the assistance of a caregiver. And there are some cases where being unable to perform one ADL — eating or going to the bathroom or another activity — requires the assistance of a caregiver,” he said.

“Doctors certainly should receive more guidance as to how to make those determinations,” Fuentes said. “But we think that savings (through cost avoidance) can be achieved by extending eligibility criteria as is.”

Veteran representatives spent much of their time before the House committee knocking down claims by Republicans that the current caregiver program is widely abused or offers benefits duplicative of other VA programs.

Two weeks after hearing, Roe said he supports expanding the caregiver program to older generations but “we must have an honest conversation about the right balance between both the cost and clinical appropriateness of any expansion.”

Therefore, he will hold a roundtable discussion with veteran service organizations and members of the House and Senate committees to get feedback on his proposed legislation. That will be followed by a televised hearing where he plans to move caregiver expansion legislation forward to the full House.

Caregivers of older generations should recognize now that it’s up to Congress to act, Shulkin suggested.

“This is really your decision,” he told the House committee. “The Senate and the House have to come to agreement on this.”

To comment, write Military Update, P.O. Box 231111, Centreville, VA, 20120 or email milupdate@aol.com or twitter: Tom Philpott @Military_Update