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Witness Testimony of Ralph Ibson, National Policy Director, Wounded Warrior Project

Chairwoman Buerkle, Ranking Member Michaud and members of the Subcommittee:

Thank you for inviting Wounded Warrior Project (WWP) to testify on the Department of Veterans Affairs’ (VA) implementation plan for the caregiver-assistance program established in Public Law 111-163 (the Caregivers Act).  VA’s implementation plan has profoundly concerned and disappointed us, and we greatly appreciate your holding this early hearing.

With our mission of honoring and empowering wounded warriors, WWP’s vision is to foster the most successful, well-adjusted generation of veterans in our nation’s history.   WWP’s highest legislative priority during the last Congress was the enactment of legislation requiring the Department of Veterans Affairs to establish a program of comprehensive supports for family caregivers of those seriously wounded in Operation Enduring Freedom and Operation Iraqi Freedom.  In light of Congress’ decisive action last year in passing a very strong Caregivers Act, successful implementation of that program is now our top priority.  But VA’s implementation plan falls far short of our goal.  More importantly it falls far short of what the law requires.  Among its most egregious flaws are rigid clinical eligibility criteria that have no foundation in the law and would disenfranchise several thousand veterans intended to be covered under the Act, many of whom have severe cognitive and other impairments resulting from traumatic brain injury.

Background: VA’s Fierce Opposition to Caregiver Legislation

In attempting to understand why VA has submitted a plan that is so fundamentally flawed, it is worth noting VA’s longstanding, deep opposition to caregiver-assistance legislation.  From the perspective of an organization that saw the profound need for caregiver-assistance and advocated hard for it, VA’s position during the period of this law’s development and consideration was deeply disappointing.

Over a period of several years during which caregiver-assistance legislation was under consideration in Congress, VA seemingly struggled to identify a rationale for its consistent opposition to the concept.  In 2008, VA testified before this Subcommittee that such legislation was unnecessary because “VA already has a program in place that accomplishes [its] goals more efficiently and effectively.”[1]  The following year, it advised the Senate Veterans Affairs Committee at a legislative hearing that it “strongly opposes” the then-pending caregiver-assistance bill,[2] which it characterized as “divert[ing] VA from its primary mission of treating veterans and training clinicians.”  VA’s testimony also stated that such legislation was premature in that Congress should not mount a program of this complexity without piloting it first; yet VA also expressed the contradictory view that any caregiver-support initiative should not be limited by date of service.[3]  At a subsequent hearing before this Subcommittee, VA expressed “recogni[tion] that some veterans, particularly young veterans, will need care for the rest of their lives” and stated that it was “currently undertaking a comprehensive reassessment of caregiver programs… and look forward to working with Congress to identify the most feasible and effective caregiver program improvements.”[4] VA’s strongest point of opposition appeared to have been aimed at providing modest financial assistance to any caregivers.  As VA Secretary Shinseki testified recently in acknowledging the Department’s efforts to strip the stipend from any caregiver legislation, “[o]ur proposal…was to use an existing mechanism…called Aid & Attendance [which already provides special monthly compensation to the veteran] …,[but] our position didn’t prevail.”[5] 

The bottom line is that from the outset of the legislative process VA balked at the notion of providing caregivers with vitally needed supports and, despite a clear statutory mandate in the Caregivers Act, VA’s very restrictive eligibility criteria continue to evidence that opposition.

VA Caregiver-Assistance Implementation Plan

The Caregivers Act directed VA to develop a plan, in consultation with stakeholders, for implementing the comprehensive assistance program, and to submit that plan to the Senate and House Veterans Affairs Committees not later than 180 days after enactment.  The Act further directed VA to implement the program 90 days later.  

The provisions of the Caregivers Act are noteworthy in several respects.  First, the law is detailed and prescriptive, and is quite explicit as to who is an eligible veteran.[6] Second, it provides a very robust role for stakeholders like WWP.  Specifically, the law directs VA to consult with stakeholders in the development of an implementation plan and to report to Congress on the recommendations stakeholders offer and, where such recommendations are not adopted to provide the rationale for that decision.  Finally, the law sets critical due dates: VA was to develop and submit an implementation plan to Congress six months after enactment (which fell on November 1st, 2010) and was to implement the law nine months after enactment, January 30th, 2011. 

Based on those requirements of the Act, WWP had three general expectations.  First, we had every reason to expect that VA would develop an implementation plan for the comprehensive-assistance program that honored the plain meaning of the law.   We expected, therefore, that it would closely track the law and cover caregivers of those who in line of duty on or after 9/11 had sustained a serious injury – including “traumatic brain injury, psychological trauma, or other mental disorder”[7] – and were “in need of personal care services because of (i) an inability to perform one or more activities of daily living; [or] (ii) a need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury.”[8] Our second expectation was that VA would work diligently and in coordination with the Administration to ensure that the deadlines set in the law were met.  And our third expectation, based on the consultation provision of the law, was that there would be open dialogue and transparency vis a vis stakeholders in the program’s development and implementation. 

None of these expectations has been met.  As you know, VA has failed to meet the deadlines set in the law.  Communication with stakeholders has been decidedly one-sided.  VA staff solicited stakeholders views only very late in the process.  At no time were stakeholders given a glimpse of a preliminary implementation plan, or a basis for believing that our recommendations were even being seriously considered.  VA’s deliberation and decision-making regarding implementation has been marked by a level of secrecy more appropriate to a military combat operation than to an effort to help families.   But most tragic, the substance of VA’s implementation plan falls far short of the requirements of the law; indeed with respect to the question of who would be eligible for comprehensive caregiver support, the plan bears almost no resemblance to the law.

VA Clinical Eligibility Criteria: Who Will Be Hurt and Why

WWP was given no inkling of the contents of the VA implementation plan prior to its submission to the House and Senate Committees, but we have since presented VA officials with a detailed critique of their plan.  Most recently, in response to the suggestion that the Administration was moving to expedite its implementation, we presented VA a paper entitled “Caregiver Law Implementation: Accelerated Start Is Less Vital than Getting the Plan Right.”    Among the problems we highlighted were the plan’s unreasonably rigid “clinical eligibility criteria.”  It is critical to appreciate that these criteria are fundamentally inconsistent with those set in the law; in fact, a core requirement of the VA plan was considered and rejected during the course of development of the legislation itself.  To underscore the implications of these criteria, we offered the following examples of the impact these criteria would have on wounded warriors and their caregivers, drawing on our direct experience with these families. 

Case 1:  A veteran sustained a severe traumatic brain injury.   Five years post-injury, he lives with his wife and while he can carry out all activities of daily living he cannot live independently due to residual cognitive impairment, impaired judgment, and anxiety when in the community.  His condition requires that his wife manage all household affairs, finances, telephoning, etc., and accompany him when traveling.  While the veteran cannot live independently, he could live in another supervised setting, but because he is not so impaired as to need nursing home care he would not be deemed an “eligible veteran” under the VA implementation plan, and his wife would not be eligible for caregiver-supports.   Even if that were not an obstacle, coverage would likely be denied under the VA plan’s definition of “serious injury” based on its requirement that the veteran be “at high risk for personal safety” – a particularly high threshold this veteran might not meet.   

Case 2:  A veteran has sustained polytraumatic injuries that have resulted in blindness and cognitive deficits.  Because of his cognitive impairment he has not achieved maximum benefit of blind rehabilitation and needs regular assistance with food preparation, shopping, laundry, finances, housekeeping and transportation.  His mother provides this assistance on a daily basis.  But because his condition is stable, he does not require “continual medical management;” and although there are some issues of personal safety, he is not “at high risk for personal safety” – he does not meet one of the VA’s required clinical eligibility criteria (or the definitions of the term “serious injury” or “personal care services”)

WWP sees no need for VA to establish clinical eligibility criteria beyond those set forth in the law itself.  But we also see absolutely no basis in law for VA to superimpose the following requirements, which have the effect of severely limiting eligibility, particularly for those with one of the signature wounds of this war, traumatic brain injury:

a.  Requiring that without caregiver-support, the veteran would require institutional care:  The language of the law provides no credible basis for inserting this criterion.  It sets an unreasonably high bar, and is fundamentally inconsistent with the explicit criteria in the law.  Under the law, the critical issue in determining whether an individual is an “eligible veteran,” for purposes of the comprehensive caregiver assistance program, is whether the veteran “is in need of personal care services because of…an inability to perform one or more activities of daily living…[or] a need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury.”  But VA, by imposing the much higher requirement – need for institutional care -- would deem ineligible many veterans who cannot live independently and need the full-time supervision or protection afforded by a family member because of residuals of traumatic brain injury, but are not so profoundly impaired as to need institutional care.  VA is saying in effect that even though a veteran needs personal care services, the caregiver who provides those needed services would not be deemed eligible for support.   Under this bizarre construct, VA tells a single mother who has left the workforce to care for her son, that she’s not eligible for the modest stipend and other support because – although her son can’t live independently, he doesn’t need nursing home care.   What makes this strange reading of the law even more disturbing is that the “need for institutional care” criterion was considered in the development of this legislation and rejected, as discussed in the Explanatory Statement describing the compromise agreement on the Caregivers Act developed by the Senate and House Veterans Affairs Committees.[9]  It is unreasonable for VA to revive this rejected standard, and in so doing dramatically restrict eligibility. 

b.  Requiring that the veteran must either need “continuing medical management” or be “at high risk for personal safety:”   In creating this criterion, VA again goes too far.  Requiring “continuing medical management” has nothing to do with a need for personal care.  A veteran’s condition can be medically stable, yet make it impossible for the individual to live independently.  The plan provides an alternative – a finding that the veteran is “at high risk for personal safety.” But such a requirement sets an artificially high threshold:  to require that a veteran be at “high risk for personal safety” is to say that a young mother with a brain-injured spouse who poses “only” a moderately-high risk of leaving the stove unattended or crossing the street unaware of cars does not merit caregiver support.  This high threshold also reads the phrase “need for supervision” out of the statute.  The law clearly is not focused solely on safety, but also on behaviors often associated with traumatic brain injury or severe behavioral health problems, either of which could require a caregiving-attendant to provide needed supervision.

c.  Defining the term “serious injury” so narrowly that it frustrates the purposes of the law:  VA’s plan defines the term “serious injury” by stating that an individual with a serious injury is one who, due to that injury, (i) “require[s] ongoing care,” (ii) exhibits impaired ability to function independently, (iii) is vulnerable, (iv) is “at high risk for personal safety,” and (v) requires at least six months of continuous caregiver support to enable them to live outside an institutional care setting.  This definition would artificially create a far higher eligibility standard than the criteria expressly set forth in the law: need for personal care services because of an inability to perform one or more activities of daily living or a need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury.[10] The language of the law[11] is consistent with

VA policy,[12] and expressly identifies specific kinds of trauma and injury as encompassed by the term “serious injury.”  As made clear in the Joint Explanatory Statement, seriously injured veterans are those who need personal care services under the criteria specified in the law.[13]   VA, in utterly distorting the term “serious injury,” has not only ignored the plain meaning of the law, but ignored its own recent definition. VHA Directive 2009-018 defines virtually the same term, “seriously injured or ill OEF or OIF Veteran,” as one who has “one or more of the following diagnoses or medical conditions…: (a) Burns; (b) Spinal Cord Injury; (c) Amputation or loss of function of arm, leg, hand, or foot;  (d) Post-traumatic Stress Disorder; (e) Visual impairment; or (f) Traumatic brain injury.”[14] 

d.  Defining the term “personal care services” in a manner inconsistent with law:  The VA plan defines the term in pertinent part, as a need for assistance “to prevent harm to self or others….” while the law employs very different terminology specifying    “a need for “supervision or protection based on symptoms or residuals of neurological or other impairment or injury” (38 USC sec. 1720G(a)(2)(C)(ii)). The plan definition not only reads the word “supervision” out of the statute, but inappropriately substitutes a test that comes closer to the strict standard applied to involuntary civil commitment.

VA’s Rationale for Setting Eligibility Requirements Far Stricter than Those Set in Law:

VA’s Office of General Counsel recently provided the Senate Veterans Affairs Committee a “white paper”[15] which responded to the suggestion that it was not lawful for VA to condition eligibility on a requirement that “without caregiver support providing personal care services at home in an ongoing manner, [the Veteran] would require hospitalization, nursing home, or other institutional care.”  The General Counsel’s paper offered a thin rationale for its conclusion that “there would be a ‘rational basis’ for including such a criterion…such that it would likely withstand any legal challenge.”  We respectfully differ with that view.  But more importantly, the white paper raises the question whether the Secretary of Veterans Affairs, who “is responsible for the proper execution and administration of all laws administered by the Department”[16], or any officer of the Department acting in his behalf on this matter, ever asked the Office of General Counsel a question such as, “What IS the Secretary’s responsibility to caregivers of wounded warriors and to Congress and the American people under the Caregivers Act?”  Had that question been posed and the opinion followed, we are confident VA’s implementation plan would have looked markedly different.   But, rather than attempting to carry out the clear intent of a law it had opposed from the outset, we believe VA sought to impose the strictest-conceivable limitations on who would be eligible.

Thus, in its recent white paper, VA’s Office of General Counsel suggests that because the phrase “serious injury”[17] is not defined in the Caregivers Act, implementing regulations “must” supply an appropriate definition to promote consistency of application.  Counsel offers no support for the proposition that “consistency of application” trumps conformity to the plain language of the statute.  Even more troubling, Counsel makes no effort to explain how the phrase “serious injury” could be read to be synonymous with the phrase “catastrophic injury.”   Congress defined the term “catastrophic injury or illness” in the context of injured or ill servicemembers as “a permanent, severely disabling injury, disorder, or illness that…compromises the ability of the afflicted person to carry out the activities of daily living to such a degree that the person requires personal or mechanical assistance to leave home or bed, or constant supervision to avoid physical harm to self or others.”[18]  Counsel further conflated scattered provisions of the law that are neither structurally nor logically related to the eligibility language,[19] together with phrasing deleted from earlier legislation,[20] to arrive at a richly-imagined “implied intention.”

Having studied the VA plan, we were frankly mystified by VA’s perplexing mis-reading of the Caregivers Act.  Finally, Madam Chairwoman, your questioning of the Secretary at the Committee’s recent hearing on the VA budget for FY 12 provided the catalyst to better understanding what was at play.  Responding to your question, Secretary Shinseki attempted to defend the Administration’s budget for the new comprehensive caregiver-assistance program, which he admitted would cover only 840 families.  He acknowledged that in developing eligibility criteria, the goal was “to write a regulation that meets the immediate requirement…to Iraq and Afghanistan vets and caregivers – and yet keep the opportunity open” to expand the law to other populations.   “So, it’s an issue of fairness,”[21] he asserted.  In short, he as much as stated that VA’s eligibility-criteria were set very narrowly, and exclude many OEF/OIF veterans covered under the law, and particularly those with severe traumatic brain injury – so that these criteria might at some future date be applied to other era-veterans.

Such a position is fundamentally at odds with the law, which directs VA to establish parallel programs of caregiver support – a comprehensive program for caregivers of warriors wounded on or after 9/11 as well as a “program of general caregiver support services” (codified at 38 USC sec. 1720G(b)) for caregivers of all veterans enrolled in the VA health care system who need personal care services[22].  Under the general program, VA is to provide counseling, respite care, and educational support to eligible caregivers.  The law further directs the Secretary, within two years after the law’s implementation, to report on the feasibility and advisability of expanding the comprehensive program to caregivers of veterans injured prior to 9/11.

In short, Congress established a very deliberate framework in the Act – to assist caregivers of all eras of service – while requiring more comprehensive supports for those caring for veterans with recent injuries – an approach that could be viewed as initially limiting the scope of the comprehensive program to those in most immediate and compelling need.[23]  While offering real help for all-era caregivers, the law recognizes not only the prevalence of unique kinds of wounds this war’s veterans have survived – wounds so profound they would likely have been mortal in earlier wars -- but the fact that those with recent injuries are in most instances still undergoing rehabilitation from those injuries.  As such, it is altogether understandable that Congress would provide more robust supports for those warriors to help assure the fullest and greatest possible rehabilitation.  

With all due respect, for Secretary Shinseki, representing the Administration before Congress, to imply that eligibility rules for the Caregivers Act’s comprehensive program should be tightly restricted to enable some future Congress to extend the Act’s provisions to other populations is to suggest that the Administration’s idea of good policy should trump Congress’s.   Sadly, arising in the context of the Administration’s efforts to trim the FY 12 budget, the fact that only very limited numbers would likely receive comprehensive-supports under the plan’s cramped eligibility requirements invites speculation as to whether fiscal considerations – rather than “fairness” -- have trumped compliance with law and keeping faith with brain-injured warriors.

Other Serious Flaws in the VA Plan:

While eligibility issues have been the principal focus of controversy, VA’s plan raises other serious issues.  Let me summarize:

1.Unreasonable limits on the scope of covered mental health services:   The law calls for providing needed mental health services to a primary-caregiver under the comprehensive services program.  But VA’s plan would provide that caregiver only the very limited coverage afforded under the law’s program of general caregiver support.  That coverage is expressly limited (under 38 USC sec. 1782) to circumstances where providing services is necessary to the veteran’s treatment.  So if a warrior’s condition were stable and did not require ongoing treatment, a caregiver who, for example, was experiencing severe anxiety associated with caregiving might not be covered – defeating the very purpose of the benefit.  And, under the plan, a caregiver experiencing a bout of depression associated with the stresses of caregiving, for example, would likely not be covered for drug therapy under the plan’s strictures.  In sum, this limited coverage falls far short of the law’s intent as well as short of the kind of support contemplated in the White House’s "Strengthening Our Military Families" program.

2.Ongoing monitoring through routine home-visits at least every 90 days:   The VA plan calls for ongoing monitoring at least every 90 days.  Yet as noted in the Joint Explanatory Statement, the compromise agreement contains the Senate provision which was modified to delete a provision that called for “mak[ing] home visits every six months.”[24]  Having successfully pressed the point that routine home visits are inherently intrusive and unwarranted as applied to longstanding, devoted caregivers, WWP finds it very troubling that VA’s plan requires routine home-visits twice as frequently as earlier proposed.   The intrusiveness of such monitoring is heightened for the many caregivers who also serve as the veteran’s fiduciary.  As such, they are subject to periodic home visits to check on the veteran’s well-being.  While the monitoring requirements are highly problematic, the plan is still more objectionable for its failure to address these overlapping inspections.  A reasonable plan would at least provide for tapering off the frequency of any monitoring in the absence of problems, and for eliminating the dual intrusion posed for many caregivers by fiduciary-oversight visits 

3.Flawed Criteria for Determining Stipend Amount:  Under the law, an individual’s stipend is to be based on “the amount and degree of personal care services provided.”  The term “personal care services” is defined in the law to mean “assistance with one or more independent activities of daily living” (as well as any other non-institutional extended care).   (Independent activities of daily living (IADL’s) include the ability to use the telephone, shopping, food preparation, housekeeping, laundry, ability to travel, responsibility for one’s medication, and handling finances.)   But VA’s plan – rather than determining stipend amount by reference to IADL’s, as required by the law – does so principally by reference to activities of daily living (ADL’s).  The implications of this misapplication of the law are all too apparent to families caring for a loved one with cognitive and other impairments associated with traumatic brain injury, since IADL’s take account of such impairments while ADL’s do not.  The following example illustrates the point:

A veteran sustained severe traumatic brain injury as a result of an IED blast in Iraq.  While he also suffered a below-the-knee amputation, he is able to perform all the activities of daily living.  But he cannot live independently because significant cognitive impairment, markedly impaired judgment and impulsivity create a very serious risk for safety.  His father, who has left the workforce, is with him almost constantly, providing for his safety, and also attends to a wide range of the veteran’s needs, including telephoning, food preparation, laundry, housekeeping, finances, and transportation.  While the veteran meets the VA plan’s eligibility criteria, the father would receive only a very nominal stipend under the VA plan because it bases the magnitude of the stipend on the extent of deficits in activities of daily living (feeding, toileting, etc.) – which the veteran can do – rather than independent activities of daily living – which the veteran cannot, and which render him highly dependent.

Madam Chairwoman, the Caregivers Act is not only historic legislation; it represents a solemn promise to spouses, parents, and other family members who devotedly care for their seriously wounded loved ones.  The VA plan would break that promise, and we urge you to stand firm and join us in voicing strong objection.  The Administration must not speed through a regulation that covers only a fraction of those eligible under the law.  It must not abandon those vulnerable veterans who cannot live independently because of cognitive or other deficits due to traumatic brain injuries. 

Thank you for your attention to these deep concerns.


[1] Statement of Gerald Cross, MD; Department of Veterans Affairs, before the Subcommittee on Health, House Committee on Veterans Affairs, September 9, 2008.

[2] S. 801, 111th Cong.,established the framework for what became the comprehensive caregiver-assistance program.

[3] Statement of Gerald Cross, MD; Department of Veterans Affairs, before the Senate Committee on Veterans Affairs, April 22, 2009.

[4]  Statement of Madhulika Agarwal, MD; Department of Veterans Affairs, before the Subcommittee on Health, House Committee on Veterans Affairs, June 4, 2009.

[5] Testimony of Secretary Eric Shinseki before the House Committee on Veterans Affairs on VA’s budget for FY 2012, February 17, 2011.  Indeed even after both the Senate and House had passed caregiver bills that both included a stipend provision, senior VA staff sought unsuccessfully in a meeting on December 1, 2009, to negotiate for an alternative that would scale back the legislation to eliminate provision of a stipend.

[6]Contrast the Act with H.R. 3051, 110th Congress, a similar-purpose measure which in pertinent part provided simply that “The Secretary of Veterans Affairs shall establish a program on training and certification of family caregivers of veterans and members of the Armed Forces with traumatic brain injury as personal care attendants of such veterans and members…. [and] shall determine the eligibility of a family member of a veteran or member of the Armed Forces for participation in the program required by subsection (a)…based on the clinical needs of the veteran or member of the Armed Forces concerned, as determined by the physician of such veteran or member… A family caregiver of a veteran or member of the Armed Forces who receives certification as a personal care attendant under this section shall be eligible for compensation from the Department of Veterans Affairs for care provided to such veteran or member.”  Accessed at http://www.thomas.gov/cgi-bin/query/D?c110:1:./temp/~c110wUzrc0::

[7] 38 USC sec. 1720G(a)(2)(B)

[8] 38 USC sec. 1720G(a)(2)(C); the term “personal care services is defined at USC sec. 1720G(d)(4).

[9] As noted in the Joint Explanatory Statement accompanying the amendment of the House of Representatives to S. 1963, enacted as Pub.L. No. 111-163, under the earlier House-passed caregiver-assistance bill, H.R. 3155, “[e]ligible OEF or OIF veterans are defined as those…in need of caregiver services without which the veteran wouldbe hospitalized, or placed in nursing home care or other residential institutional care…”, but “[t]he Compromise Agreement contains the Senate provision” and only “follows the House bill in creating a separate program of general family caregiver support services for…caregivers of veterans of any era.”  

[10] 38 U.S.C. sec. 1720G(a)(2)(C).

[11] “…an eligible veteran is any individual who…has a serious injury (including traumatic brain injury, psychological trauma, or other mental disorder)…”, 38 U.S.C. sec. 1720G(a)(2)(B).

[12] VHA Directive 2009-018, Tracking Severely Injured or Ill Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans Using the Non-primary Care Team Function in the Primary Care Management Module (PCMM), March 24, 2009. Sec. 2.c.(1), Accessed at http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1863.

[13] Joint Explanatory Statement, ibid.

[14] VHA Directive 2009-018, Tracking Severely Injured or Ill Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans Using the Non-primary Care Team Function in the Primary Care Management Module (PCMM), March 24, 2009. Sec. 2.c.(1), Accessed at http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1863.

[15] VA Office of General Counsel, “Family Caregiver Program Implementation Plan: Question on Proposed Eligibility Requirements,” February 22, 2011.

[16] 38 USC sec. 303.

[17] “…an eligible veteran is any individual who…has a serious injury (including traumatic brain injury, psychological trauma, or other mental disorder)…[who] is in need of personal care services….” 38 USC sec. 1720G(a)(2) (emphasis added).

[18] National Defense Authorization Act of 2010, Pub. L. No. 110-84, sec. 603 (2010).

[19] Counsel places heavy reliance on two provisions of the law relating to respite care benefits as supporting its reading.  But surely VA social workers, if not its lawyers, would appreciate that a family caregiver would need periodic respite whether or not the veteran was so impaired as to require nursing home care. 

[20] Counsel would have it both ways.  It assigns significance to a statement of purpose dropped from an earlier Senate bill, while rejecting the notion that there is any significance to be attached to the fact that the compromise agreement did not adopt the pertinent provisions of House-passed H.R. 3155, which had included the phrase “without such services, the veteran would require hospitalization, nursing home care, or other residential institutional care.”

[21] Testimony of Secretary Eric Shinseki before the House Committee on Veterans Affairs on VA’s budget for FY 2012, February 17, 2011.

[22] Under the Caregivers Act the criteria employed in describing what constitutes a “need for personal care services” for purposes of the program of general caregiver support services are the same as for the program of comprehensive assistance; cf. 38 USC sec. 1720G(a)(2)(C) and 38 USC sec. 1720G(b)(2).

[23] Limiting the scope of the comprehensive program in this manner, Congress was arguably drawing lines consistent with VA’s earlier testimony counseling that caregiver assistance be approached in phases, beginning as VA proposed with a pilot effort.

[24] Joint Explanatory Statement, ibid.