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Submission For The Record of Tom Tarantino, Senior Legislative Associate, Iraq and Afghanistan Veterans of America

Madame Chairwoman, Ranking Member, and members of the committee, on behalf of Iraq and Afghanistan Veterans of America’s 200,000 Member Veterans and supporters, I thank you for inviting me to testify at this hearing to share our members’ views on this important issue. 

My name is Tom Tarantino and I am the Senior Legislative Associate with IAVA.  I proudly served 10 years in the Army beginning my career as an enlisted Reservist and leaving service as an Active Duty Cavalry Officer.  Throughout those 10 years, my single most important duty was to take care of other soldiers.  In the military, they teach us to have each other’s backs. Although my uniform is now a suit and tie, I am proud to work with this Congress to ensure the entire country has the backs of America’s service members and veterans.

The fight is not over when our warriors leave the combat zone. They have made a commitment: we have asked them to sacrifice their time and families, to risk their lives and limbs, to protect us. It is only right that we as a people, as a nation, make good on our commitment to take care of our warriors, especially when they leave pieces of themselves on the battlefield. Taking care of our veterans often means taking care of their families.

IAVA strongly supports the Caregivers Assistance Program. We recognize that wounded warriors deserve the chance to live the fullest life possible. Whether their wounds are physical, mental, or some combination of the two, veterans heal better and faster when they are comfortable and happy with access to the support of family and friends. If the choice is between being warehoused in a VA or DoD facility or recovering at home surrounded by family and friends, IAVA believes that the compassionate choice and the logical choice are one and the same. As one spouse of a wounded warrior put it, “[We] just want to be included in our society rather than being segregated.”

It is our duty to ensure that the any assistance program fully meets the needs of those it is designed to help. To that end, IAVA would like to make some suggestions about modifications to the Interim Final Rule for the Caregivers Assistance Program.

  1. The GAF score required to enter the program is too restrictive. In addition, the requirement to have a continuously low GAF score is restrictive and self-defeating.

The Interim Final Rule sets several criteria for entry into the program; one of these is evaluation using the General Assessment of Functioning (GAF). To be eligible for the program, a veteran must have a GAF score of 30 or below at the beginning and end of a 90 day period and the score cannot rise above 30 in the interim. In other words, 3 continuous months of a 30 or below GAF score.

The first problem we see is that a GAF score of 30 corresponds to such severe impairment that a veteran would need treatment that is beyond the scope of a family caregiver. Higher GAF scores still present serious problems: a GAF score of 31-40 denotes “some impairment in reality testing and communication or major impairment in several areas” including being unable to work. A GAF score of 41-50 denotes “Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning” including the inability to keep a job or maintain friendships.

The point of any rehabilitation is to help veterans get better. Under the VA rule, however, if a veteran shows improvement by receiving a single GAF score above 30, he or she becomes ineligible to receive Caregivers Assistance. The VA rule appears to force a choice: get treated, get better and be ineligible or remain non-functional with a poor quality of life and be eligible.

IAVA believes that relaxing the GAF criteria would be in the best interests of veterans. Raising the GAF score required to participate in the program to as high as 50 would still mean that veterans with profound mental health issues would be eligible for the program and not be penalized for improving.

  1. Stronger coordination with DoD programs and third-party providers is necessary

The VA definition of primary care team on 26149 of Vol. 76 No. 87 of the Federal Register does not make it clear who composes that team. Because a significant population eligible for this program are retired medically from service or covered by insurers outside the VA, many receive treatment outside the VA system, for example from TRICARE providers and third-party providers under fee-for-service programs. Veterans who are diagnosed with mental or physical disabilities that make them eligible for the Caregivers Assistance Program after separation from service may also have been treated by physicians and clinicians outside the VA system, i.e. through private insurance. With pending legislation that is likely to expand fee-for-service programs and third-party providers, situations where a veteran is under the care of a doctor outside the VA system will only increase. It is imperative that VA primary care teams consult these doctors and utilizes their assessments and that this requirement is explicitly stated.

IAVA has spoken with veterans or family members being treated outside of the VA system whose treating physicians have never been consulted by VA clinicians making eligibility determinations or treatment recommendations. In one case, a clinical psychiatrist who for over 5 ½ years has treated a veteran with traumatic brain injury (TBI) and mental health issues stemming from his war injuries has never spoken to or been contacted by VA personnel in any capacity. If such a long-standing relationship does not qualify for the “primary care team” then what will?

IAVA does not support the contention that clinicians outside the VA should make the call on who is eligible for the program. It is a VA program and the VA should administer it. However, IAVA believes that review of existing patient records and consultations with non-VA clinicians who are treating a particular veteran should form at least part of the basis for decisions. Clinicians who determine entry into the program and progress in the program must consult with clinicians who are actually treating the veteran. There is no need to reinvent the wheel and delay veterans and their families’ entry into the Caregivers Assistance Program.

  1. Differentiation between Primary Family Caregivers (PFC) and Secondary Family Caregivers (SFC) needs to be lessened. Qualifications for SFC, particularly the requirements reside with the veteran, need to be relaxed.

IAVA understands the levels of caregiver differentiation and agrees that different levels of commitment should receive different levels of benefits. The structure that the VA has proposed for the levels of responsibility and the number of Family Caregivers (FC), however, will negatively impact Family Caregivers, particularly during periods of respite care. Accommodation in the VA’s interpretation of 38 CFR 71 should be made for exceptional circumstances and the authority to accommodate should be made clear as well.

VA has established that there can only be one PFC, although there does not need to be one at all. VA has also established that there can be a maximum of only two SFC, even if there is no PFC. A veteran, therefore, could have between 1 and 3 Family Caregivers. A veteran may have an unlimited number of General Caregivers (GC). VA describes GC as “Good Samaritans” [Federal Register Vol 76 No 87 26152] and that corresponds to the level of benefits they receive: just enough to make them helpful with “less critical personal care.” This means that the bulk of care rests on the shoulders of PFC and SFC. The difference between PFC and SFC are that PFC receive all the benefits of SFC and a monthly stipend, respite care for at least 30 days per year and health care coverage through CHAMPVA. Any FC must be “(i) The eligible veteran's spouse, son, daughter, parent, step-family member, or extended family member; or (ii) Someone who lives with the eligible veteran full-time or will do so if designated as a Family Caregiver.”

 Keeping in mind the above restrictions and benefits, let us consider the following scenario: a wounded veteran without a large family who has no PFC. Essentially, with the requirements for entry into the Caregivers Assistance Program, that veteran will rely on 1 to 3 SFC for assistance with the vast majority of their specialized needs. The veteran may not have a PFC for a variety of reasons: inability of family or friends to commit as the primary source of care, desire of the veteran not to be a burden on family, or a small family or no family, i.e. an orphan. Whatever the reason, if there is no PFC then the SFC should be pro-rated a monthly stipend based upon their level of care. This will help defray the costs of care for the SFC, who receive the same training and are expected by the VA to perform the same tasks at the same level of competency as the PFC. One can easily imagine a scenario with a rotation of SFC who share the responsibilities of care on a rotating basis and they should be eligible for benefits commensurate with their level of responsibility.

In addition, the restriction on FC to live with the veteran should be relaxed. For example, if a spouse of a wounded veteran is the PFC then a sibling or parent might be willing to be a SFC. However, under the current interpretation, a best friend or a cousin would not be eligible to be a SFC unless that person lives with the veteran “full-time.” This distinction does not recognize that in some cases immediate family members may not have as close a relationship with a veteran as the veteran’s best friend, for example. If the SFC “generally serves as a back up to the Primary Family Caregiver” [Federal Register Vol. 76 No. 87 26148] then anyone with (1) a close relationship that mirrors that of a family member and (2) who is willing to accept the responsibility of an SFC should be classified as an “extended family member” and allowed to function as an SFC if the veteran and/or PFC approve regardless of whether or not they are domiciled with the veteran. In addition, the definition of “Someone who lives with the designated veteran full-time” should be interpreted to recognize that “full-time” living might occur on a part-time basis as in the next suggestion.

  1. The provision of “respite care” needs to be clearly defined

What respite care consists of or entails is not clearly defined but in practice has been either placing a veteran into a VA hospital or placing a home health care aide in the veteran’s home.  While these are acceptable alternatives, with the availability of SFC and GC creating an unfamiliar environment should be the last resort rather than the first option. The practice of the provision of respite care is too rigid and, as one caregiver put it, “People won’t use it because it doesn’t meet their needs” nor does it meet the intent of the Caregivers Assistance Program.

Another scenario similar to the ones given above might entail the respite of a PFC. During this period, VA will provide “respite care.” In conjunction with the suggestion above, relaxing the definition of extended family would allow the option of a SFC to move in with a veteran full-time for a short period of time, enough to allow respite for a FC while still giving the veteran the continuity of care and home life the program is intended to provide.

In addition, pro-rating a stipend for SFC would allow them to defray part of the costs associated with providing respite for another FC. Covering travel for the respite caregiver would also be beneficial. The current interpretation appears to assume that all who take on the role of a FC reside in geographic proximity. This is often not the case and accommodation should be made. Provision should be made for covering the actual costs of travel, as is done under TRICARE.

While some might contend that these measures will add costs to the program, the associated benefits of meeting the intent of the program (allowing a veteran to  remain in a home environment while recovering) and the cost of removing a veteran to a VA hospital or providing in-home care through an unfamiliar home health care aide are likely greater.

IAVA understands the need establish solid criteria to receive caregivers assistance. With budgets coming under tremendous scrutiny, government agencies must do their utmost to make certain that there is not even the perception of fraud, waste or abuse. However, the Caregivers Assistance Program is not a boondoggle or a giveaway. It is not a program designed to make anyone wealthy. It is not even designed to make anyone, veteran or family member, whole again. The Caregivers Assistance Program merely provides the ability to exist at an extremely modest level while helping a loved one.

The story of Sarah Wade, who has been instrumental in getting this program instituted, is a great example. When her husband, Ted, was injured, she was enrolled in college with the hope of becoming a Foreign Service officer; Ted was going to become a commissioned officer through the Army’s Green to Gold program. Our country lost the future contributions of a fantastic couple dedicated to public service; the Wade’s lost their plans for the future. Now, Sarah cares for Ted and his very modest benefits from medical retirement and SSI, as well as her part–time work, sustains them. Had life continued for them as planned, they would have made very comfortable salaries. Now though, as Sarah succinctly puts it “Ted was capped at an E-5 for the rest of his life. Our standard of living was frozen.”

While the “VA does not intend that the stipend replace career earnings” [p. 26155, Federal Register Vol. 76, No. 87], caring for a veteran who qualifies for the Caregivers Assistance Program is a full-time job in itself. The income from the Caregivers Assistance Program will not make anyone rich nor will it place veterans and their families remotely close to where they would have been financially before their injuries. But it will give them, and thousands of other veterans and their families, a small cushion and a little peace of mind while their (and our) heroes recover.

IAVA believes that the Congress, the VA and the American people have recognized how important this issue is. We support the efforts of all those who are dedicated to taking care of our warriors when they return home, especially those wounded warriors who need our help the most. We hope that our comments help make that goal a reality.