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Tom Tarantino, Senior Legislative Associate, Iraq and Afghanistan Veterans of America

Madam Chairwoman, Ranking Member and members of the Committee, on behalf of Iraq and Afghanistan of America’s 200,000 Member Veterans and supporters, thank you for the opportunity to testify here today on the critical issue of the implementation of the Caregivers and Veterans Omnibus Health Services Act of 2010 (S. 1963) and specifically caregivers’ assistance.

My name is Tom Tarantino and I am a Senior Legislative Associate with IAVA.  I proudly served 10 years in the Army beginning my career as an enlisted Reservist, and leaving the service as an Active Duty Cavalry Officer.  During these ten years, my family served along with me.  They experienced every deployment as well as the challenges of every transition home. Because of the nature of the wars in Iraq and Afghanistan, many families like mine continue to serve long after their veterans have returned home.

The wars in Iraq and Afghanistan are unique. In the last 10 years, improvements in medical technology have decreased the overall number of combat deaths. But while more service members are returning home, thousands are coming back with injuries that will require a lifetime of care.  Since the start of the wars, the Department of Defense has counted more than 40,000 service members wounded in action.

Soldiers, Marines, Airmen and Sailors, as young as eighteen, are coming home to the prospect of having someone feed, clothe and care for them for the rest of their lives. All across the country, mothers and fathers, husbands and wives, brothers and sisters, and boyfriends and girlfriends are stepping up, putting aside their own lives and plans to take care of these wounded warriors.

Many caregivers have had to leave their full-time jobs, losing income and benefits. A recent study by the National Alliance for Caregiving (NAC) found that 62 percent of veteran caregivers reduced their job hours and half quit their jobs or opted for early retirement--compared to only 10 percent of caregivers nationally.  Moreover, half of veteran caregivers reported that they experienced a high degree of financial hardship.[i]  Even though helping their veteran is now their full-time job, veteran caregivers right now do not receive the necessary financial support to do so without financial risk.

Far too many are also working without any formal instruction, training or support to care for their veteran. As a result, the NAC study found that 88 percent of veteran caregivers reported increased stress or anxiety.  Only 15 percent of them received respite care from the VA or another community support service in the past 12 months.[ii]

Natalie Cobb is an example of the selflessness displayed by military families across the country. Her husband Steve, who served in Iraq in 2004, received a concussion in a vehicle accident and then later was severely wounded during patrol when a mortar exploded less than fifty feet away.  Following his deployment, Natalie immediately noticed a difference in his behavior.  A CT scan revealed an ambiguous spot in his brain and he was sent to Walter Reed Army Medical Center. Steve spent thirteen months receiving care there after doctors diagnosed him with Traumatic Brain Injury and Post-Traumatic Stress Disorder.  A short time after his release, Steve suffered a heart attack as a result of his anxiety. Natalie remained by his side throughout his long recovery and now, over six years later, still serves as Steve’s primary caregiver.

Natalie had to learn to take care of Steve on her own. She navigated the VA paperwork by herself. Today, she manages their household while taking care of Steve 24 hours a day. Since she doesn’t trust anyone to replace her as his caregiver, she has not had any respite in over six years.

The veterans’ community came together two ago to help Natalie and Steve and the many families like them across America.  IAVA and all of the veterans’ service organizations worked closely with Congress, military families and the caregiver community to craft a law that would meet the needs of these selfless caregivers.  

This committee and its counterpart in the Senate worked tirelessly to ensure that families like the Cobb’s would get the support that they needed, including health care, mental health care, respite care and living stipends. Our goal was to make caregivers’ lives easier, so that they could devote more time to their wounded warriors without wearing themselves out both physically and financially.

At the time, we believed that we had accomplished our mission. The Caregivers and Veterans Omnibus Health Services Act of 2010 (S. 1963) outlined the law we expected to see from the VA. It was written specifically to apply to more, rather than less, veterans in need of caregivers. It also was intended to cover veterans with Traumatic Brain Injury and Post-Traumatic Stress Disorder, the signature wounds of this war.

We expected to see the implementation plan from the VA within 180 days of enactment of the law on May 5, 2010, and we hoped that caregivers would start receiving much-needed support within 270 days as was stated in the law. But October 2010 came and went without the implementation plan and benefits did not start flowing to caregivers in January as required.

We understand the complexity of regulating S. 1963. This will be the first time that the VA provides direct benefits to family members, outside of a small group of family members who qualify for CHAMPVA. Moreover, the VA must come up with equitable definitions of eligibility for wounded veterans, which is undoubtedly complicated. 

We also appreciate that the VA has moved forward on aspects of the law that did not require regulation. The creation of a hotline and website for caregivers that provides them with information and assistance in accessing benefits is critical. One of the main challenges caregivers face is a lack of understanding of the benefits available to them. Aggregating these resources and making it easier to find and access them is a big step forward.

Nonetheless, we are disappointed by the delay in implementing the law and specifically in the regulations for eligibility.  Since the regulatory process is finally moving forward, I will state that we believe it should continue to move forward quickly. We need to ensure that caregivers do not have to wait any longer for the help that we promised them almost a year ago.

But urgency should not lead us to make more mistakes. The current eligibility requirement is a significant mistake that, if it stands, will gut the spirit of the legislation that we worked so hard to push forward and that this committee put so much time into crafting. 

The law states that eligibility for personal care services will hinge on: one, “an inability to perform one or more activities of daily living,” and two, “a need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury.”[iii] The law also specifically mentions “traumatic brain injury, psychological trauma, or other mental disorder” as serious injuries that would make a veteran eligible.[iv]

Along with representatives of our fellow Veterans Service Organizations, I spent two days at the VA this past October discussing how to make sure that the law was regulated appropriately. At the time, we made it clear that the goal was to ensure that all caregivers who needed help received it.  In real numbers, we are not talking about a huge segment of the American population—roughly only 3,000 caregivers. These men and women have given up everything to take care of their wounded veterans.  It is unacceptable to shortchange this small population at a time when they need our help. Congress made sure this would not be the case by appropriating $1.5 billion from 2011-2015 for support of primary and non-primary family caregivers.[v]

Yet, the regulations proposed by the VA are far more limiting than S. 1963 intended when it comes to eligibility for the critical services that primary caregivers need. The VA’s proposed regulations specifically require that the veteran “without caregiver support providing personal care services at home in an ongoing manner, would require hospitalization, nursing home, or other institutional care.”[vi] Many veterans coming home from Iraq and Afghanistan with TBI or PTSD might well need constant care; however, they don’t necessarily need institutionalization. These injuries and hospital care are not synonymous, and making the need for institutionalization the threshold for eligibility misses the goal of S. 1963.

In addition, the definition that the VA uses in the S.1963 regulations for “serious injury” is very specific: “Individuals with a serious injury are individuals who, due to their injury, psychological trauma, or mental disorder, require ongoing medical care, exhibit impaired ability to function independently in their community, are vulnerable and at high risk for personal safety, and for whom at least 6 months of continuous and approved caregiver support is required to enable them to live outside of an institutional care setting.”[vii] Yet, the definition of “seriously injured or ill OEF or OIF veteran” according to a directive by the Veterans Health Administration from 2009 is defined as “having one or more of the following diagnoses of medical conditions … (a) Burns; (b) Spinal Cord Injury (SCI); (c) Amputation or loss of function of arm, leg, hand or, foot; (d) Post-Traumatic Stress Disorder (PTSD); (e) visual impairment, or (f) Traumatic Brain Injury.”[viii] In this case, the more restrictive definition used by the VA unnecessarily limits which caregivers will be eligible to act as primary caregivers and receive stipends and support.

The VA has acknowledged that in the VSO meetings some participants “verbalized concern that this [reliance on specific definitions of ‘severely injured’ and reference to prevention of institutionalization as criteria to assess eligibility] could lead to a ‘restrictive’ interpretation of eligibility.”[ix]  Those of us who voiced that opinion were speaking from the experience of our members and their families--and we were right. This regulation is too restrictive. As a consequence, far too many veterans and their families will simply not get the support our country promised them.

The VA’s explanation of why it did not take this feedback into account in regulation has so far been insufficient.  It ultimately argues that VSO representatives “stated repeatedly that the intent [of the law] was ‘to avoid having to place veterans in institutions.’”[x] That, indeed, was part of the intent. The main goal, however, was and remains to support a population of caregivers who had to change their lives to care for their wounded warrior; women and men who are living in some cases with no regular income and no health insurance, just so that they can take care of veterans who can no longer take care of themselves.

Is it hard to come up with the right eligibility criteria? Yes. Does this mean that the only solution is to settle on restrictive criteria? No.  To the extent it will help the VA, IAVA and our fellow Veteran Service Organizations are more than willing to work with officials to identify the best criteria. But as it is now the regulation should not stand.

Madam Chairwoman, we are grateful for this opportunity to share the thoughts of Iraq and Afghanistan veterans and their families on the implementation of S. 1963. We also appreciate the VA’s efforts to regulate this complicated law and expedite its enforcement. We would like to see it implemented as quickly as possible to give our veteran caregivers the overdue support they deserve. Before any part of the law is enforced, however, regulations on eligibility as they were submitted to the Office of Management and Budget must be changed.  We look forward to working with you to ensure this happens swiftly.

[i] Caregivers of Veterans—Serving on the Homefront, National Alliance for Caregiving, November 2010, p. 17:

[ii] Ibid., p. 18.

[iii] Caregivers and Veterans Omnibus Health Services Act of 2010, S. 1963, 111th Congress, §1720G

[iv] Ibid.

[v] Ibid.

[vi] Plan for Implementation, Public Law 111-163, “Caregivers and Veterans Omnibus Health Services Act of 2010” Title 1, Caregiver Support, Section 1010, Assistance and Support Services for Caregivers, p. 4.

[vii] Ibid., p. 4-5.

[viii] “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), VHA Directive 2009-018, March 24, 2009.

[ix] VA Plan for Implementation, p. 34.

[x] Ibid.