Senate Veterans’ Affairs Committee Issues Report on Caring for Our Veterans Act (Part 4 of 7)

WASHINGTON, March 8 -- The Senate Veterans' Affairs Committee issued a report (S.Rpt. 115-212) on legislation (S. 2193) to amend title 38, U.S. Code (hereinafter, "U.S.C."), to improve health care for veterans. The report was advanced by Sen. Johnny Isakson, R-Georgia, on March 7.

TITLE III--FAMILY CAREGIVERS

Sec. 301. Expansion of family caregiver program of Department of Veterans Affairs

Subsec. 301(a)(1). Expansion of family caregiver program of Department of Veterans Affairs.

Section 301(a)(1) of the Committee bill, which is derived from S. 591, would expand eligibility for VA's Program of Comprehensive Assistance for Family Caregivers.

Background. The Caregivers and Veterans Omnibus Health Services Act of 2010 was signed into law on May 5, 2010. It established the Program of General Caregiver Support Services and the Program of Comprehensive Assistance for Family Caregivers. The Program of Comprehensive Assistance for Family Caregivers (hereinafter, "the Program") provides additional support services to caregivers beyond what is provided through the Program of General Caregiver Support Services, including a monthly financial stipend, health care coverage through CHAMPVA, counseling and mental health services, respite care, and technical assistance. The Program is only available to veterans who have serious injuries (including traumatic brain injury, psychological trauma, or other mental disorder) incurred or aggravated in the line of duty in the active military, naval, or air service on or after September 11, 2001.

In September 2014, GAO released a report on the Program titled "Actions Needed to Address Higher-Than-Expected Demand for the Family Caregiver Program." The report noted, "Caregivers enable those for whom they are caring to live better quality lives and can contribute to faster rehabilitation and recovery." Supporting caregiving activities not only ensures equity of services and benefits available to the caregivers of our most seriously injured veterans, it may further enable veterans to remain at home rather than admitting them to a potentially more expensive institutional setting, such as a nursing home.

Prior to the Program's implementation, VA initially estimated that 4,000 caregivers would be approved for the program; however, as of November 2, 2017, 21,990 caregivers had been approved. GAO's 2014 report on the Program made specific recommendations for improvement. Among its recommendations, GAO recommended that VA "expedite the process for identifying and implementing an [IT] system that fully supports the program and will enable [VHA] program officials to comprehensively monitor the program's workload, including data on the status of applications, appeals, home visits, and the use of other support services, such as respite care." GAO also recommended that the VA Secretary direct the Under Secretary for Health "to use data from the IT system, once implemented, as well as other relevant data to formally reassess how key aspects of the program are structured and to identify and implement modifications as needed to ensure that the program is functioning as envisioned so that caregivers can receive the services they need in a timely manner."

Committee Bill. Section 301(a)(1) would amend section 1720G of title 38, U.S.C., to require VA to expand eligibility for the Program to all eras of veterans in two phases. The first phase of expanded eligibility would begin during the 2-year period beginning on the date on which the VA Secretary submits to Congress a certification that VA has fully implemented an IT system to support the Program. Section 301(a)(1)(B) of the Committee bill would require VA to submit the certification date in the Federal Register within 30 days to ensure public notification. The first phase includes veterans with a serious injury incurred or aggravated in the line of duty in the active military, naval, or air service on or before May 7, 1975. The second phase of eligibility would begin 2 years after the first phase. This includes those injured in the line of duty after May 7, 1975, and before September 11, 2001.

The current eligibility criteria creates an inequity between post-9/11 veterans and pre-9/11 veterans. However, VA has encountered numerous challenges in implementing the program, and it is clear improvements are needed to ensure the program is meeting the needs of those currently enrolled and can sustain an increase in eligible veterans. The Committee bill ensures those improvements are made prior to expansion to pre-9/11 veterans and their caregivers.

For example, the Program's expansion in two phases, as required by this section, is intended to ensure the Program does not get overwhelmed and continues to operate as intended, providing services in a timely manner, while enrolling those who have become newly eligible. The publication of the VA Secretary's certification date in the Federal Register is intended to ensure veterans are notified of the Program's impending expansion.

Subsec. 301(a)(2). Expansion of needed services in eligibility criteria.

Section 301(a)(2) of the Committee bill, which is derived from S. 591, would expand the Program's eligibility criteria for needed services.

Background. Current law, section 1720G of title 38, U.S.C., provides that veterans eligible for the Program must be in need of personal care services because of an inability to perform one or more activities of daily living, a need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury, or such other matters as the Secretary considers appropriate.

Committee Bill. Section 301(a)(2) would amend subsection (a)(2)(C) of section 1720G of title 38, U.S.C., to include a need for regular or extensive instruction or supervision without which the ability of the veteran to function in daily life would be seriously impaired among the criteria considered for needed personal care services. It is the intent of the Committee to ensure the Program is consistently inclusive of the caregiving needs required by mental health conditions, traumatic brain injuries or other conditions with which eligible veterans may be diagnosed.

Subsec. 301(a)(3). Expansion of services provided.

Section 301(a)(3) of the Committee bill, which is derived from S. 591, would expand the services provided to caregivers under the Program to include legal and financial planning services.

Background. In 2014, the RAND Corporation released a report, "Hidden Heroes: America's Military Caregivers," which examined characteristics of military caregivers and services available to them. The report indicates that, of the military caregiver-specific programs identified by RAND, few provide long-term planning assistance, including legal and financial planning, for military caregivers.

Committee Bill. Section 301(a)(3) would amend subsection (a)(3)(A)(ii) of section 1720G of title 38, U.S.C., to require VA to include financial planning services and legal services related to the needs of injured veterans and their caregivers as among the services provided to caregivers. The section makes clear that VA should provide these services through the use of contracts with or the provision of grants to public or private entities.

While section 301(a)(3) would require that financial planning and legal services be offered to caregivers in the Program, it is the Committee's intent that VA and VA employees not provide these services, but instead partner with public or private entities. It is also the Committee's intent that, to the maximum extent practicable, VA should utilize partnerships that will provide the services pro bono.

Subsec. 301(a)(4). Modification of stipend calculation.

Section 301(a)(4) of the Committee bill, which is derived from S. 591, would expand the number of factors VA should consider when determining the amount and degree of personal care services provided for certain veterans.

Background. Currently, there are three levels of caregiver stipends based on the amount and degree of personal care services provided. This was established pursuant to section 1720G of title 38, U.S.C. According to current regulations, the stipend payment is based on the number of hours of caregiving required by the veteran. The maximum stipend is based on the requirement of 40 hours of caregiving each week, the median stipend is based on the requirement of 25 hours of caregiving each week, and the lowest stipend is based on the requirement of 10 hours of caregiving each week. In order to determine the degree of personal care services required by the veteran, VA evaluates the veteran and establishes a clinical rating based on specific criteria regarding the ability to perform activities of daily living and the need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury.

Committee Bill. Section 301(a)(4) would amend subsection (a)(3)(C) of section 1720G of title 38, U.S.C., to ensure VA is considering the assessment by the family caregiver of the needs and limitations of the veteran; the extent to which the veteran can function safely and independently in the absence of such supervision, protection, or instruction; and the amount of time required for the family caregiver to provide such supervision, protection, or instruction to the veteran when determining the amount and degree of personal care services provided for a veteran whose need for personal care services is based on a need for supervision or protection or regular instruction or supervision under subsection (a)(2)(C) of section 1720G of title 38, U.S.C.

The Committee understands that these determinations are made at the VAMC level and the intent is to ensure consistency by VA in determining the amount of hours of caregiving required by the veteran.

Subsec. 301(a)(5). Periodic evaluation of need for certain services.

Section 301(a)(5) of the Committee bill, which is derived from S. 591, would require VA to periodically evaluate the needs of the veteran and the skills of the family caregiver to determine if additional instruction, preparation, training, or technical support is needed.

Background. Under section 1720G of title 38, U.S.C., VA is required to provide instruction, preparation, and training for family caregivers to provide care to veterans, in addition to ongoing technical support to address routine, emergency, and specialized caregiving needs of the family caregiver.

Committee Bill. Section 301(a)(5) would amend subsection (a)(3) of section 1720G of title 38, U.S.C., to require that, in providing instruction, preparation, and training under subparagraph (A)(i)(I) of that section and technical support under subparagraph (A)(i)(II) of that section to each approved family caregiver, the Secretary periodically evaluate the needs of the veteran and the skills of the family caregiver to determine if additional instruction, preparation, training, or technical support is necessary.

The requirement for periodic evaluation of this support will ensure that caregivers have ongoing access to resources and support for their unique needs as they care for veterans, especially given that a veteran's needs and caregiving techniques and best practices may change over time.

Subsec. 301(a)(6). Use of primary care teams.

Section 301(a)(6) of the Committee bill, which is derived from S. 591, would require the VA Secretary to collaborate with the veteran's primary care team when evaluating applications for the Program, to the extent practicable.

Background. Under subsection (a)(5) of section 1720G of title 38, U.S.C., when reviewing applications submitted jointly by the veteran and family caregiver, VA is required to evaluate the veteran to identify the personal care services required and to determine whether the requirements could be significantly or substantially satisfied through personal care services from a family member. The determination for a veteran's approval for the Program is a clinical decision; however, there is no statutory requirement that VA include the veteran's primary care team in the evaluation.

Committee Bill. Section 301(a)(6) would amend subsection (a)(5) of section 1720G of title 38, U.S.C., to require that the Secretary evaluate each application submitted jointly by an eligible veteran and family member in collaboration with the veteran's primary care team to the maximum extent practicable.

Though the veteran's primary care team maintains the veteran's treatment once in the Program, it is the intent of the Committee to ensure multidisciplinary input in the initial evaluation process, when possible.

Subsec. 301(a)(7). Assistance for family caregivers.

Section 301(a)(7) of the Committee bill, which is derived from S. 591, would authorize VA, in providing caregiver services required under current law, to partner with Federal agencies, States, and private, non-profit, and other entities to provide the assistance.

Background. There are numerous public and private entities that provide caregiver services. According to VA's FY 2016 annual report to Congress on assistance and support services for caregivers, VA has contracted and collaborated with non- profit organizations to provide the family caregivers' core curriculum training and optional additional training opportunities. VA has also indicated that it works with respite care providers in communities to provide that service to veterans in the Program.

Committee Bill. Section 301(a)(7) would amend subsection (a) of section 1720G of title 38, U.S.C., to authorize VA to enter into contracts, provider agreements, and memoranda of understanding with Federal agencies, States, and private, non- profit, and other entities to provide family caregiver services required by section 1720G of title 38, U.S.C. The VA Secretary may provide assistance under this authority only if it is reasonably accessible to the family caregiver and is substantially equivalent or better in quality to similar services provided by VA. In addition, the Secretary could provide fair compensation to entities that provide assistance under this authority.

The Committee recognizes that other entities provide services the Program is required to provide, including respite care, and that VA in some cases is already partnering with these other entities to provide services. It is the Committee's intent that, if appropriate in order to provide the services and they are equivalent or better in quality to similar services provided by VA, VA continues to utilize its authority to partner with entities. This could ensure availability of services and could reduce any duplication.

Subsec. 301(b). Modification of definition of personal care services.

Section 301(b) of the Committee bill, which is derived from S. 591, would modify the definition of personal care services.

Background. Subsection (d)(4) of section 1720G of title 38, U.S.C., defines "personal care services" as services that provide the veteran assistance with one or more independent activities of daily living (subsection (d)(4)(A) of section 1720G of title 38, U.S.C.) and any other non-institutional extended care (subsection (d)(4)(B) of section 1720G of title 38, U.S.C.).

Committee Bill. Section 301(b)(1) would strike "independent" in subsection (d)(4)(A) of section 1720G of title 38, U.S.C., and amend subsection (d)(4) to include supervision or protection based on symptoms or residuals of neurological or other impairment or injury and regular or extensive instruction or supervision without which the ability of the veteran to function in daily life would be seriously impaired.

This section is consistent with changes made by sections 301(a)(2) and 301(a)(4) of the Committee bill, which recognize the need for regular or extensive instruction or supervision within the definition of personal care services and ensure the consideration of these personal care needs when determining the caregiver stipend.

Sec. 302. Implementation of information technology system of Department of Veterans Affairs to assess and improve the family caregiver program.

Section 302 of the Committee bill, a freestanding provision derived from S. 591, would require VA to implement a new IT system and conduct ongoing monitoring and modifications after the system is implemented.

Background. The requirement that VA implement a new IT system that can easily retrieve data that will allow all aspects of the Program to be assessed and comprehensively monitored, that can manage data, and that has the ability to integrate with other relevant VHA IT systems, is consistent with recommendations made by GAO in its September 2014 report. The report indicated that the IT system currently utilized, the Caregiver Application Tracker, was developed quickly due to time constraints on implementing the Program. VA initially expected the Program to be much smaller, and the Caregiver Application Tracker was not designed to manage a high volume of information. As a result, VA is not able to effectively monitor and assess the Program.

Committee Bill. Section 302 would outline requirements for implementing an IT system. Section 302(a) of the Committee bill would require VA to implement an IT system that fully supports the Program and allows for data assessment and comprehensive monitoring of the Program not later than June 1, 2018. The IT system would also be required to include the ability to easily retrieve data that will allow for comprehensive monitoring of all aspects of the Program and workload trends, in addition to the ability to manage data with respect to a number of caregivers that is greater than the number of caregivers expected to apply for the Program, and the ability to integrate the system with other relevant VHA IT systems. These requirements are consistent with the GAO recommendations, and it is the Committee's understanding that the process for developing the new IT system to support the Program is already underway.

Section 302(b) of the Committee bill would require VA to use the IT system to assess key aspects of the Program within 180 days of implementation. Section 302(c) of the Committee bill would require VA to also use the IT system for ongoing monitoring and assessment, including data on the status of applications and the use by caregivers of support services such as respite care. In addition, VA would be required to identify and implement necessary modifications to ensure the Program is functioning as intended and providing veterans and caregivers with services in a timely manner. These requirements are also consistent with the recommendations made by GAO. In order for expansion of the Program to begin, the Secretary must certify to the Committee on Veterans' Affairs of the Senate and House of Representatives and the Comptroller General that the IT system has been implemented. Section 302(d)(3) of the Committee bill would require VA to submit the certification, along with a description of its implementation and utilization for program monitoring not later than June 1, 2019.

Section 302(d)(1) of the Committee bill would require VA, within 90 days of enactment, to submit a report to the Committee on Veterans' Affairs of the Senate and House of Representatives and the Comptroller General, providing an update on the status of the planning, development, and deployment of the IT system. The section would also require that the report include an assessment of the needs of family caregivers and veterans who would be eligible for the Program, as expanded, as well as resources needed for their inclusion.

The intent of this requirement is to ensure proper preparation for the expansion. The Committee expects to be kept up to date on the progress of the IT system implementation and deployment and be informed of any changes to the timeline. By including GAO as a recipient of the report, GAO will have the opportunity to review VA's progress in implementing its recommendations, as required by section 302(d)(2) of the Committee bill. The Committee understands that GAO's audit quality control processes require GAO to at least annually follow up on, track, and record the extent to which GAO's recommendations have been implemented. The Committee expects GAO to follow up on its recommendations for the Program more often than annually and to periodically inform the Committees on VA's implementation status until VA has taken the appropriate corrective actions to address GAO's findings and recommendations. The Committee also directs the Comptroller General to notify the Committee on Veterans' Affairs of the Senate and the House of Representatives once it has verified that the recommended actions have been implemented and, to the extent possible, that the desired outcomes are being achieved, within 45 days of that determination.

Sec. 303. Modifications to annual evaluation report on caregiver program of Department of Veterans Affairs.

Section 303 of the Committee bill, which is derived from S. 591, would amend requirements for VA's annual evaluation report on VA's caregiver programs.

Background. P.L. 111-163, the Caregivers and Veterans Omnibus Health Services Act of 2010, requires VA to submit an annual report to the Committees on Veterans' Affairs of the Senate and House of Representatives. Currently, VA is required to report on both the Program of Comprehensive Assistance for Family Caregivers and the Program of General Caregiver Support and include information regarding the number of caregivers receiving assistance, the cost to VA to provide such assistance, a description of outcomes achieved by the program, an assessment of their effectiveness and efficiency, and recommendations for legislative or administrative action. For the Program of Comprehensive Assistance for Family Caregivers, VA is also required to report on outreach activities carried out, in addition to an assessment of the manner in which resources are expended.

Committee Bill. Section 303 would amend subparagraph (A)(iv) of section 101(c)(2) of the Caregivers and Veterans Omnibus Health Services Act of 2010 to require that VA's annual evaluation report on the Program of Comprehensive Assistance for Family Caregivers and the Program of General Caregiver Support include a description of any barriers veterans or caregivers experience in accessing and receiving care and services. It would also amend subparagraph (B) of such section to require that the report on the Program of Comprehensive Assistance for Family Caregivers also include an evaluation of the sufficiency and consistency of the training provided to family caregivers. The additional information on barriers to care and services and the sufficiency and consistency of training will help further inform the Committee on the effectiveness of the Program and potential issues that may need to be addressed.

TITLE IV--APPROPRIATIONS OF AMOUNTS

Sec. 401. Appropriation of amounts for health care from Department of Veterans Affairs.

Section 401 of the Committee bill, a freestanding original provision, would provide $1 billion for the Secretary to administer EDRP, increase the number of GME residency positions, and allow for recruitment, retention and relocation incentives as authorized under section 221 of the Committee bill.

Background. Section 801 of P.L. 113-146, authorized and appropriated $5 billion in funding to increase access to care at VA facilities and improve the physical infrastructure of VA facilities.

Committee Bill. Section 401(a) would provide $1 billion in funding for the Secretary to administer EDRP, increase the number of graduate medical education residency positions, and implement section 221 of the Committee bill.

Section 401(b) would provide that the funds would be available without fiscal year limitation. Section 401(c) would direct that the funds be used to increase the number of graduate medical education residency positions, and allow for recruitment, retention and relocation incentives as authorized under section 221 of the Committee bill. Section 401(d) would direct that the Secretary provide the appropriate committees of Congress with a funding plan describing how the Secretary would intend to use the amounts appropriated in subsection 401(a). Section 401(e) would make explicit that the funds provided in subsection 401(a) are to supplement and not supplant other funding provided to EDRP. Section 401(f) would direct the Secretary to provide the appropriate committees of Congress with a report describing how the Secretary has obligated the amounts appropriated in subsection 401(a) as of the date of the submission of the report. Section 401(g) would define the appropriate committees of Congress.

Sec. 402. Appropriation of Amounts for the Veterans Choice Program.

Section 402 of the Committee bill, a freestanding original provision, would provide an additional $4 billion for the Veterans Choice Program.

Background. Section 101 of P.L. 113-146 authorized veterans to receive care in the community if they would wait more than 30 days for care in a VA facility or lived more than 40 miles from a VA facility. However, funding for care provided under the Veterans Choice Program was tied to $10 billion in funding provided in the Veterans Choice Fund as created by section 802 of P.L. 113-146. In July 2017, when VA indicated that the funds for Veterans Choice Program were close to being depleted, Congress provided an additional $2.1 billion in funding for the Veterans Choice Program. In December 2017, after VA indicated funds for the Veterans Choice Program would be depleted in January 2018, Congress appropriated an additional $2.1 billion.

Committee Bill. Section 402(a) would provide an additional $4 billion in funding for the Veterans Choice Program. Section 402(b) would direct that the funds would be available until expended or the date specified in section 802(c)(4), December 31, 2018, as amended by section 142 of the Committee bill.

Committee Bill Cost Estimate

In compliance with paragraph 11(a) of rule XXVI of the Standing Rules of the Senate, the Committee, based on information supplied by the Congressional Budget Office (hereinafter, "CBO"), estimates that enactment of the Committee bill would, relative to current law, increase discretionary spending by $43.3 billion over 5 years and increase mandatory spending by $5.6 billion over 10 years. Enactment of the Committee bill would impose a governmental mandate, as defined by the Unfunded Mandates Reform Act, that would limit the application of State laws but would not result in additional spending or any significant loss in revenue.

The cost estimate provided by CBO, setting forth a detailed breakdown of costs, follows:

Congressional Budget Office,

Washington, DC, January 17, 2018.

Hon. Johnny Isakson,

Chairman,

Committee on Veterans' Affairs,

U.S. Senate, Washington, DC.

Dear Mr. Chairman: The Congressional Budget Office has prepared the enclosed cost estimate for S. 2193, the Caring for Our Veterans Act of 2017.

If you wish further details on this estimate, we will be pleased to provide them. The CBO staff contact is Ann E. Futrell.

Sincerely,

Keith Hall,

Director.

Enclosure.

S. 2193--Caring for Our Veterans Act of 2017

Summary: S. 2193 would increase the use of community health care and long-term care by the Department of Veterans Affairs (VA) by broadening eligibility for such care and allowing VA to enter into agreements with health care providers in the private sector without complying with the Federal Acquisition Regulation (FAR). The bill also would make changes to VA's health care programs and compensation of employees, including expanding the caregivers program, increasing pay for employees, and reimbursing medical staff for professional training. In total, CBO estimates that implementing the bill would cost $43.3 billion over the 2018-2022 period, assuming appropriation of the necessary amounts.

In addition, S. 2193 would directly appropriate $4 billion for the Veterans Choice Program (VCP) and $1 billion to provide educational assistance for health professionals at VA. The bill also would expand VA's authority to enter into leases for medical facilities. In total, CBO estimates that enacting the bill would increase direct spending by $5.6 billion over the 2018-2027 period.

Pay-as-you-go procedures apply because enacting S. 2193 would affect direct spending. Enacting the bill would not affect revenues.

CBO estimates that enacting S. 2193 would not increase net direct spending or on-budget deficits by more than $2.5 billion in any of the four consecutive 10-year periods beginning in 2028.

S. 2193 would impose an intergovernmental mandate as defined in the Unfunded Mandates Reform Act (UMRA) by preempting state laws that prohibit VA physicians from practicing telemedicine to treat veterans across state lines. Although it would limit the application of state regulations, the bill would impose no duty on state governments that would result in additional spending or any significant loss of revenues.

The bill contains no private-sector mandates as defined in UMRA.

Estimated cost to the Federal Government: The estimated budgetary effects of S. 2193 are shown in Table 1. The costs of this legislation fall within budget function 700 (veterans benefits and services).

Table 1.--Estimated Budgetary Effects of S.2193, The Caring for Our Veterans Act of 2017

(TABLE OMITTED)

Basis of estimate: For this estimate, CBO assumes that the bill will be enacted near the beginning of calendar year 2018 and that the estimated amounts will be appropriated each year. Estimated outlays are based on historical spending patterns for the affected programs.

Spending subject to appropriation

CBO estimates that implementing S. 2193 would cost $43.3 billion over the 2018-2022 period, subject to appropriation of the necessary amounts (see Table 2). Most of the bill's estimated costs stem from provisions that would expand community health care for veterans, increase eligibility and benefits for caregivers, and increase pay for medical staff.

Veterans Community Care Program. Section 101 would establish the Veterans Community Care Program (VCCP) under which VA would be required to enter into contracts to establish networks of health care providers outside of VA to furnish hospital care, medical services, and extended-care services to veterans enrolled in the VA health care system.

Table 2.--Estimate of the Effects on Spending Subject to Appropriation of S.2193, The Caring for Our Veterans Act of 2017

(TABLE OMITTED)

Under this program, subject to appropriations, VA would be required to provide care through those networks, at the veteran's discretion, in the following situations:

VA does not offer the care needed,

The veteran resides in New Hampshire, or

The veteran, as of the day before enactment, lives 40 miles away from a VA medical facility.

VA also would be required to provide such community care if the veteran's primary care provider and the veteran agree it is in the best medical interest of the veteran to do so, based on criteria to be developed by VA that consider the nature and frequency of the needed care and how accessible that care is to the veteran. In addition, VA would be authorized to offer community care if it determines that a VA medical center is not meeting the standards for timeliness and quality that would be developed by the department for different types of care. Section 101 would require VA to promulgate regulations to implement the program within 1 year.

The VCCP would replace an existing program that authorizes VA to provide community care to veterans with service-connected disabilities (SCDs) when VA does not offer the needed care or when that care is geographically inaccessible to the veteran and to women veterans who need hospital care. Under its existing program, VA currently spends roughly $9 billion a year for community care (excluding emergency care). CBO expects the VCCP could cost several times more than the existing program although several factors would limit the rate and ultimate extent of cost growth. Cost would be higher because:

VA would be required, subject to appropriations, rather than authorized to provide community care,

The number of eligible veterans would be several times larger than the number eligible for the current program,

The criteria for offering community care would be broader, and

The convenience of community care could encourage more veterans to enroll in the VA health care system.

However, CBO expects these factors would limit the rate and ultimate extent of cost growth:

A greater number of enrolled veterans receiving community care could shorten wait times for care provided in VA facilities, and thus reduce the number of veterans that need to be referred to community care because VA care is not available in a timely fashion.

Many of the regulations that need to be written to implement the program could curtail use. For instance, VA would probably require all veterans to be seen by a VA caregiver before being referred for community care.

The community care networks could be limited in size and scope, particularly in more rural areas, reducing the accessibility of such care.

VA might implement the program slowly, as happened with the VCP.

To estimate the cost of this program over the next 5 years, CBO focused primarily on the extent to which the number of veterans eligible for VCCP would be larger than those eligible for the existing community care program. The currently eligible population--veterans with SCDs and women veterans needing hospital care--represents about 30 percent of enrolled veterans. Under VCCP, the eligible population would more than triple because all enrolled veterans would be eligible.

After accounting for the factors that might restrict use, CBO estimates that in the early years of the program, the newly eligible population would use community care at about half the rate of veterans in the current community care program. In addition, CBO expects that the program would be implemented gradually. On that basis, CBO estimates that implementing section 101 would cost $17.3 billion over the 2018-2022 period.

Veterans Care Agreements. Section 102 would allow VA to enter into Veterans Care Agreements with health care providers in the community to provide hospital care, medical services, or extended care to eligible veterans. Such agreements would:

Exempt VA from using the competitive bidding procedures as required under the FAR,

Require VA to verify that those community providers meet the conditions for certification, and

Require VA to periodically review the necessity of the agreements.

Under current law, VA must comply with the FAR for agreements and contracts with community health care and extended-care providers. The FAR is an extensive and complex set of rules governing the federal government's purchasing processes. According to VA, the FAR's requirements are appropriate for large and long-term agreements for contracted health care services but may not be practical for case-by-case arrangements in all regions of the United States. This bill would allow VA to use other agreements for certain health care services and extended care provided outside the VA system.

For 2018, the Congress has provided roughly $10 billion for community health care at VA (excluding the VCP). Using information from VA, CBO estimates that implementing section 102 would give VA the legal authority to continue to provide about 40 percent (or $4 billion annually) of that community health care. After adjusting for inflation and accounting for existing appropriations, CBO estimates that implementing this section would cost $17.3 billion over the 2018-2022 period.

Expansion of the Family Caregivers Program. Section 301 would expand access to the Family Caregivers Program, which provides stipends, health insurance, respite care, training, and other forms of support to caregivers of eligible veterans enrolled in the program. Veterans are eligible for the program if they require assistance in activities of daily living, such as bathing, eating, or grooming, as a result of injuries incurred during military service on or after September 11, 2001. Section 301 would open that program in two stages to eligible veterans of any era and would expand its benefits to include legal and financial-planning services. In total, CBO estimates that implementing section 301 would cost $3.1 billion over the 2018-2022 period.

Under stage one, eligible veterans who were injured during service on or before May 7, 1975, could enter the Family Caregivers Program. That stage would begin within 2 years of enactment (after VA develops and certifies a new information technology [IT] system to track benefits, as required under section 302). Stage two would begin 2 years after stage one and would open the program to the remaining eligible veterans-- those injured during service after May 7, 1975, and before September 11, 2001. For the purposes of this estimate, CBO assumes that the bill will be enacted near the beginning of calendar year 2018, that stage one of the proposal will begin early in 2020, and that stage two will begin early in 2022.

In 2016, costs for the Family Caregivers Program totaled $493 million, about $19,000 per participating veteran. Most of that cost resulted from monthly stipends paid to caregivers. Stipends are based on the hours of daily care the veteran requires and the prevailing wage for home health aides. In 2016, the annual stipends paid under the program ranged from $7,800 to $30,000 and averaged roughly $20,000. Caregivers also are eligible to participate in the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), a program run by VA that provides health insurance for dependents and survivors of certain disabled veterans. In addition, the Family Caregivers Program provides up to 30 days of respite care each year as well as training and 15 other support services. In 2016, costs under the Family Caregivers Program for CHAMPVA and the remaining services averaged about $2,600 per veteran.

CBO's estimate of the cost of expanding the caregivers program is based on the patterns of use and the average costs of the existing program and the number of veterans with significant, service-connected disabilities in the cohorts that would be newly eligible. Furthermore, to account for the advanced age of the newly eligible veterans, the estimate reflects the following findings from a 2014 RAND study:1

1Rajeev Ramchand and others, Hidden Heroes: America's Military Caregivers (RAND Corporation, 2014), www.rand.org/pubs/ research_reports/RR499.html.

Disabled veterans rely more heavily on assistance for daily activities as they age,

Older veterans tend to rely on older caregivers, and

Health care costs for caregivers increase with age.

For stage one, CBO estimates that about 22,000 additional veterans would participate in the program in 2020, increasing to roughly 46,000 by 2022. CBO expects that the youngest would be in their late 60s. After factoring in a heavier reliance on caregiver assistance for activities of daily living and higher health care costs for an older group of caregivers, CBO estimates that the average cost per participant in 2020 would be about $30,500. However, VA already provides respite care to assist some caregivers through its General Caregiver Program, which provides limited support services to caregivers of eligible veterans from all eras. Accounting for those current benefits in the estimate reduces the average added cost per participant to $30,000. After accounting for gradual implementation and incorporating annual inflation, CBO estimates that stage one of the proposal would cost $2.6 billion over the 2020-2022 period.

For stage two, CBO estimates that about 30,000 additional veterans would use the Family Caregivers Program in 2022. Because those veterans would be younger than the group under the initial expansion, they would have less need for caregiver assistance (with a correspondingly lower stipend amount) and the caregivers would be younger (and have lower CHAMPVA costs). After accounting for existing benefits under the General Caregiver Program, the average incremental cost per participant in 2022 would be $29,000, about 12 percent lower than the cost for participants under stage one in that year. After factoring in a gradual implementation for the second stage of expansion and incorporating annual inflation, CBO estimates that the additional costs for stage two of the Family Caregivers Program would be $417 million in 2022. Those costs would rise to billions of dollars a year by the end of the 10-year window, CBO estimates.

In addition, CBO estimates that roughly 30,000 caregivers in the current Family Caregivers Program (for veterans injured during service on or after September 11, 2001) would receive legal and financial support services. On the basis of the resources necessary to provide counseling under the existing program, CBO estimates an average annual cost of $130 per beneficiary for legal and financial services. CBO estimates a cost of $15 million over the 2018-2022 period to provide those benefits to individuals eligible for the Family Caregivers Program under current law. The costs of providing that additional benefit for newly eligible enrollees in the Family Caregivers Program under this provision are included in the estimates above for adding those people to the program.

Furthermore, in anticipation of the surge of new applications upon expansion of the Family Caregivers Program, VA would need to hire and train additional staff to manage the program (to staff a caregiver support line, provide outreach, and monitor the program). On the basis of program data from 2014 and adjusting for inflation, CBO estimates overhead costs of about $400 per participant to process 22,000 new applications starting in 2020. As a result, CBO estimates the additional overhead costs would be $17 million over the 2018- 2022 period.

Pay Caps for Nurses. Section 224 would increase the maximum rate of pay for registered nurses at VA to executive level III ($172,100 in 2017) from the current maximum of executive level IV ($161,900 in 2017)--an increase of 6.3 percent. VA employs roughly 68,000 registered nurses. CBO expects that such a change would result in average pay for registered nurses increasing by that same percentage, from $89,000 to $94,600 in 2017. In addition, the higher pay level could help ameliorate VA's current difficulties in recruiting and retaining registered nurses and would thus increase the total number of nurses employed by VA. Using data from VA on hiring and retaining nurses, CBO estimates that, under section 224, VA would employ roughly 71,000 registered nurses by 2022 (or a 4 percent increase above current staffing). On that basis, CBO estimates that implementing section 224 would cost $2.8 billion over the 2018-2022 period for increased compensation for registered nurses.

Section 224 also would increase the maximum rate of pay for nurse executives at VA to executive level I ($207,800 in 2017) from the current maximum of executive level IV ($161,900 in 2017)--an increase of 28 percent. VA employs about 160 nurse executives at average salaries of $136,995. CBO expects that VA would gradually increase the salaries of the nurse executives to reach a 28 percent increase, on average, by 2022. As a result, CBO estimates that increasing the cap for nurse executives would cost $16 million over the 2018-2022 period. In total, CBO estimates that implementing section 224 would cost $2.8 billion over the 2018-2022 period.

Walk-In Clinics. Within a year of enactment, section 105 would require VA to provide access to walk-in clinics operated by non-VA entities for veterans actively using the VA health care system. For their first two visits to a private clinic in any year, veterans' copayments would be limited to the amount, if any, required at VA facilities, as determined by the department. For subsequent visits, the veterans would be required to make copayments in an amount set by the department.

Using information from VA, CBO estimates that the department would reimburse about 2.7 million claims for visits to walk-in clinics each year, at an average of $200 per visit. After adjusting for time to prepare the regulations and a gradual implementation, CBO estimates that implementing section 105 would cost $947 million over the 2018-2022 period.

Agreements for State Veterans Homes. Section 103 would waive the requirements of the FAR for contracts and agreements that VA enters into with state-run nursing homes for veterans. Under current law, the state veterans' homes (SVHs) must fill 75 percent of their beds with veterans. VA pays SVHs the full cost of care for veterans with an SCD rating of 70 percent or more, under a contract or agreement. For all other veterans, VA pays SVHs a grant based on a fixed daily allowance.

According to VA, in 2015 the department used such agreements to reimburse state-run nursing homes at a daily rate of $380 for each veteran with an SCD of 70 percent or more--at an annual cost of roughly $350 million (or 37 percent of the total reimbursed to SVHs). However, those agreements do not comply with the FAR, and VA does not expect to be able to enter into new FAR agreements with any of the SVHs. In the absence of this legislation, CBO expects that VA would gradually phase out the use of such agreements as veterans who are currently under that payment structure die or leave the SVHs. Those veterans would probably be replaced by veterans under the lower daily allowance rate of roughly $100 per patient. By allowing VA to enter into agreements outside of the FAR framework, CBO estimates, this proposal would nearly triple VA's reimbursements to SVHs for veterans with SCDs of 70 percent or more.

As a result, after factoring in a gradual phase out of existing non-FAR agreements, CBO estimates that enacting this provision would cost $450 million over the 2018-2022 period. The additional costs from waiving the FAR requirements would begin in 2019. Because appropriations have already been provided for such agreements in 2018, we estimate no additional funding would be necessary in that year.

Prompt Payment to Providers. Section 111 would establish standards for prompt payment of claims for reimbursement for health care provided to veterans in the community, and it would require VA to enter into a contract or agreement with a nondepartment entity to process those claims. In total, CBO estimates, implementing this section would cost $305 million over the 2018-2022 period.

Expedited Processing of Claims. Currently, department standards require VA to process 90 percent of claims for reimbursement of non-VA health care within 30 days. However, VA has been unable to meet such standards. Under section 111, VA would be required to reimburse non-VA providers within 30 to 45 days of receiving a completed claim form. On the basis of a report by the Government Accountability Office and information from VA, CBO estimates that the department would need 340 additional claims processors at an average annual compensation of $51,000 to meet the expedited time frame for reimbursing existing non-VA health care. After factoring in the period for VA to prepare regulations in 2018, CBO estimates that expediting the processing of claims for such health care would cost $62 million over the 2018-2022 period.

Contracted Claims Processors. Section 111 also would require VA to outsource the processing of claims for non-VA health care. Currently, VA employs about 2,000 claims processors for that purpose at an average compensation of $51,000. CBO expects that the costs for using contractors rather than VA employees would be the same; therefore, no additional costs are estimated for replacing existing VA claims processors with contractors.

Upon entering into contracts for claims processors, CBO expects that VA would offer current existing claims processors the following options:

Accept placement in another vacant local position at VA,

Relocate to a position that already exists in another VA location, or

Voluntarily separate from VA employment.

CBO estimates that placing one-third (or about 600) of the claims processors in other local positions would present minimal costs for administrative duties to select and train the staff. CBO expects that the other two-thirds (about 1,100 claims processors) would relocate or voluntarily end their employment at VA. Using information from VA, CBO estimates that the average cost for relocation or incentive payments for voluntary separation would be $20,000 per employee. As a result, CBO estimates that relocating or ending employment for VA claims processors would cost $24 million over the 2019-2020 period.

Processing New Claims. In order to handle the additional claims of the VCCP established under section 101 of the legislation, CBO estimates that VA would gradually expand the contract discussed above to account for the more than doubling of non-VA health care. By 2022, an additional 2,230 processors would be needed at an average annual compensation of $51,000. After factoring in a gradual implementation of the program, adding those claims processors would cost about $220 million over the 2018-2022 period.

Shared Medical Facilities. Section 242 would allow VA to enter into agreements with other federal departments to construct shared medical facilities.

Implementing this section could reduce VA's share of the cost of some construction projects and some projects would no longer require legislative authorization. Using information from VA, CBO estimates that the total cost for such major construction projects would average about $100 million each year. On that basis, CBO estimates costs of $225 million over the 2018-2022 period for additional construction projects.

Section 242 also would expand VA's authority to enter into leases for medical facilities. CBO estimates that VA would enter into one additional lease each year, with a total annual rent payment of $3 million. For those leases, VA would record obligations of $7 million each year as it enters those contracts at a cost of $13 million over the 2021-2022 period for additional leases. Entering into those leases also would increase direct spending; which is discussed below under the heading "Direct Spending."

In total, CBO estimates section 242 would cost $238 million over the 2018-2022 period.

Staffing Vacant Medical Positions. Within 180 days of enactment, section 206 would require VA to identify and fill vacant positions in the areas of mental health care (such as psychologists, psychiatrists, and additional therapists and counselors) and staff on Patient Aligned Care Teams or PACTs (such as mental health professionals and primary care physicians). PACTs use a team-based model of care to address the comprehensive needs of patients receiving health care at VA medical centers.

VA has advertised vacant positions for mental health professionals and primary care physicians. CBO estimates about 130 vacant positions for mental health professionals and 130 positions for primary care physicians in PACTs would be filled under this section. Using information from VA, CBO expects an average compensation of $120,000 for a mental health care provider and $220,000 for a primary care physician in 2018. VA would probably need to offer special recruitment incentives (such as hiring bonuses) to meet the hiring deadline under this proposal. Under current law, VA offers up to 25 percent of the rate of basic pay as a recruitment bonus. Such onetime bonuses would amount to roughly $23,000 for mental health providers and $43,000 for physicians. After accounting for the expected growth in wages, CBO estimates that implementing this section would cost $230 million over the 2018-2022 period.

Reimbursement for Education of Nurses. Section 213 would require VA to reimburse nurses for up to $1,000 of the cost of continuing professional education. Under current law, VA is only required to reimburse physicians and dentists for such costs. However, the department currently reimburses registered nurses an average of $500 per year. VA employs roughly 68,000 registered nurses. CBO estimates that this provision would increase reimbursement for continuing professional education by $500 per nurse, on average. As a result, CBO estimates that implementing this section would cost $162 million over the 2018-2022 period.

Transplant Donors. Section 252 would allow VA to cover costs related to organ transplant procedures for veterans and their living donors at nondepartment facilities. Currently, VA covers the medical and service expenses (such as transportation and lodging) for veterans and their living donors only for procedures performed at the Department of Veterans Affairs Transplant Centers (VATCs). For procedures that take place at nondepartment facilities, VA reimburses donors only for transportation and lodging. In 2017, VA provided 560 organ transplants, most of which occurred at VATCs. Of those operations, about 200 were for kidney transplants and about 20 were with living donors.

Continues with Part 5 of 7

TARGETED NEWS SERVICE: Myron Struck, editor; 703/304-1897; [email protected]; https://targetednews.com