Elizabeth Dole Foundation
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Written Statement of Steve Schwab, CEO of the Elizabeth Dole Foundation Before the House Committee on Veterans’ Affairs Subcommittee on Health,

United States House of Representatives on “The Silver Tsunami: Is VA Ready?”

Chairwoman Brownley, Ranking Member Dunn, and Members of the Subcommittee, the Elizabeth Dole Foundation is pleased to provide our comments in advance of the Subcommitte’s hearing, “The Silver Tsunami: is VA ready?” We applaud the Subcommittee for focusing its attention on VA’s readiness to meet the needs of the largest cohort of veterans, baby boomers, as they enter old age.

We thank the Subcommittee for its continued support of the estimated 5.5 million military and Veteran caregivers nationwide, many of whom are caring for an aging Veteran population. According to the 2012 U.S. Census brief, there are over 12.4 million veterans who are 65 years old or older, mostly consisting of those who served in World War II, Korea, Vietnam, and even the Persian Gulf. Every conflict or military engagement comes with its own unique set of health challenges for active duty service members, and as veterans age, the long term effects of their injuries or illnesses are only compounded by the natural effects of aging.

A recent GAO report found that more than half a million veterans received long-term care from the VA in 2018, either in a nursing home or through elder care and home support programs.  Demand for long-term care increased 14 percent from 2014 to 2018, alone.  Over the next decade, pre-9/11 veterans will increasingly require long-term care.  The VA projects that their spending on long-term care will double by 2037. However, increasingly, aging seniors and baby boomers are seeking to age-in-place and remain in their homes for as long as possible before seeking institutional care. In fact, a 2016 AARP study found that more than 90 percent of adults over the age of 65 report they would prefer to stay in their current residence as they age. Home-based geriatrics care is an attractive option for patients and the VA alike, potentially representing millions of dollars in savings each year. However, a home-based solution is often dependent on family caregivers, who support everything from medication assistance and wound care to food preparation and mobility assistance.

In 2014, the Elizabeth Dole Foundation commissioned a study by the RAND Corporation to better understand the needs of our nation’s Hidden Heroes, the spouses, parents, siblings, and other loved ones providing care for our nation’s wounded warriors. Beyond quantifying the number of military caregivers as 5.5 million individuals nationwide, the report provided us with insights regarding the demographics of this population and specific challenges these military families were facing. Key findings from this study include:

  • Seventeen percent of civilian caregivers reported spending more than 40 hours per week providing care (8 percent reported spending more than 80 hours per week)
  • Military caregivers consistently experience worse health outcomes, greater strains in family relationships, and more workplace problems than non-caregivers, and post-9/11 military caregivers fare worst in these areas.

The Elizabeth Dole Foundation commends VA’s Geriatrics and Extended Care Program and their new Choose Home Initiative which seeks to establish partnerships to support aging veterans with home aids and support within their homes.  However, evidence is mounting that more support is needed to help the millions of military and veteran caregivers who will increasingly be called upon for support as veterans age over the next decade.

 A cornerstone of this additional support is expansion of the VA Program of Comprehensive Assistance for Family Caregivers (PCAFC) that was authorized in the VA MISSION Act of 2018. To date, PCAFC has been restricted to post-9/11 veteran caregivers, effectively shutting out the estimated 4.4 million veteran caregivers who support pre-9/11 veterans. With the MISSION Act, VA was authorized to use a phased approach to expand PCAFC to eligible veterans from all eras. However, despite passage of the MISSION Act in 2018, expansion of the program has been met with frequent delays by the VA, with the Department struggling to get new technology and processes in place to be able to process new applicants to the program. We ask that the Subcommittee continue to pressure VA officials for updates regarding the PCAFC expansion effort, so that we are supporting the millions of Hidden Heroes nationwide who are providing countless hours of support to our wounded warriors each day.

Beyond the PCAFC, there are a number of other VA programs that provide support for aging veterans and their caregivers.  These include:

  • The VA Fiduciary Program
  • Veteran Directed Home & Community-Based Care
  • Aid & Attendance Pension Benefit
  • Housebound Pension Benefit
  • Respite Care


We have provided a short summary on each of these programs below for your reference.


VA Fiduciary Program

The VA Fiduciary Program was established to protect veterans who, due to an injury, disease or aging issues, are unable to manage their financial affairs.  In these instances, VA will appoint a fiduciary to oversee financial management of VA benefit payments. Often time, family caregivers or other family members serve as fiduciaries for beneficiaries, however if family or friends are not able to serve, the VA can also work with qualified individuals or organizations to serve this role.

The Elizabeth Dole Foundation notes that the Fiduciary Program is an important resource for caregivers of aging veterans. Often, these veterans are receiving a number of different benefits that must be managed – VA benefits, social security payments, retirement benefits, etc.  While becoming a fiduciary comes with a number of important responsibilities, the program allows for the caregiver to be an active member of the Veteran’s team and ensure that the financial well-being of the veteran is in order.

Veteran Directed Home & Community Based Care

In partnership with the VA, the Department of Health and Human Services established the Veteran Directed Home & Community Based Care program (formerly known as VD-HCBS). Veteran Directed Home care is a consumer directed service that allows for veterans to choose what kind of care they need and deserve. Since the program’s launch, the Elizabeth Dole Foundation has heard from countless veterans and caregivers participating in the program that the flexibility of the care model has increased their family’s quality of life substantially. However, a challenge with the program is that it is only offered in 37 states and individual VA Medical Centers are responsible for establishing a Veteran Directed Home Program at their facility.  We ask that the Subcommittee pressure the VA to push for full expansion of the program to all 50 states.

VA Aid & Attendance Benefit

Under this Veteran Benefits Administration benefit, eligible veterans may receive a VA Aid and Attendance monthly benefit added to their monthly VA pension to help with activities of daily living. A Veteran may use these funds to pay an informal caregiver to provide the care and support they may need. This informal caregiver can be an adult child, grandchild, or other family member; however paying a spouse to provide that in-home care is not viable through this option. Like many of these options, the eligibility for this benefit is a challenge. In order to be eligible, the veteran must first qualify for the basic VA pension.

Housebound Pension Benefit

Similar to the Aid & Attendance pension, the Housebound Pension Benefit allows veterans who is permanently disabled to pay a non-spousal relative to be their caregiver. In order to qualify for this pension benefit, the veteran must qualify for a basic VA pension and prove that they are unable to leave the home due to disability.


No matter the benefits that a veteran and their caregiver may qualify for, respite may be the most important benefit that is available to a caregiver. Respite allows for a caregiver to take a short-term break to recharge. While the VA does offer respite, not all caregivers qualify. Respite care is also offered through a myriad of local and state resources through grants from the Department of Health and Human Services and the LIFESPAN Respite Care Act. The challenge of having respite care offered through many different venues and different eligibility requirements, means that caregivers may feel too exhausted to explore their options because it is too much work to navigate the systems on their own. The Elizabeth Dole Foundation has long advocated for accessibility to quality respite care for veteran caregivers. If a caregiver is not able to provide the care their veteran needs due to caregiver burnout, the family may have to explore the options of institutional care.


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Often Veteran caregivers give up their lives to serve their veterans and ensure that they receive the quality of life they deserve after making the ultimate sacrifice in service to our nation. As the American health care system prepares for the largest population subset to enter retirement, the Veterans Health Administration and the Veterans Benefits Administration must also prepare to support the Veteran caregivers that will be taking care of these aging veterans. With statistics showing that many pre-9/11 Veteran caregivers are often the children of veterans, this may mean they are part of the “sandwich generation,” providing simultaneous care for their parents and their children. This will bring about its own set of challenges that the DoD, VA, and HHS must be prepared to address.

A challenge that will need to be addressed is the eligibility and criteria for these benefits and programs. The Elizabeth Dole Foundation urges Congress, the VA, DoD, and HHS to listen to the caregivers who are performing these tasks for this population of veterans to better understand their needs so the systems can be better prepared for the “silver tsunami.”

Thank you again for this opportunity to provide a written testimony to the House Veteran’s Affairs Subcommittee on Health for the “Silver Tsunami: is the VA ready?” hearing. We look forward to our continued work together to support our nation’s military and veteran caregivers.