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Senators attach VA caregiver expansion to ‘Choice’ reform plan

By TOM PHILPOTT | SPECIAL TO STARS AND STRIPES Published: December 7, 2017

The Senate Veterans’ Affairs Committee has embraced a plan from Sen. Patty Murray, D-Wash., to expand eligibility for Post-9/11 caregiver benefits to older generations of veterans and caregivers, attaching her bill to a legislative package whose centerpiece — reform of the Choice program — is seen as critical for Congress to pass, if not this month then by early next year.

“It is moving with another bill that has a lot of member support, so that gives me a great deal of hope,” Murray said in a phone interview immediately after the committee voted 14-1 last Wednesday to forward its omnibus veterans bill, the Caring for Our Veterans Act (S 2193), to the full Senate for debate and a vote.

Murray conceded there are still high hurdles to clear, including end-of-year budget chaos with Republican leaders planning to extend the freeze on spending levels from fiscal 2017 at least through Dec. 22 to avoid a government shutdown.

Also, the Caring for Our Veterans Act carries a five-year price tag of $56 billion, including $3.4 billion to expand eligibility for and to improve caregiver benefits. A Choice reform package taking shape in the House would cost $15 billion less and doesn’t include caregiver benefit expansion, leaving lawmakers with a significant disparity to reconcile. Passage of any Choice reform legislation before January, when the first term of the 115th Congress expires, is increasingly unlikely.

Whether passage occurs in December or in the early months of 2018, Murray is hopeful that she and Senate colleagues, buoyed by strong support of veteran service organizations, can keep expansion of caregiver benefits part of any final Choice reform package that is negotiated with the House.

Even if this strategy succeeds, caregivers of severely injured veterans from earlier wars face at least a year’s wait and possibly longer before the first group of them gains eligibility for a monthly stipend, skill training and other benefits that first became available to the Post-9/11 generation of caregivers six years ago.

That caregivers of vets from earlier wars, including Vietnam and Korea, aren’t yet eligible for benefits bestowed on Afghanistan and Iraq war veterans “is something I hear about all the time from those I call the hidden heroes of this country,” Murray said. The caregivers didn’t go to war, she added, “but are caring for someone who did, who needs that care, and [to provide it] they give up so much. To know we are moving forward to expand [benefits] to veterans of all ages, and to expand some services I know are so critical, is a great first step.”

Replacing Choice: The foundation of the Caring for Our Veterans Act, however, are provisions to replace the flawed 2014 Choice program, which Congress rushed to enact amid a VA patient wait-time scandal. It was meant to give veterans greater access to private-sector care if their waits for VA care are longer than 30 days or involved one-way trips longer than 40 miles.

The Senate committee, led by Chairman Johnny Isakson, R-Ga., and ranking Democrat Jon Tester, of Montana, has endorsed the Choice replacement plan that Veterans Affairs Secretary David Shulkin and staff shaped over the past year. It would scrap wait-time and mileage triggers for automatic access to non-VA community health care. Instead, each VA-enrolled patient would be assigned to a VA primary-care provider who would be responsible for all referrals, including to non-VA care, based on clinical needs and after consulting with the patient.

The reform plan, which VA calls the CARE (Coordinated Access & Rewarding Experiences) Act, also would consolidate seven “community care” programs down to one, strengthen partnerships with non-VA providers and state and federal departments, improve payment processes and information sharing with private-sector providers, and build out high-performing civilian provider networks across the country to support VA in giving veterans timely, quality care when VA cannot.

The plan also would authorize VA to negotiate with a commercial retailer like Walgreens or CVS to offer veterans access to walk-in clinics for treatment of minor injuries or illnesses. Shulkin said the first two visits per year would be free for veterans with service-connected conditions with other veterans paying the same co-pay they do at VA. After two visits, veterans with service-connected conditions would see a modest co-pay and others would pay more than they do for VA care.

Rep. Phil Roe, R-Tenn., chairman of the House Veterans’ Affairs Committee, unveiled his own plan to replace Choice in late October. His bill VA Care in the Community Act (HR 4242) would be similar to the Senate plan but doesn’t support a network of commercially run walk-in clinics.

As the two chambers move to adopt a final Choice reform plan, VA has confirmed reports that it, the White House and the Department of Defense, are considering having veterans use the Tricare networks of civilian health care providers that the military relies on to support its own medical system. The Trump administration sees significant potential savings from a merger of networks.

The issue wasn’t discussed, however, at the Senate committee hearing last week nor by the House Committee when Roe unveiled his own Choice reform bill.

In recent months these committees seemed intent on having a replacement plan for Choice approved this month, given that funds for Choice are to run out by early January. The goal now appears to be to keep Choice operating through 2018 with a fresh appropriation of as much as $4 billion. That would give the House and Senate months longer to reconcile plans to replace Choice and perhaps consider what role Tricare networks might play in any final design.

Caregiver expansion: So far only the Senate bill of Choice reforms includes language to expand eligibility for caregiver benefits. But Murray and caregiver advocates note that both Isakson and ranking Democrat Tester gave the caregiver provisions a strong endorsement in marking up their bill last week.

The House committee didn’t hold a hearing this year on a companion caregiver bill introduced by Rep. James Langevin, D-R.I., but it has 82 co-sponsors.

Under these bills, caregiver benefits couldn’t be expanded to older generations until VA certifies it has modernized its information technology sufficiently to support a bigger program. The could take at least a year.

Benefits then would be extended first to caregivers of veterans severely injured in the line of duty on or before May 7, 1975, which would include the Vietnam War and earlier conflicts. If that expansion runs well, two years later eligibility for the program would be opened to veterans with severe injuries incurred in the line of duty from May 8, 1975 through Sept. 10, 2001.

More than 22,000 Post-9/11 veterans are currently eligible for benefits. The Congressional Budget Office estimated last year that 20,000 more veterans would benefit from caregiver benefits in the first year of stage one expansion. That would grow to roughly 44,000 more in three years. With stage two expansion, 29,000 more veterans with caregivers, including Persian Gulf War vets, would gain access.

CBO estimated the average cost to VA per participant at $30,000 a year when planned improvements to legal and financial advice services are considered. Murray’s provisions also would seek to improve stipend calculations to more fully include observations of caregivers on the time they spend providing daily care.

“There are a lot of caregivers who are absolutely counting on this,” Murray said. “It’s survival for them and it’s what we owe them.”

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