VA Secretary David Shulkin testifies at a House Veterans' Affairs Committee hearing on veteran caregivers, Feb. 6, 2018 on Capitol Hill. Next to him is Margaret Kabat, acting chief consultant on care management, chaplain and social work service for the Veterans Health Administration.

WASHINGTON — Department of Veterans Affairs Secretary David Shulkin is considering new restrictions to a program that provides monthly stipends and other assistance to family caregivers of post-9/11 veterans.

Testifying before the House Committee on Veterans’ Affairs on Tuesday, Shulkin said he wanted to limit eligibility for the program to the most severely injured and ill veterans in order to expand benefits to veterans of all eras without inflating costs.

As is, the Program of Comprehensive Assistance for Family Caregivers provides monthly stipends, medical training and access to other services, such as mental health counseling, to family members of veterans injured after the 9/11 terrorist attacks. Some advocates have fought for years for an extension of caregiver benefits to veterans injured before 9/11, describing it as an unfair disparity.

Officials with President Donald Trump’s administration told Congress last month that the White House couldn’t support an extension because of fiscal restraints, but Shulkin said Tuesday that new eligibility criteria would allow for an expansion without the cost.

“We can do this in a cost-effective way and focus on who needs the benefit the most,” he said. “This is about learning how we can do this better going forward.”

Shulkin wants to restrict eligibility to veterans who need help with at least three activities of daily living, such as eating, bathing and dressing. Veterans with cognitive dysfunction would remain eligible, he said.

With the changes, the 26,000 caregivers already enrolled into the program could still receive the benefit with the old rules, Shulkin said. The new rules would apply to all new enrollees.

If the program were expanded with the current eligibility rules, the VA would enroll 188,000 caregivers in the next 10 years, the agency estimated. With proposed restrictions, the number of caregivers receiving assistance would grow to only 40,000 in the next 10 years. The agency predicted it would avoid about $2.5 billion in implementation costs.

Legislation to expand the program has been stalled in the House and Senate for months because of disagreements over costs. Rep. Phil Roe, R-Tenn., chairman of the House committee, said he thinks an expansion — done in coordination with eligibility restrictions — would hit the right balance to garner enough support to pass through Congress.

Democrats concerned over restrictions

But a group of Democrats in the House and Senate cited concerns about the VA altering regulations to restrict eligibility for the caregivers program. In a pair of letters submitted to the VA on Monday, 16 senators and representatives on the veterans’ affairs committees expressed worries the agency would make changes that would lead to an overall decrease in the number of veterans being served.

“I am concerned… that the VA may attempt to justify cuts or changes to the program at the expense of our most vulnerable veterans, rather than working to improve and expand the program,” Rep. Julia Brownley, D-Calif., said Tuesday.

In part, their suspicions were caused by guidance from White House officials last month that suggested the Senate Veterans’ Affairs Committee eliminate a proposal from a broad VA reform bill that would expand caregiver benefits to veterans injured pre-9/11. The guidance cited fiscal restraints as the reason Trump’s administration couldn’t support an expansion.

In their letter, the Democrats warned the agency against going beyond the scope of its authority.

“We want to strongly caution the VA against considering any modifications to eligibility that would lead to any decrease in benefits provided or number of veterans served and urge you to consult with us on the nature of these issues before moving forward with any modifications to the program,” they wrote. “It is the VA’s job to implement the laws as Congress writes them, not to artificially narrow the laws in regulations.”

Shulkin told reporters following the hearing Tuesday that he would present new eligibility standards to Congress, which would be responsible for any final decision.

“We’re just going to provide the very best recommendations that we can to congress,” Shulkin said. “It’s up to them. They built these eligibility standards into the current law, so it will be theirs to decide to change.”

VA gathering input

Shulkin also argued the eligibility changes could bring more consistency to a flawed program.

The VA initiated a review of the program last April, following an NPR investigation that found 32 VA medical centers had cut the number of families from the program since 2014, some of them by more than half. There were inconsistent decisions across the VA system about who should be removed, and some caregivers and veterans were kicked out erroneously.

“Needless to say, significantly higher-than-expected demand for the program has created set-backs,” Roe said. “There has been miscommunication, confusion, and frustration from veterans, caregivers and VA employees alike concerning practically every aspect of this program.”

Since April, the agency stopped removing veterans from the program for three months while it trained employees who work with caregivers, Shulkin said. Prior to the training, the VA removed an average of 237 caregivers each month from the support program. Now, an average of 192 are removed.

The VA was seeking input recently from the public about possible changes, such as how injured a veteran must be to qualify, how often their eligibility should be reassessed and how the VA should calculate monthly stipend amounts.

The one-month public comment period ended Monday and garnered about 300 responses. The VA will go through the answers in the next six to eight weeks, find patterns and use the answers to guide regulatory changes, Shulkin said.

“The VA leads the country in an unprecedented way in providing care like this, and in every program where you’re leading the way, there’s no road map,” he said. “We had inconsistencies in this program and felt it wasn’t working the way we thought it should. That was really unacceptable.”

Fighting for expansion

In its request for public comment, the VA asked for input only about changes that the VA could make under the current law, not about whether caregiver benefits should be extended to pre-9/11 veterans, which would require an act of Congress. But many respondents pleaded for an expansion in their comments, anyway.

One commenter, Annette McNamara, who signed off as “grandma” on her comment, wrote: “Please don’t divide the wars against each other with this program.” Another commenter, LaDonn Hembree, wrote: “I think that it is very sad when spouses such as myself do not qualify as a caregiver to my husband because he served at the wrong time.”

The comments are indicative of a prevailing feeling among veterans, caregivers and advocates that an unfair disparity exists between veterans injured before and after 9/11.

“There are a lot of aging caregivers that have been doing this for decades,” said Rep. Elizabeth Esty, D-Conn. “I think it’s unfair and unwise not to give them the assistance that they deserve after all this time.”

Last March, when Shulkin was pressed on the issue in front of a congressional committee, he said the caregiver program “needs to be for all veterans.”

He reiterated that message Tuesday, with the caveat that more eligibility restrictions accompany an expansion.

“I believe we must expand caregiver support to all eligible veterans who need it. Let me repeat that, I am in favor of expanding this benefit to those who are pre-9/11,” Shulkin said. “Regardless of any age, of when they served. But we have to do it in a way that’s very thoughtful.”

Representatives from the Elizabeth Dole Foundation, Paralyzed Veterans of America and Disabled American Veterans – groups that have long-fought for an expansion of caregiver support – said Tuesday that they supported the restrictions that Shulkin wants to carry out, as long as they’d lead to more pre-9/11 veterans receiving care.

“We are not adverse to the secretary’s proposal,” said Adrian Atizado, who is with Disabled American Veterans. “I want to make sure the committee is sensitive to the urgency of having to do this. Every day we have members who are passing away and family caregivers who are impoverishing themselves and need help now.”

Sarah Dean, with Paralyzed Veterans of America, told lawmakers PVA would also support the eligibility changes but said, “It won’t be the end of the conversation.”

wentling.nikki@stripes.com

Twitter: @nikkiwentling