As we move toward more individualized, home-based approaches throughout our programs for aging and disabled Americans, the time has come for a strategic, bottom-up examination of how we support both these Americans and those who care for them. …Through the work of a new advisory committee, we will undertake a comprehensive assessment of the experience of caregivers, the recipients of their care, and how our system supports them.
As Prepared for Delivery
Good afternoon, everyone. Thank you, Sarah [Verardo], for that introduction, and thank you, Sen. [Elizabeth] Dole, for inviting me here today. You have done remarkable work to shine a light on the accomplishments and needs of military caregivers, our country’s hidden heroes.
It is an honor to be here alongside Vice President Pence and [Veterans Affairs] Secretary [Robert] Wilkie. It is also an honor to serve under a president who cares as deeply about fulfilling our promises to veterans as President Trump does. Finally, it is an honor to address all of you here, every one of whom in some way contributes to fulfilling those promises and caring for those who have served our country.
The work done by caregivers—all 45 million of them in the United States today—often goes unsung—and yet our families, our communities and our whole healthcare system depend on them.
The department I lead, the Department of Health and Human Services, depends on the work of caregivers, too. Our mission is to improve the health and well-being of every American.
That includes America’s 20 million veterans, several thousand of whom we are proud to employ at HHS and millions of whom we support through the healthcare and human services programs we run. We as Americans owe veterans, especially disabled and older veterans, a unique duty, and we at HHS recognize that.
HHS is a massive agency: At $1.3 trillion in budget, we almost double the Pentagon in size. We run more than 300 individual programs: some huge, like Medicare and Medicaid, and some much more specialized. We also support public health work and research into the biomedical and social sciences, which includes working on issues of special concern to veterans, such as pain, prosthetics and trauma.
But even as such a massive department, we rely on so many other partners to ensure Americans receive the care they need.
All of you know that very well: HHS, alongside VA and other government agencies, support veterans and their caregivers in various ways. But ultimately, the responsibility falls on individual caregivers to actually provide the support needed by those whom they love.
We are attentive to the fact that each caregiver, and each veteran they care for, has individual needs. It can be easy to forget when you are running a department larger than the Pentagon, but the best way to care for those in need is to take an individual approach.
Today, I want to talk about how we are implementing that kind of individual approach across HHS programs, in Medicare, Medicaid, and the systems we run for aging Americans and Americans with disabilities. Then, I want to recognize how important the perspective of caregivers will be to building a system that cares for today’s veterans and future generations.
We need flexibility and individualized approaches not just because each person has unique needs, but also because the needs of veterans and their caregivers are always changing. As one example, the RAND study commissioned by the Dole Foundation found that rates of mental health challenges and substance use disorder among post 9/11 veterans are almost twice as high as among the pre-9/11 generation. This requires new levels of support for caregivers, and new expertise and understanding for all of those who support them.
Thankfully, in many ways, the American system is set up to adapt to changing circumstances and individual needs. In part, this is because many efforts to support veterans and their caregivers occur outside of government.
The RAND study found that the most common source of support for military caregivers is, by far, friends and family. After that, it’s VA. But almost tied with VA are churches or other places of worship, and not far behind that, private organizations that specifically support military caregivers.
This constellation of resources can help meet the particular needs of caregivers and the veterans they care for. Ideally, we can set up our large government programs in much the same way: delivering flexible supports and services, rather than a one-size-fits-all approach.
This is a major priority for HHS, one that is crucial to building a system that works for all Americans who are caregivers, and all Americans who will eventually need long-term care.
An individualized approach is especially important to supporting Americans with serious healthcare needs in their homes, rather than in an inpatient facility. No American should be in a nursing home who doesn’t need or want to be—but helping Americans stay in their homes is an incredibly complex challenge. Where one person may need more attention from a skilled nurse, another needs modifications to his home or help preparing meals.
We can address this challenge through making our programs better at addressing not just needs on an individual basis, but also more holistically. It is penny-wise and pound-foolish for us to be willing to pay for healthcare in the form of hospital or nursing home stays, when older adults and people with disabilities could remain in their home if they and their caregivers had access to the right supports.
This year, we were pleased to unveil new flexibilities in the Medicare Advantage program that will allow these private Medicare plans, which cover more than one-third of seniors, to pay for a greater array of benefits that can support health. These can include transportation, in-home health visits, home-delivered meals, home modifications, and more. Two of the largest insurance plans, in Florida and Texas, will pay for up to 42 hours of help from a home health aide for people who need help at home to provide their regular caregiver with a respite.
We are also seeing more shifts to meet individual needs and support home-based care in the Medicaid program, which covers nearly 1 in 10 veterans and pays for 60 percent of the nursing-home spending in America. It’s important to provide that coverage for Americans who need to be in a nursing home, but we’d much rather be helping Americans stay in their own homes.
HHS has been able to expand our support for what is called home-and-community-based services through an ever-growing number of demonstrations with states, which administer the Medicaid program. Today, more than half of spending on long-term care in Medicaid is on home-and-community-based services, and we are working with states to raise that number even more.
As you heard from Secretary Wilkie, providing veterans and their caregivers with the mix of services they need to maintain their independence is a priority for VA, too. This vision underlies the “Choose Home” idea being embraced by VA, and we are eager to bring our resources and expertise together to help veterans benefit from the overall shift toward more individualized and home-based services.
One great example is the work we’re doing with VA on assistive technology. Sometimes, the best way to support a caregiver is to make it possible for the person they care for to do more things on their own. Simple consumer devices, like Amazon’s Alexa, can make it possible even for people who are completely paralyzed to control their environment: turning lights on and off, controlling the television, or adjusting the temperature. There are also low-tech tools, like spoons that adjust for tremor to make it possible for people to feed themselves. Those little things add up for a caregiver, and VA and HHS are working to better coordinate our assistive technology programs to serve more people.
Another great example is the Veteran-Directed Care program, or VDC, which is a joint effort of VA and HHS. Under VDC, veterans who otherwise would be eligible for residential care are given a budget to purchase long-term support and services to live in their community. They manage the budget, decide what mix of goods and services meets their needs, and hire and supervise their own caregivers, with the support of a counselor from the aging and disability networks funded by HHS’s Administration for Community Living. Importantly, it can also include supporting friends or family in their work as caregivers.
The flexibility of this program can be remarkable in the hands of a creative family. For instance, we know of one younger veteran, who is part of the VDC program and suffered a traumatic brain injury in a recent conflict. He’s also a marathon runner, but, tragically, his injury affected his ability to remember how to navigate long-distance runs.
His wife is his primary caregiver, and also the family bread winner. She’s a pretty busy woman—she didn’t exactly have time to start training for marathons with her husband. So, the veteran and his wife realized that they could use the VDC to hire his Army buddy to run with him. He gets the support he needs to continue a hobby that helps him maintain his health and fitness. Here, a customizable approach allows one service to do double duty: supporting the veteran, and also his caregiver, who gets a respite and doesn’t have to start running marathons.
This is just one example of a unique service a veteran might need. Through the VDC’s partnership with HHS’s aging and disability networks, we can put veterans and their caregivers in contact with a whole constellation of potential services they may need.
These networks include more than 30,000 separate service providers, in communities all across the country. We want them to be a resource for all caregivers who support aging or disabled Americans, including veterans. But we know the existing system can be confusing: It’s not easy to even get a grasp on the availability of services through both HHS and VA programs, let alone to find the right service or support a caregiver or veteran might need.
Together, HHS and VA are working with states to address this. Through the “No Wrong Door” model, which every state is working to implement, caregivers who come to any of the organizations who serve older adults and people with disabilities will be connected to the services that work for them, wherever those might be found. Those could be VA services, or ACL services, or they may be services and resources available through state and local organizations. We are also incredibly appreciative of the work that the Dole Foundation and Phillips have done with VA to build an interactive roadmap for caregivers.
But better ways for caregivers to navigate our system is one challenge—a system that is fundamentally built to support caregivers is quite another.
As we move toward more individualized, home-based approaches throughout our programs for aging and disabled Americans, the time has come for a strategic, bottom-up examination of how we support both these Americans and those who care for them.
That is why we at HHS were pleased that Congress passed and funded the RAISE Act, which calls on HHS to examine the state of how we support caregivers and what a better system would look like. Through the work of a new advisory committee, we will undertake a comprehensive assessment of the experience of caregivers, the recipients of their care, and how our system supports them. I want to note that, through December 3, we are still accepting nominations for this advisory council, which by law will include caregivers.
With the help of this committee, we can start thinking about what reforms may be needed to build a system where we don’t just talk about the need for individualized care and home-based services—we offer the strongest possible support for those who provide them, too.
As more Americans age, and as more veterans live longer with greater needs and disabilities, there is no better time to start thinking about what such a system would look like.
I don’t think there is much disagreement about where we want to go: We all want a system where our loved ones receive the care they need, in their homes or in their communities, from well-supported caregivers. We all want to make sure that system works, in particular, for those who have served our country in uniform and on the battlefield. And we all want to make sure that system is a welcoming, supportive one for those who serve those who served and protected us—our nation’s military caregivers.
Delivering America’s veterans the care they deserve means supporting the hidden heroes who offer that care. And you have my commitment that HHS will always be ready to listen to you, to learn from you, and support you. Thank you very much for having me here today.