although it could be a dangerous escalation, is really attack on the consulate in damascus, a number of iranians killed. for the first time attacking israeli soil from its soil and then israel also retaliating in the same fashion. i think and i will try to explain the view from tehran more, the israeli attack came on the heels of years of a shadow war and this was way before october 7 between iran and israel so they have been engaged in this shadow war mainly in syria across the region and they

have been back and forth but not to that level. i think what happened as far as that attack on the consulate from tehran's viewpoint was seen as an escalation and brazen attack on a diplomatic facility. gary publicly they saw that on a different level and something worth responding to. the way they reported as establishing deterrence, not necessarily escalating into something bigger. i think the response entailed from tehran's side was to show that they have the capacity to attack israeli soil and also the will. the assumption was that they wouldn't. maybe they can, but they wouldn't. that they are not interested in an open war with israel which i think is true. actually i would argue one of the sides are interested in bringing that shadow war into the open direct confrontation. the third very important party here, the united states is not interested in either direct confrontation with iran or iran and israel. so looking at that triangle, i

think the iranians saw what escalation. they tried to respond but in a calculated way they had been telegraphing they were going to respond using back channels, letting the americans now. all of that aim to that minimizing the impact or the casualties. and then the israeli response on iranian soil i think was also measured and calculated, aimed at showing they are also willing to respond but not really taking this into the next level and the role of the u.s. with the biden administration making it clear that they would be in the defense so when iran attacks the u.s. helped israel but they wouldn't engage in an offense, attacking iran, which is something that many analysts had been fearing.

the netanyahu government pulling the united states into open war with iran. i think the biden administration drew that line very clear. and that triangle essentially turned into this not really escalating into next level both sides establishing deterrence and new redlines. the redlines have been moving in blurring since october 7 across the region with the dynamic shifting. this brought iran and israel kind of to a new level but also back to where they saw they were as far as the shadow war. to your next question on weaponization, i don't think this episode has changed the thinking where the policy in tehran. we just saw that letter from the iranian mission in response to the e.u. letter yesterday

emphasizing diplomacy, the fact that their nuclear program is peaceful, not interested in weaponizing. i think tehran once enjoyed being in this threshold state that kelsey explained in much better detail but not breaking into an actual weapons program. having the option, using that as leverage. but i don't think the calculation is to weaponize, the policy hasn't been that for about two decades. so until he is alive, he is supreme leader and nothing really major has changed or shifted, even that episode with israel, some thought maybe that would be the final straw, but that didn't change. so unless something major

happens like a u.s. attack on iran's nuclear program ironically may actually change that kind of decision-making. but i don't foresee anything major that would make them shift towards the weapons program but i think they enjoy pushing the line and going even further for leverage. >> i'm going to lob a couple of questions that you. i think it's important for the people in the room to understand the distinction between the ability to produce fissile material for nuclear weapons and weaponization. that is to say the actual ability to build a nuclear device that can explode when and where you want it to. iran is now a week from the ability to produce enough enriched uranium or for one bomb

, what is publicly known about its weaponization efforts. to your knowledge is there anything to have changed the nie from 2006 which said the u.s. intelligence community believed iran had ceased weaponization efforts in 2003? where are we on weaponization and how long might it take for iran to actually build a weapon if they wish to? >> it's a fairly quick question. i'm not sure i have a quick answer unfortunately. the timeframe for produced fiscal material is relatively short. weaponization is much more difficult to gauge the time frames. many experts and myself address that waste on the work iran had done prior to 2003 when they had an organized program but if tehran really wanted to, they could probably build a nuclear weapon in as little as six months.

the congressional research service has quoted a u.s. official as saying a year, others say one to two years. but to a certain extent, that timeframe is less important when we are talking about risk because once iran has produced its fissile material, it is likely to divert that material to covert locations, possibly multiple. for the weaponization process. so if the united states or israel is looking to disrupt a bomb, the best chance that they have is in the fiscal material production phase because they know where it is and ideally because of the existing monitoring, they would have some time to try to react if it was clear that iran was enriching to 90%. that's another reason why i think that the short time frames, the lack of monitoring is so concerning.

i agree with the assessment that the supreme leader does feel bound by his fatwa and there hasn't been a decision in iran to develop nuclear weapons. current u.s. intelligence community assessments support that. but the chance of miscalculating iran's intentions right now is i think higher than it ever has been in the history of the iranian nuclear issue. we now have senior officials in iran and former officials saying that iran's calculus might change. it might rethink the fatwa security change. combine that with a weak breakout and a misperception, misinterpretation of an iranian development, and accidental spike in enrichment, all of these could put us on the path to conflict because we don't have the time to analyze the

response because i do think the united states and israel are very serious when they say they will resort to force rather than allow iran to develop nuclear weapons. so even though the weaponization timeframe makes it sound like we have more time, my fear is that these windows have become so small, the risk of miscalculation and the ability to use meaningful diplomacy if we fear breakout is quite compressed and that's why we need this diplomacy now. >> i would like to ask you both a question about what the ie knows and doesn't know. there have been no snap inspections for three years. that is to say those are the inspections where the iaea says we are going to an undeclared nuclear site and we want to see what's going on there. secondly, and i'm going to get a little wonky that i know those of you in the room will be

pleased and not dismayed by this. if i understand it right, under so-called modified code 3.1, iran is obliged under a safeguards agreement to tell the iaea if it is building a nuclear facility. and if i understand the iranians correctly, they said we are not doing that anymore and the iaea said you have to. given the absence of snap inspections and given this, does the iaea actually have the ability to figure out what it doesn't know or are we know and a world where iran is perfectly capable of building secret sites and potentially diverting some indeterminate number of centrifuge parts which i don't think the iaea knows how many there are. >> do you want to go first or do

you want me to? >> sure, i will take a stab at it. the biggest hurdle in the nuclear weapons enterprise is the fissile material production. so that should give you a sense. iran is enriching up to 60% and could go higher. so all this talk about how long does it take, the six month timeframe is used in the u.s. government or at least it was when i was there, that's kind of an assumption. once you get the fissile material, anybody should pretty much be able to do it. my guess is that it's much shorter for iran. i think you can rebar between the lines of -- read between the lines of iaea and understand that their challenge.

and you have to ask the question, these snap inspections or the ability to go anywhere anytime, which is never really anywhere any time, and there is a host of ways in which a country can delay things, obfuscate. the weather is bad today. the road is closed. so many different ways they can do that. i don't see the modified iran's statement that it would not adhere to the early declaration of new facilities. to me that's a red herring. if they're going to have a secret facility, it's not like they are going to build it and then eventually tell the iaea. they are just going to do it. and the problem with uranium enrichment and specifically with centrifuge facilities is that there are very few signatures.

but you can detect remotely. so it is always a good thing to have people on the ground on-site inspections. it is always a good thing to be able to interview people. we found that out in iraq in the 1990's. you learn a lot of things by walking around. and seeing how people react. so i agree. the less access, the restrictions on access, that degrades the iaea's capability but i think also in the popular press and popularly, people think of the international atomic energy agency as this watchdog. it's going to go out there and find things. the truth of the matter is much more that countries who are concerned help the iaea and a

lot of that depends on levels of cooperation, levels of cooperation even within the secretariat of the iaea. and all of that cooperation has dropped down significantly. for a variety of reasons. i will leave it at that. >> kelce did so well on that, i'm going to pass over to you on this one. you talked about your review that the administration should seek a sort of de-escalate torres set of stats. you talked about dangling some carrots like the unfreezing of assets. two questions. one, do you think there is a

plausible diplomatic path to a meaningful agreement that would rollback iran's nuclear program? and second, why would iran ever trust the united states to adhere to a nuclear deal given the experience that they just had of negotiating one with the obama administration and seeing that tossed aside a couple of years later by the trump administration? >> i certainly think there's a plausible path to immediate discoloration in the short -- de-escalation in the short term. i think just last year iran was willing to engage in moderating some of its more proliferation sensitive activities in exchange for the unfreezing of u.s. assets.

the u.s. re-froze those assets after october 7. iran no longer felt bound by the voluntary actions that agreed to take. i think some of tehran's statements just around similar type of arrangement. in conversations between the atomic energy organization of iran and the iaea, those officials have said they are looking for sanctions really in exchange for additional transparency and monitoring. the iaea cannot put that on the table. united states can. i think it's critical the united states tries to follow up on this perhaps opening that iran might be signaling once the new iranian president is elected. i don't think we're going to see anything until after that election in terms of diplomacy and space. would iran be interested in a broader deal that rolls back its

program, i think that's a much more challenging question right now because iran is trying to leverage its threshold status for its security and national interests. will it be willing to give that up? i don't know, but i think we have to test that prospect because what the united states can put on the table in terms of economic benefits i still think would be attractive to iran, particularly if we can think about how to realize the sanctions lifting given some of iran's other stated goals. because of the advances i mentioned, i think rollback is challenging. this is going to have to be a much more focused monitoring arrangement, perhaps some unique elements that provide greater visibility and perhaps monitoring on some of the weaponization aspects of the program, but certainly i think there are enough indications coming from tehran that they are

interested in agreement and we have to pursue something in the short term but also think about that new framework for the long-term. because the idea of iran staying on the threshold is just not sustainable. there's too much risk, the security -- there's too much risk of miscalculation. so really we need that longer-term framework than it's worth investing time now into thinking what it's look like. >> why would the iranians trust the united states given the memories of 1953 are also quite fresh in the iranian minds? why would they engage in such an agreement? >> even the jcpoa, the trump administration withdrawal surprised many of us in the u.s. and around, sidelined that idea

of that camp in iran, the more moderate pro-diplomacy camp that there is a way that we can deliver, negotiate and get a deal. i don't think anything like that would be possible but i still think there is interest for diplomacy. it wouldn't look like something like jcpoa, something that encompassing and future looking. the jcpoa had a lot of promises in terms of investment into the future. i think what iranians are more interested in or looking for is step by step, unfreezing of assets. something tangible that you can see, that you don't have to rely on for administrations after. i think the biden administration missed a very golden window of opportunity at the beginning of the administration about six

months when they overlap with the previous iranian administration in tehran. that was really the time for the u.s., before ukraine, before october 7. before the world got so crazy to either return to the jcpoa or reach out with serious meaningful diplomacy and unfortunately that didn't happen until about april and it hit the presidential election in iran. with the death of the iranian president, there may be a new opening. we still have to wait and see. iranian elections are coming up soon. there are indications that there may be a slight shift to the center. not towards moderate or reformist by any means but a less hard-line president and a less hard-line minister could indicate -- whoever becomes u.s.

president. we have these important elections coming up in iran and also in the u.s. that can show us a path forward. going back to what kelsey was saying, even in the jcpoa they say. in more different and creative format. >> thank. if president trump is reelected. do you expect him to pursue a so-called maximum pressure policy toward iran? and is maximum pressure in an economic sense even conceivable in the world in which china seems quite happy to buy iranian oil, albeit not with its

official state refineries. one of the unusual things about jcpoa was you had this consensus among the p5 plus one and the chinese did significantly reduce the purchases. do you see maximum pressure and is that even possible today? >> i think i learned my lesson during the first trump administration of the challenges of trying to predict what might happen. you can take this with a grain of salt. i do think that we would see a second trump administration lean very hard into the maximum pressure focus with an attempt to get iran back to the negotiating table to get a deal better than the jcpoa. but as you said, maximum pressure today cannot what maximum pressure was during the first trump administration and it cannot be what the pressure campaign was in the lead up to the jcpoa in large part because

of the geopolitical situation that we are in. one thing that is striking is that we have lost some of the core unity between the p5 on certain nonproliferation norms. it was not that long ago that we had cooperation at the security council on north korea. it was not that long ago that russia and china implemented sanctions on iran under the security council and engaged very helpfully within the jcpoa context. so without that basis, i think it's going to be much more challenging to sustain pressure on iran. i could be disrupted even further if the european union or e3, france and the united kingdom go ahead with trying to impose u.n.

sanctions that were lifted under the jcpoa. there is a measure that would allow them to do that in a way that cannot be vetoed by russia and china. enacting this measure before it expires october 2025 is likely to deepen the rift between the left -- the west and russia and more importantly at the westin china because china has more influence on iran and china does not want to see iran develop nuclear weapons, but they will not want to risk the snapback of u.n. measures, so i think the international disunity makes addressing the iran crisis more challenging, and i think we have to look for more novel ways to try to reinforce nonproliferation norms at least between the u.s., europe, and china in a way that can help support addressing the iranian

crisis even if we do not directly reference iran. i think we are much more likely to garner beijing's support if we talk about nonproliferation norms were broadly, and if it is the u.s. that directs them as being applicable in the iranian case. so i think a maximum pressure will be on the table but i am not sure how maximum it will be. >> how do you think iran may respond to a trump maximum pressure campaign such as it would be? do you think one would see additional -- you know, attacks by our iranian proxies like the attacks on the oil facilities in saudi arabia? do you think you will see our iranian nuclear acceleration or regional escalation? how do you think they would respond to it? >> i think more of what we saw

under the trump administration -- let's not forget, donald trump is the person who pulled the united states out of the jcpoa and assassinated general stella many -- general soleimani. it creates a challenge for iran and the larger ally network they have, the axis of resistance to sit and negotiate and actually make a deal with this person, which is donald. so the personnel makes it very difficult. it depends also who keep rings with himself to the white house. will it be mike pompeo and john boltons, or is it going to be a new breed of person? all of that i think matters, but

assuming it will be more of the same, maximum pressure 2.0, i agree with kelsey. i do not think it achieved what he was supposed to be achieved either in the form of a better deal or making iran capitulate to the 10 point request of secretary pompeo. so i think it will be more of the same, so iran pushing the envelope as much as they can, creating headaches here and there depending upon how the regional dynamic unfolds. the war in gaza is a very top issue, how that will be by the time of the was election. will there be a cease-fire, whether we -- will there be escalation? that slows down i think all of these moving parts we have to look at and two becomes president in iran.

is it someone more to the center of the hardliners? or is it someone like the big names? all of these will make a shift that will show again the path forward. >> i would like to pick up on something you said, kelsey. someone spoke about the october 20, october 25 moment for britain and france to trigger the snapback of u.s. sanctions that will expire. you may declared you do not think that is such a good idea. do you think it might prompt iran to withdraw from the mpt? >> yes. [laughter] i think iran has been consistent in messaging that snapback would prompted to take that step.

now what i think we could see from iran is notifying of its intention to withdraw from the mpt, but using the window between notification and withdrawal to try to really leverage something from the united states and europe to get it to not follow through on withdrawal. so i think that is a long way of saying even if iran takes that step, we should not assume iran is necessarily going to develop nuclear weapons. certainly it would be concerning if iran did that, particularly if they take out all iaea sectors and do not negotiate any new arrangement, but i think that is a real risk looking to october 2025 that the europeans will do this if there is no progress on the diplomatic front, which to me again underscores that we have to be

presuming diplomacy with iran with a much more urgency, with much more creativity, more flexibility and looking to partners like china that might have more influence to try and use those relationships to address this issue before we get to october 2025, because we should not test iran on whether or not it will withdraw in that scenario. >> lets pivot to saudi arabia for a moment. sharon, what do you think we are likely to see in a u.s.-saudi nuclear cooperation deal? is there any possibility of there being a separate 1-2-3 agreement that is not embedded in the other broader things i described at the beginning and all part of a package for israeli-saudi normalization? and the last question, don't the

strategic folks always win out over the nonproliferation folks? i say that as a native washingtonian. it seems like the people who pursue strategic goals are usually able to be the people who pursue nonproliferation goals, however strategic those might be? >> let me answer that second question first, yes, which is why we need a deep guide on exactly how their strategic goals are faring. because i think historically you will see that it does not always quite worked out the way they wanted to. i thought you were going to ask me the question if iran pulls out of the mpt will saudi arabia pull out of the mpt? >> please. >> i don't know, but i like the fact that kelsey brought up or kind of implicitly suggested we should not panic immediately if iran leaves the mpt, because it

would provide them with a lot of leverage. i think your idea is great. 123 agreement should not be embedded in any kind of bigger deal, but the real problem is that the congressional review of nuclear cooperation agreements -- that process is broken. it is broken for a lot of reasons, but let me tell you how it works now. the administration signs an agreement and presented in front of congress, and it will go through does it check the requirements of section 123. invariably it says yes, and it goes through unless congress can enact a law against it. right? that is a huge hurdle. how it was supposed to work was

that the administration was supposed to consult with senate foreign to and house committee on foreign affairs. the law all along in the process, and i will say there was a hearing on the hill several weeks ago, and there were very few questions answered by the administration on this deal. so really, if somebody made me amber heard tomorrow -- made me emperor tomorrow, i would amend the atomic energy act to provide more oversight or to somehow tweak it so that it really is a better review process. there is another trend that has flown under the radar forever, and that is that these agreements -- they have a certain duration, but then there is a clause that says rolling extension every five years, or in the case of taiwan and japan

indefinite extension, so we are nuclear cooperation partners with japan and taiwan forever no matter what happens. ok, so the agreement itself says if the test nuclear the cooperation agreement is dead, but surely there must be other things short of testing a nuclear device that might cause us to reconsider. i have testified before congress a couple of times on this and made a bunch of recommendations, really i think congress needs to think hard about the approval process. in general what they have done, and that means amending the atomic energy act -- what they have done is country specific legislation. they did it on india. there is a bill on the hill right now with the saudi agreement. it is hard to pass a bill. i heard recently only 3% of

bills ever get enacted into law. above all though, also at the nonproliferation assessment statement, which at the state department is required to do any classified and unclassified way. i think that congress needs to said specific requirements for those, because the ones that i have read at the unclassified level barely scratch the surface. this is -- i understand that there is a perspective in the u.s. government now that, though, we have to do nuclear trade with a lot of countries because if we do not do with the russians were the chinese will, and our cooperation is better than theirs because we uphold nonproliferation standards. if that is the case, then we

have to be very serious about those nonproliferation standards , and i get the sense that in this rush to compete with russia and china that it is actually a rush to -- i forget what the phrase is. >> are rushed bottom. >> a rush to the bottom, exactly. if you really think nuclear energy will make a difference for climate change and we need to build thousands of reactors, this is a very serious issue that needs to get as much attention and money as the promotion of nuclear reactor exports does. >> i would like to ask you a question we got online from chase winter. what leverage does the united states have with iran given the gaza war, regional escalation, the upcoming change of supreme

leader that could change iran's political calculus? what leverage does the u.s. have vis-a-vis iran? >> i think it is a lot, was the economic leverage. iran has been over sanctioned by consecutive administrations, so the u.s. has a lot of leverage in the form of sanctions. it can be short-term, long-term, it could be in the form of oil sales, enforcement of sanctions, freezing of assets. so i think what iran is looking to the other side, and this is not just the u.s., but also europe is mostly in the form of that economic and if it were the leverage. the jcpoa promise long-term more cooperation with this especially

with europe, which is something the moderate camp in iran promised in the form of an investment, opening up trade and bilateral relations with europe. i think the hopes in iran are not that high. the u.s. has immense leverage in the form of economic incentives, but the iranians have not either publicly or privately alluded to. >> we have another online question. do you think the iranians will choose ultimately to follow the bomb on the shelf approach for the bomb in the basement approach? >> i am going to apply understand the bomb in the basement to be -- >> i don't know what the utility of having a secret promise, but

anyway. >> there is some evidence to suggest that looking in some of the documents that israel stole from iran in 2018, the atomic archive as it is referred to that iran's plan for developing nuclear weapons prior to 2003 may have been to build a small number of nuclear devices but not draw attention to then or publicly say iran had deterrence unless it was necessary for security. would iran go down that route again? i think in general it would be very challenging for iran to develop an entire parallel covert program to build nuclear weapons from start to finish without detection somewhere in the process. and i am not thinking as much

year of the iaea on the ground -- that is important, but when you think of this surveillance and intelligence gathering that the united states, israel, others do on iran, we are able to detect secret facilities in the past, and i think we would likely be able to do so again if they tried to go that complete covert pathway. my biggest concern is we would see a combination of the overt and covert if there was a decision to develop nuclear weapons, and what i mean by that is iran has this stockpile of near weapons grade material sitting at its declared facilities. if it moves that material and tries to enrich it at an illicit site, would we be able to follow that? would we be able to take action against the facility if we were able to identify it?

i may be more concerned about the bond that is between the basement and the shelf and that combination of pathways without ranking where the risk is, but i think for now absent a significant degradation of the security situation, whether that be an attack, and direct attack on iran by the united states or israel or significant degradation of iran's partners, iran will be content to stay in that threshold status unless it is induced by the united states to move back. so again, i probably sound like a broken record, but the urgency of diplomacy now is so critical that we do not have to defend against one on the shelf or in the basement. >> can i ask you a follow-up? in a way you were talking about your fear of a bomb on a u-haul truck? do you think other intelligence

agencies the track this, would you bet that they would be able to detect that? >> if it was just one, i would say it may be, yes, they would be able to detect that. nobody is worried about iran breaking out to build one bomb. one bomb does not provide them a deterrent. if they can break out to build fiber six, can we monitor five or six u-haul's? i do not want to be in a position to where we find out whether the united states or israel can actually do that, so diplomacy now so we do not have to test that capability. >> i would like to ask all of you a final question, which is to look at and night here in scenario that is several steps ahead. that is iran does choose to build nuclear weapons. it builds multiple nuclear weapons.

saudi arabia carries through with its intent to build nuclear weapons. you then see further proliferation in turkey and elsewhere. let's assume that we are all living in that world of multiple nuclear armed states in the middle east. how do you deal with that? is there any plausible way to deter those states from attacking each other, attacking the united states? how do you grapple with that ugly scenario? [laughter] >> ok, i can go first. i don't want to envision that in part because it makes me feel that i with a failed at my job if we get there, but that aside, again i think there is a difference between a willingness to possess nuclear weapons and

an intention to use them, and if we have multiple nuclear armed states, i think they will be focused on deterring each other. i imagine in that scenario the united states will still have significantly a larger nuclear arsenal that could be utilized with the partners and allies in the region that might be trying to respond to any attempt at nuclear coercion by iran, but if we do end up in that scenario it might also open the door for more creative regional solutions. and i think one thing we have to keep in mind when we think about nuclear diplomacy with iran is it is not going to be a panacea for all of the problems the united states has with iran and all the security dynamics when the region -- dynamics within the region, so we have to be supporting the regional states and looking at their own

security arrangements so that no state in the region ever gets to the point where it is going to think it needs nuclear weapons. i know, diplomacy again. thinking about nuclear diplomacy accompanied by support for regional security to prevent that reality is crucial. >> would either review like to take on that scenario? >> i commend kelsey for her diplomatic response. i will be less diplomatic. if you love the cold war, you are really going to love that proliferated world. it is a nightmare scenario for so many different reasons, and you have to ask the question at one point -- at what point does the u.s. simply throw up its hands because with so many

nuclear weapons states there, it gets very complicated. we were almost coddled by the -- and very lucky in our ability to deter nuclear war between the u.s. and soviet union and russia now so far, so that is a world i don't want to contemplate or live in, so let's avoid it. >> listen. >> it really is a nightmare scenario, i don't want to envision it. i don't think we're there yet, and i don't think it would happen overnight. a lot of things would have to go wrong for the region to get there, but i agree with sharon and kelsey. it is a nightmare, let's hope we do not get there, and let's use diplomacy. it is the only possible word and

meaningful discussion. it has been the only successful solution that was tried and succeeded temporarily, and the other path is not brought any results, so let's try to focus and use diplomacy in this space as well. >> thank you all very much for the panel ended the session, and i think we are going to have a brief coffee break, so thank you all. [applause] >> i want to thank everyone on this panel, your great moderation, and meg for stepping in at the 11th hour, and i also went to expressed a public thank you for kelsey davenport, whom i have had the pleasure to work with for over a decade who has

been leading efforts on the iran nuclear file, and i wish things were in better shape, but we will keep pressing forward. we will take a brief five minute break what we do a microphone switchover. do not go far, because we have got a great panel of on issues related to u.s. arms transfer poli

>> welcome to our first joint hearing. this joint committee hearing, this congress, entitled heroes at home, improving services for veterans and their caregivers. sen. casey: it's been more than a decade since the aging committee held a joint hearing and i want to thank senator tester and senator moran for

bringing together our two committees today to examine the important issues and unique challenges faced by veterans and their caregivers. i also want to note that senator scott will be serving as the ranking member for the aging committee hearing today that's part of this joint hearing and i'm grateful for his leadership and acting in that capacity. our conversation today is particularly timely given that tomorrow is the 80th anniversary of d-day, commemorating the allied invasion of normandy during world war ii. we thank those service members who fought on that day and obviously just saying that doesn't convey anywhere near the depth of our gratitude for all that they did to save our country and to literally save the world. and we of course extend that thanks to those who are serving today. all members of the armed forces for the work they do every day

protecting our nation. veterans and their families make great sacrifices to serve our country. our duty as members of the senate is to provide support to those who serve our country. we must provide care for those who return home from service with injuries both mental and physical, and for those who face disease or illness later in life. today's hearing is about the military family and paid caregivers who uphold this duty to provide invaluable long-term care to veterans. joining us today are some of the most resilient people in the nation. both our veterans and their caregivers. the caregivers who provide unwavering support to the men and women who served in the armed forces. i've said this before, we cannot claim to be the greatest country in the world if we do not have the greatest care giving in the world. and that includes supporting the military families and their paid

caregivers. military caregivers come in many different forms. spouses, family, friends, neighbors and paid workers. the majority -- actually more than 96% of those caregivers are women. and we'll hear from our witnesses today that caring for a loved one can place a significant physical, emotional and financial stress on the veteran, the care giver and family members. additional challenges for caregivers include navigating the v.a. system, applying for programs and finding other resources. we'll hear today from peter townsend who comes to us from susquehanna county, pennsylvania. he's joined by his wife and caregiver, lisa, and we'll hear from them about the needs and the experience of being a care recipient and what that care means to his continued quality of life and health. long-term care is intended to

provide supports and services to help people live independently and as safely as possible in the setting of their choice. care giving services may include, of course, help with activities of daily living, managing medications, transportation and so much more. the v.a. offers a wide range of long-term care programs, providing a model of how to honor the desires of those who want to continue living independently in their homes and in their communities. for example, many veterans rely on v.a. respite care so caregivers can take a much-needed time off for themselves or home health aid services to help them in their homes. excuse me. while the v.a. offers options and supports for veterans and their caregivers, we'll hear from our witnesses today that we must do an awful lot more. we must strengthen the long-term

care supports that are currently available and help more caregivers access these services. that's why i'm proud to support bipartisan and bicameral legislation to expand veterans' access to long-term care services and supports through the elizabeth dole home care act. i want to thank my colleagues, senator tester, senator moran and senator hassan, for leading on this important effort. the v.a.'s program of comprehensive assistance for family caregivers known as pc a.f.c. is an important support for family caregivers. it has, however, had challenges over the past decade. in 2017 the senate aging committee head a hearing on military -- held a hearing on military caregivers. during that hearing, two of my constituents, wanda and samuel, discussed how the v.a. pushed

them out of the family caregivers program. in response to those concerns, i released a report on the program entitled, discharged and denied. my report found that the v.a. failed to anticipate the need of the caregivers program, then abruptly discharged thousands of veterans, all without oversight or a clear appeals process. now the veterans of all eras are eligible for the family caregivers program, the v.a. must, must not repeat its earlier mistakes. the v.a. should act swiftly to ensure the program benefits every single family who is meant to serve. with the recent passage and implementation of the pact act, we've seen the largest health care and benefit expansion in the v.a.'s history. the pact act expanded access to health care for veterans who experienced toxic exposures in the vietnam, gulf war and post-9/11 eras, which has now

helped grant one million claims to veterans. we need to make sure the v.a. has the resources it needs to support these newly enrolled veterans and their caregivers and we need to make sure the v.a.'s resources are accessible to those who are -- they're designed to serve. as chairman of this committee, the aging committee, i've pushed to make the v.a. make its websites and technology accessible for people with disabilities. including injured service members as required by law. i'm pleased that the v.a. has made progress, but more work remains to be done. i'm working with senator scott to pass the senate bill 2516, the veterans' accessibility act, which will require the v.a. to establish a veterans advisory committee on equal access. to evaluate the v.a.'s compliance with all, all federal disability laws. i want to thank senator scott for your support on the

veterans' accessibility act and to the dole foundation for endorsing the bill. thank you for that. we have our work cut out for us, obviously. we need to uphold our duty and it is our duty to support our veterans and their families. we need to make sure the programs designed to serve them are working as intended and we need to make sure v.a. resources are accessible. we need to take our lessons learned from the v.a. to ensure that all who provide long-term care support and services, whether they're military or civilian, family members or direct care workers, with he need to make sure these individuals are valued and are compensated for their work. i look forward to hearing from our witnesses today about their essential work and how congress and especially the senate can better support our nation's military caregivers and their families. before i turn to chairman tester, i'm going to run out because i have to go to a judiciary committee to introduce the judge for a brief period of time and i'll be running back so i'll miss chairman tester's

opening, but i'll make sure that i tune in to c-span to see it. thank you, chairman tester. sen. tester: we will miss you for a few minutes. thank you, chairman casey, and i want to thank senator scott for being here from the aging committee, for jointly convening this important hearing with the veterans' affairs committee, to discuss veterans' caregivers. other the years -- over the years i've worked with leadership on these committees on several pour initiatives including the elizabeth dole home care act. with ranking member moran and chairman casey and the care act with ranking member braun. today we hope to get additional feedback and direction from our witnesses, to guide these and future efforts. so i want to thank all the witnesses for being here. you're critically important in this process. i especially want to welcome hanna nieskens. she's from the metropolitan of cardwell, montana.

she cares for her husband, kelly, to who was injured while serving in the montana army national guard back in 2005. that means that hanna's been kelly's primary care giver for nearly 20 years while raising three kids and working at white hall school district. i want to thank you for everything you do. you're an inspiration to the folks on this side of the dias. our caregivers do their jobs every single day. providing critical care and support to veterans when they need it most. but for them to get the support and assistance they truly need, congress needs to do its job. i want to note -- i'd like to note that the house is currently deliberating the path forward on a package of bills negotiated by the senate and house committees. this is comprehensive legislation that would expand access to home and community-based care programs for our veterans and bolster home health care staffing, attempts so strengthen the v.a.

care giver and long-term care programs. i look forward to getting this piece of legislation done by working with the dole foundation who has been a long-time champion of these issues and this legislation. i look forward to working with the veteran service organizations to finally get this over the finish line on behalf of our nation's caregivers. why? because our veterans have earned this. with that i'm going to turn it over to senator scott for his remarks. sen. scott: thank you, chair tester. good morning. i'd like to thank everyone for being here today. and want to welcome you all to this historic joint meeting of the senate aging and veterans' affairs committees. i want to thank chairman casey and tester, as well as ranking members braun and moran, for having this hearing today. it's an honor to stand in for ranking member braun today, especially on an issue so personal to me and my family and millions of americans nationwide. i would like to put in senator

braun's -- ranking member braun's testimony into the record. sen. tester: without objection. sen. scott: this hear something an important opportunity to hear about some key issues. as a navy veteran and the son of a world war ii veteran, i know the sacrifices made by our military members and their families. my dad had a sixth grade education and joined the army as a teenager. he did all combat jumps in world war ii with the 82nd airborn. he flew into normandy that morning. so he was proud to wear the uniform and defend our freedoms. he told me the germans were bad, the food was bad, the foxholes were bad, so i joined the navy. the opportunities and freedoms we have as american, none would be possible without the dedicated services of our heroes. that's why throughout my time as governor of florida, i made it my mission to turn our state into the most active duty military and veteran-friendly

state in the nation by championing important legislation and funding to support priorities that matter most to floridians, florida's active duty military and veterans' families. fighting for our heroes is a top priority as a u.s. senator. do i everything i can to support our veterans and their a phenomenals so they can succeed and pursue their dreams in our state. i'm proud to be a co-response and supporter of dozens of veteran-related bills in the senate including the elizabeth dole home care act and the pact act. our veterans showed up for our nation and sacrificed so much. it's so important we show up to support them after their service and make sure they have every resource they need. it's also imperative today to recognize the critical role played by our country's 5.5 million military caregivers who range from spouses, parent, children, friends and family members. who dedicate their lives and often give up so much to care for those who served our country. i have the greatest honor of serving as united states senator and representing our veterans, honorable caregivers,

hardworking florida families and the american people. thank you, chair tester. sen. tester: senator moran. sen. moran: thank you. i thank you and the ranking member, senator scott, for leading this hearing today. and i welcome our witnesses and look forward to their testimony. caregivers who are often overlooked and forgotten simply have a profound impact on our nation's veterans. they are invaluable in making certain that veterans with even the most complex conditions receive the care and dignity that they deserve. it's disheartening to hear too frequently from dedicated caregivers in kansas and elsewhere about the numerous obstacles they face in dealing with the department of veterans affairs. i've heard from caregivers who were denied services from the v.a. family caregivers program for vegas reasons and -- vague reasons and in some cases were only given a one-sentence explanation. in far too many cases and a lot of what i know about this is what veterans and their

caregivers tell me and what case work we do in our office to try to solve those problems, far too often in these cases the v.a.'s failing to provide families with the clear, detailed explanation of how to appeal a v.a. decision or what other v.a. programs and services they might be eligible for. this leaves the care giver and veteran alike in limbo, uncertain how to get the support they so desperately need. congress expanded the family care giver program to veterans of all ages in the mission act, which was signed into law six years ago tomorrow. while i expect there to be growing pains, that's to be expected, when the v.a. is implementing new legislation, it's always disappointing to hear that the expanded family care giver program is not in a better place than it is today. as we await for the v.a. to issue new regulations, i look forward to hearing from our witnesses.

i introduced the elizabeth dole home care act which would address the needs of veterans' caregivers and their families. this legislation, if implemented correctly, would make it easier for veterans to stay at home as they age by expanding and improverring the v.a.'s home and community-based programs. almost half of v.a. patient population is over 65. and we know an increasing number of those veterans want to live at home. surrounded by their families, in their communities, and loved ones, rather than the transition into a nursing home. v.a. should honor veteran preferences when, where and how to receive care. i also look forward to discussing how congress and the v.a. can better support state veteran homes, which play a critical role in caring for veterans across the country. we have two in our state and we're trying to develop a third and the process we're going through to accomplish that third one is amazingly slow.

again, thanks to our witnesses and to my colleagues on the aging and veterans' affairs committees for being here today and with that, mr. chairman, i yield. sen. tester: i want to thank both of you and congressman scott for your testimonies. what? >> senator. sen. tester: oh. you skipped that as i did. thank you very much. senator scott. sorry about that. i'm going to introduce the first witness today and then we'll introduce the second ones before they come up to speak. the first witness is from casey country, his name is peter townsend. he's from auburn township in the great state of pennsylvania. mr. townsend served in the united states army on active duty from 1982 to 1986. he later worked as physician assistant until early retirement in 2014. sorry, boby, i'm taking your thunder. in 2014 due to complications

from primary progressive multiple sclerosis. he's accompanied by his wife, lisa, who serves as his full-time caregiver. i want to thank you both for being here today. unless bob has something he'd like to add. you can progress with your testimony. mr. townsend. mr. townsend thank you. chairmans casey and tester, ranking members braun and moran, and distinguished members of the committees, thank you for the opportunity to speak with you today regarding my experiences with caregiver support services available through the v.a. my name is peter townsend, i'm currently 60 years old. and live in susquehanna county, pennsylvania, with my wife, lisa, who is also my caregiver. i served on active duty in the united states army from 1982 to 1986. following my discharging in 1986 i went on to work for over two decades as a physician assistant before retiring prematurely due to complications of multiple

sclerosis. as my disease progressed, i began to experience significant difficulties with mobility, fatigue,ing couldnition and -- cognition. today i rely upon a power khaoel chair out in the community and a walker for short distances at home. through conversations with fellow veterans, i learned that m.s. was a medical condition that the v.a. recognized as a service-connected disease and with the assistance of paralyzed veterans of america, of which i am a member, i was able to successfully file a claim and am now rated 100% service disabled due to m. s. as my symptom pros agreesed, i began to rely -- symptoms progressed, i began to rely more on the assistance of my wife, lisa. my m.s. can vary dramatically. although most days are good days where i can function fairly independently, when i have a flair or exacerbation, i can become temporary incapacitated. during these times i rely very heavily upon lisa for assistance with a variety of activities to

include intermittent katherrization, transfer, toileting, personal hygiene, dressing and meal preparation. i've had no fewer than three of these episodes already this year. prior to leaving the workforce, lisa had been working as a case manager for keystone community resources. generally as my condition deteriorated, lisa decided to retire early from her position at age 61 to become my full-time caregiver. around this time, primarily through a process of self-education and online resources, we learned of the v.a.'s program of comprehensive assistance for family caregivers. the pcafc. we applied when eligibility opened to veterans of all service areas in october, 2022. unfortunately our application was denied. as i understand it, we were denied due to the v.a.'s determination that i did not require assistance with the performance of certain activities of daily living each

time that activity was performed or that the level of assistance did not, quote, rise to the level required to participate in the pcafc, end quote. this strict interpretation of the eligibility criteria by the v.a. is of particular concern to veterans like myself. with medical conditions whose symptoms are highly variably and unpredictable. lisa was eventually enrolled into the program of general caregiver support services, the pgcss. however, this transition to the pgcss was not automatic and we went for some time thinking we were enrolled in the general program, although we were not. one of the most valuable benefits of the program of comprehensive assistance is the availability of medical insurance coverage for caregivers through the civilian health and medical program at the department of veterans affairs. champva was the only way we

could afford for lisa to retire early. the program of general caregiver support services offers fewer benefits than the pcafc, but one significant benefit it does offer is respite care. we utilized this benefit when lisa underwent surgery. staff at the v.a. arranged for me to be admitted to the community living center for three weeks while lisa recovered from her surgery. lisa knew that regardless of what was happening with my health, i was being cared for so that she could focus on her recovery. i can't emphasize enough how important this valuable -- i should say the valuable -- how valuable the respite care benefit was to our family and is comforting to know that it will be there if we need it again in the future. throughout this journey, our goal has been to create an environment that allows me to live in our home as long as possible and to avoid the need

for long-term care. participation in v.a.'s caregiver programs helps us to achieve that goal. the reality is that my current level of disability is such that i'm no longer title of the bill live independently and would require placement in an assisted living facility were it not for lisa's efforts. i would like to make it clear that lisa and i remain very grateful for all the benefits that we have received and continue to receive. to show my gratitude, i currently serve as a red coat ambassador at the wicksberry v.a. medical center. by volunteering i can help other veterans connect to and navigate services more seamlessly and give back to the organization that has done so much for me. the system is not perfect, however. and there will always be room for improvement. i encourage the committees to work with the v.a. to, one, ensure a more seamless transition to the pgcss following denial of the pcafc.

two, to better communicate resources and benefits available to veterans and, three, value the work of caregivers by passing legislation which would give social security credit to caregivers who have left the workforce prematurely to care for their loved ones. i thank you for this opportunity to share our experiences and look forward to answering any questions that you may have. sen. casey: thanks for your testimony. we're grateful that you're here. i'll turn next to chairman tester for his introduction and then we'll alternate and -- we'll do the introductions first and then we'll turn to our next witness for testimony. chairman tester. sen. tester: so our next witness is hannah nieskens. hannahafrbgs is joining us from montana. her husband sustained traumatic brain injury while serving in iraq and she serves as his

caregiver full time. she's an elizabeth dole foundation ahrupl in a and is an advocate and spokesperson about mental health issues associated with brain injuries. and i just want to say it's not a short trip from montana to washington, d.c., and thank you for being here. sen. casey: thank you. our next witness is andrea sauer. she's -- sawyer. after her husband sustained injuries in iraq, she became his caregiver and an advocate for those, other wounded warrior families. we want to thank you for being here today and sharing your experiences with us. i'll turn next to ranking member scott for the next introduction. sen. scott: i have the privilege of introducing fred sganga, veterans home at stoneybrook university.

a 350-bed skilled nursing if a silt serving honorably discharged veterans and their families. he also serves as the first vice president for the national association of state and veterans homes and is a board member of the national council of certified dementia practitioners. thanks for being here. sen. casey: our fourth and final witness is ms. measure death beck -- meredith beck. meredith is the national policy director for the elizabeth dole foundation. she's dedicated over 20 years to the veteran caregiver and military communities. we appreciate you being with us today. we'll turn for testimony to ms. nieskens. ms. nieskens: chairman casey and tester, ranking members moran and scott, and distinguished members of the committee. thank you for allowing me to test today. my name is hannah nieskens and i've been married to my husband kelly for 20 years. for 18 1/2 of those years i've also been his caregiver.

in 2005 kelly was a 23-year-old montana guardsman activated to army infantryman deployed to forward operating base mchenry in iraq. on may 4, 2005, during a routine patrol, kelly's humvee was struck by a large i.e.d. this explosion, the fifth roadside bomb to hit his vehicle since his arrival in november, left the umi have disabled and knocked the squad member, including kelly, unconscious. upon regaining consciousness, and exiting the vehicle, they came under heavy sniper fire. kelly was struck by a large caliber rifle round that traveled through his ribs, hit his armored plates and ricocheted multiple times through his torso before longing near his spine. he survived thanks to the extraordinary efforts of medics, doctors and the evac team. upon returning to civilian life, kelly faced numerous physical limitations. he had mobility issues caused by

traumatically herniated disks, as well as nerve damage, pain and neuro genyk bowels caused by scar tissue. he sured from migraines -- suffered from migraine, seizures and hearing loss. hising couldnytific impair -- his cognitive impairments also posed significant challenges. in 2016, after a decade of limited success with medications prescribed to treat ptsd, an m.r.i. performed through ucla's operation men program revealed 12 lesions on kelly's brain, some as large as a dime, confirming a significant t.b.i. for which both proper treatment and benefits had been delayed. throughout the past 12 years, the v.a.'s program of comprehensive assistance for family caregivers, the pcafc, has been an invaluable resource for me as i navigated the complexities of kelly's care and

provided me training and support. in 2021 we were subjected to a grueling reassessment process for pcafc eligibility. during a nearly two-hour virtual appointment with a contracted occupation altherr peuft, kelly and i had to painfully recount every limitation he faces. i had to quantify everything i do as a caregiver, which after two decades of care giving is difficult when those care giving tasks are so integrated into our daily life. the resulting report was incomplete and inaccurate. missing critical information and disability ratings. despite effort business the v.a. staff and me to correct these errors before review, not all were corrected. the reassessment outcome was that kelly and i did not meet eligibility criteria and i was dismissed from the program. the decision highlighted several issues. significant discrepancies exist between the veteran benefits

administration and veterans' health administration recovereds, leading to incomplete or incorrect ratings and disability information submitted in reassessment reports. for example, kelly's v.b.a. rated disability of status post through and through gun injury coat coded with a diagnostic code to muscle injuries caused by wounds from gunshots were reported in v.a. records as superphysical scars and back impairment. as there was no equivalent diagnostic code in the medical record system. his v.b.a. rating for neuro genyk bowel was recorded in the v.h.a. system as irritable colon. perhaps more importantly, his 70% rating for his t.b.i. was completely missing in the v.h.a. record as a rated service-connected disability. the reassessment process placed undue emotional strain and stress on us and i believe reassessment should occur only when a veteran's needs change

significantly. additionally, veterans with specific v.b.a. ratings such as incompetency, aid and attendance, those should have presumptive eligibility for care giving. it was also apparent that veterans with stable needs or those receiving private care were disadvantaged in reassessments due to fewer medical records tonight ins preceding the evaluation. stable needs does not equate to insignificant needs. furthermore, veterans who reside in areas with limited access to specialists such as where we reside in rural montana were penalized due to access issues. as they do not receive routine comprehensive evaluations involving multiple specialists. this may marked 19 years since kelly's injury. over these years, i have learned that aging significantly amplifies the challenges faced by people with disabilities. withdrawing support for disable abled veterans with high needs and their caregivers is incomprehensible. as the brain and body age, the

need for consistent and comprehensive care for our veterans only intensifies. removing caregivers from pcafc could lead them to seek more expensive care options for veterans, including home health aids through medicare or the v.a. health programs. utilizing home health aides instead of caregivers exacerbates the significant nationwide shortage of home health aides. in addition, the availability of home health aides, especially in rural areas, like our small montana town, which has a population of 68, is none to few. thank you for allowing me to share my story and the challenges we face. i appreciate your commitment to improving the lives of veterans and their caregivers. i'm happy to answer any questions you may have. sen. casey: thank you for being here with us today and thank you for traveling to be here. it's a long distance and grateful to have the benefit of your family's story. next, ms. sawyer.

ms. sawyer: chairman tester and casey, ranking members moran and scott, and members of the committee, thank you for holding this hearing. i'm the advocacy director for the quality of life foundation, which serves caregivers of the seriously injured veterans. we create educational resources surrounding pcafc and are one of the few organizations that assists with clinical appeals for pcafc. over the years, legislation and policy surrounding caregivers has evolved. the original legislation created the caregiver support program for post-9/11 veterans. post-9/11 veterans accepted into the pcafc under this regulation are called legacy caregivers. the mission act of 2018 expanded eligibility to pcafc to veterans of previous generations. the v.a. drafted new regulations in 2020. by march of 2022, there was a high denial rate for eligible applicants from previous

generations, around 70%. and legacy review denials were around 80%. v.a. paused legacy reassessments in march of 2022. since then, they've rewritten the regulation but no new regulation has been published. after the march, 2022, hearing on pcafc, they held collaborative sessions to discuss what we saw as the problems with the regulation. however, in the fall of 2022, the v.a. office of general council stopped these conversations and declared v.a. within the confines of rulemaking. since that time, v.s.o.'s have been given no guidance on w will be in the new regulation for the program. we ask the committees to work with v.a. and stakeholder organizations on the following items. congress needs to clarify that

the mission of pcafc is to recognize the sacrifice of caregivers providing services for their seriously injured veterans. services that would in the absence of a family caregiver, would be required to be provided by the v.a. remind v.a. that the caregiver support program was intended for the seriously injured, not the severely injured. codify the activities of daily living and supervision protection and instruction needs should only require regular assistance so that veterans are not denied pcafc for attempting any level of independence within the areas in which they need assistance. require that all veterans' medical providers give input on a veteran's application for pcafc and remove the language in the statute that states to the maximum extent possible when requiring such input. require v.h.a. to honor its duty

to assist, to collect outside medical records. create a pathway to advocacy to require v.a. to develop a program to allow v.s.o.'s to navigate the veterans health administration on behalf of veterans and caregivers. mandate that those veterans and caregivers needing additional assistance beyond pcafc are allowed to be presented with all of their potential options for care. aum of these items are in the senator elizabeth dole 21st century veterans health care and benefits improvement act as well as listed between the elizabeth dole home care act and senator tester's care act. examine caregivers' financial security for post-care giving, senate bill 3885, the veteran caregiver re-education, re-employment and retirement act would create pathways for caregivers to re-enter the workplace and study allowing them to contribute to retirement

accounts and social security so that they are not left destitute in their later years. when testifying before congress, then-v.a. secretary shulkin said the v.a. wanted to change pcafc to align it with other v.a. programs. one lawmaker at the time respond, i am concerned that v.a. may attempt to justify changes to the program at the expense of our most vulnerable veterans rather than working to expand the program. this is exactly what has happened. v.a. made the cheaper-to-run pcafc harder to get into than the more expensive injury are yacht ricks -- geriatrics and extended care programs. a pcafc care giver is paid between $8.66 an hour to $13.86 an hour. v.a. reimbursement rates for home health aides range from $31 an hour to $81 an hour. we are simply asking you to restore pcafc to one that

supports sao*ersly injured veterans -- seriously injured veterans who have a need for assistance on a regular basis. allowing family caregivers to supply this care in the home has proven to have better health outcomes for veterans, as well as cost saves for the governmene government. by passing the act, and the veteran caregiver reeducation -- re-education, re-employment and retirement act, congress would reinforce support of veterans and their family caregivers and veterans' desire to age in place at home. veterans have given their all to defend america. shouldn't we honor their right to age in place at home with the caregivers of their choice? the quality of life foundation thanks you for holding this hearing and we look forward to answering any questions you may have. sen. casey: thank you for your testimony. we're grateful you're here. next, mr. sganga.

mr. sganga: thank you for inviting the national association of state veterans homes to testify on ways to improving and expand support for aging veterans and their caregivers. i am currently the legislative officer and past president of nasvh. however my full time job is the executive director of the long island state veterans home, a 340-bed skilled nursing facility serving honorably discharged veterans and their families. they provide approximately half of all federally supported institutional long-term care for veterans. yet we receive less than 20% of the v.a.'s total nursing home care budget. it is clear that the state home

partnership provides a tremendous value for v.a. by leveraging matching state funding for the benefit of all the veterans we serve. although the veteran population is projected to decline in future years, there will always be significant numbers of veterans who will need traditional nursing home care. while we agree that v.a. should continue to expand home and community-based care, it should be in addition to, not a subtraction, from facility-based care. one of the most promising areas to expand home-based care is through the state home adult day health care programs which helps to maximize the veterans' independence and enhance their quality of life, and provide much-needed respite for family caregivers. home operates a 40-slot medical model adult day health care program. we provide them with a full array of clinical services offered at a our skilled nursing if a silt, including physical,

occupational and speech therapies, nutritional counseling, meals, recreation altherrpy, as well as things like bathing, grooming and hair care. we help stabilize chronic medical conditions, reduce emergency room visits and potential hospitalizations, delay or prevent nursing home placement and provide significant respite for caregivers. in fact, we can save a caregiver multiple trips it would take to provide all the services that we are able to provide in one single visit at the state veterans home. adult day health care programs can be a critical life line for veterans and their care givers. after graduating west point and having a 27-year military career, mike had a severe stroke and for the next two years he required hospital care. he faced the knowledge that he would need significant physical therapy and extensive support for the rest of his life. fortunately we were able to offer mike the option of enrolling in our adult day health care program at the long

island state veterans home. today he received the intensive care and support he requires five days a week while his spouse was able to return to work as a school nurse, secur -- secure in the knowledge that her loved one is in good hands during the day and returns home to her every evening. the biggest obstacles to states opening new programs is the construction or modification of a facility. unfortunately current v.a. regulations only allow existing adult day health care programs to apply for construction grants. we urge congress to enact legislation to allow state home construction programs to be used to hope new adult day health care programs. in addition, we urge you to work with v.a. so we can open satellite adult day health care programs that could offer life changing service as an option to thousands of additional veterans and their family caregivers. we also recommend that congress create pilot programs to explore new arrangements for providing

integrated home and community-based programs through and in partnership with the state veterans home program. for example, when i was forced to suspend my program during the covid-19 pandemic, we were able to quickly pivot to an innovative program that supports veterans at home by providing meals at home, p.p.e., h*el health and home care visits. i want to thank senators tester and moran for introducing legislation to create a pilot program to provide assisted living care for veterans which includes state veterans homes. we look forward to continuing to work with you to ensure that our veterans have greater access to a full spectrum of long-term care options, whether at home or in the state veterans home program. that concludes my statement and i would be pleased to answer any

and all questions that members of the committee may have. thank you so much. sen. casey: thank you for your testimony. we'll conclude with ms. beck. ms. beck: thank you. chairman casey and tester, ranking members scott and moran, and members of the committee, thank you for the opportunity to testify today. my name is meredith beck and i'm a senior policy advisor for the elizabeth dole foundation, a national nonprofit to strengthen, empower and support veteran caregivers. by working with these individuals every day, we're keenly aware of the challenges, issues and remarkable strengths of the community we are honored to serve. while we have outlined additional issues for consideration here in our written testimony, we first want to focus on the urgency of the passage of h.r. 8371, the senator elizabeth dole 21st century veterans health care and benefits improvement act, mentioned previously. clearly and without hesitation, the number one priority of the hreugsz betting dole foundation is the immediate passage of this legislation. it is not an exaggeration so he

say we hear from veterans and caregivers every day who are depends rate for the support provided by the provisions in this bill. every day we wait, their struggle continues. i will speak more about this legislation later in the statement. regarding v.a.'s program of comprehensive assistance for family caregivers, it remains a significant concern among all generations of veteran caregivers. we wish to strongly align ourselves with the comments and recommendations made by the quality of life foundation who has clearly articulated challenges in their written testimony. e.d.f. is proud to sponsor the work done by them. with respect to the anticipated pca if, c regular -- pcafc, e.d.a. notes that there's an uncertain future. many of these caregivers have enjoyed multiple pauses, regulation and leadership changes and a lack of previous program standardization. the emotional toil and financial uncertainty caused by pra*bg attic instability have weighed on veterans and caregivers alike. therefore e.d.f. asks congress to work with relevant service

organizations to consider grandfathering this population, accepting cases of fraud, waste or abuse. this would allow the caregiver support program to focus on its mission of supporting all generations rather than continuing this years' long division within the veteran care giving community. we would like to commend them for their efforts to include respite services in the availability of medical care. this has served as lifeline for many who struggled without access to care. therefore we encourage congress to broaden access to mental health services to include those enrolled in the program general caregiver support services. in addition to this, v.a. has many programs that when accessed benefit veteran caregivers. where available the veteran-directed program has high satisfaction rates across the country. unfortunately despite being created more than 16 years ago and its demonstrated success, veteran directed is still not available in every v.a. medical center. for example, mary serbs for her -- serves for her husband who

receives care at the durham v.a. in 2019, almost five years ago, mary found out another high-need veteran in the area was enrolled in veteran directive and began the process of trying to get tom enrolled. during the intervening years she's been told repeatedly the program is still unavailable in durham, again, despite knowing another veteran in the program. after significant effort on mary's part and intervention from e.d.f., the v.a. reversed course and mothery was told that they would try to enroll tom. if enrolled mary will be able to hire her own familiar home health aides andres pit care support to ensure they're -- and respite care support to ensure they're meeting tom's needs. this should not be this difficult. as a result of situations like this, ranking member moran was joined by chairman tester and others to introduce the liz both dole -- elizabeth dole health care act. the legislation takes a holistic approach to ensuring this and other relevant programs are offered nationwide, appropriately staffed and communicated to caregivers. most notably, the legislation increases expenditure cap for

noninstitutional care. this would allow the most vulnerable veterans and caregivers the support they need to stay in their homes. fellow laura from austin, texas, who is present today in this hearing cared for her 100% service-disabled husband until his death in 2022. because of the mandated cap laura constantly to fight with the v.a. to get the appropriate supports so tom could continue to enjoy movie nights with the family, opening gifts on christmas morning and even their son's high school graduation which happened in their living room so that tom could attend comfortably. all of which he would have missed if he were in the closest facility, two hours away. it was tom's greatest with wish to be home with his family and laura fought every day to make that possible. eventually this legislation which enjoys broad bipartisan support in both houses of congress was included in the recently introduced and the previously mentioned h.r. 8371. this overall package includes provisions to help veterans and caregivers. despite strong support, all major veteran service organizations and other advocacy

groups, this legislation has seemingly fallen victim to politics of the day and has been plagued by mischaracterization of its provisions. while caregivers and veterans still face significant challenge today, many can be addressed through continued oversight and the legislation initiatives. therefore e.d. tp-frpt calls on congress to come together, treat h.r. 8371 with the respect and urgency it deserves and pass it without delay. veterans and caregivers simply cannot wait any longer for this life-saving and life-saving provisions. thank you, mr. chairman, and which we look forward to your questions. sen. casey: thank you for your testimony and to all of our witnesses. we'll turn to questions. mr. townsend, i'm grateful you're here representing the people of pennsylvania and veterans. we appreciate your service in the united states army and i want to thank you for sharing the experiences that you've had in offering insights into how you and lisa have navigated v.a. care giving. both services and supports. you share that after an

infection during an overseas tour in south korea, you contracted a virus that is known to cause a progressive form of m.s. in some people. unfortunately you're now living with the daily challenges associated with m.s. after a long battle with the v.a., you were eventually deemed to have a 1 hub% service -- 100% service-connected disability. you have good days and bad days. even on your good days you require some level of assistance with your activities of daily living. you share that you applied for the program of comprehensive assistance to family caregivers and were denied. how did this make you feel? what were you thinking when that determination was made? and do you feel that the v.a.'s assessment adequately considered your needs? mr. townsend clearly we were disappointmented when we receive -- disappointed when we received the determination.

it's certainly our opinion that v.a.'s current interpretation of the eligibility criteria eliminates many veterans like myself from participating in programs like the comprehensive program in particular. simply by not requiring assistance with certain activities of daily living each time that activity is performed. i clearly think there's room for improvement and i think that was summarized best by ms. sawyer when she recommended the change to requiring regular assistance rather than assistance every single time a veteran performs that particular activity of daily living. sen. casey: thanks very much. i'll turn next to ms. nieskens. you as well shared your own story and that of your husband. and the work you've done as a caregiver and your testimony, you told us that professional home care workers are an essential part of your husband's care team and your support team. you also told us it's often hard

to find and keep these workers. we hear about that a lot. this is a story that i hear all too frequently back home and we hear it in washington as well. that it really is a care crisis across the board. not just in this context, but in the context of children and seniors and veterans as well. i've introduced several bills to improve both recruitment and retention of direct care workers. these bills would benefit older adults and people with disabilities and would also support the family caregivers who are left with little support without access to the services. i'd ask you i'd ask you to tell us what it means for you and your family when you can't find a worker. what does it mean to make sure there's a qualified work force for you and your family?

>> the availability of home health aides, as everyone here knows, i believe, is in a nationwide shortage. i do believe the pcafc helped alleviate that burden by allowing family members to fill that gap when those h.h.a.'s are unable to be found. in addition, i think it's worth mentioning the median wage for home health aide is somewhere between $13 and $14 an hour. when you consider what it requires for someone to come to my home, the nearest metropolitan area to cardwell is butte, montana, they'd have to commute 40 miles over the continental divide over a very large path in the middle of winter to come to my home to

provide health aid services. the likelihood of finding someone to do that for $13.50 an hour is slim to none. i do believe the pcafc helps alleviate those needs by allowing people already in the recipient's home or immediate community to fill those needs. sen. casey: thanks very much. i turn next to senator scott. sen. scott: how does your facility assist the caregivers when they remain in your home but still need additional support? >> our health care program is a phenomenal program and allows for the veterans to keep his or her own physician whether they be with the v.a. or the front community. we provide a tremendous service to these veterans six days a week. i'll give you an example, senator scott. when a veteran is in our adult care program, they arrive at

9:00 a.m. and bepart around 3:00 p.m. during that time we can get a lot done for the veteran. think of someone caring for their elderly parent. when at home they can receive a plebeotomy and get their eyes checked by our optometrist and receive occupational therapy and speech therapy. maybe their hearing aid needs a battery change? they can even get a haircut. what i said to you is i saved the caregiver 11 trips in the community and what we do in the state veteran care program. we're keeping veterans out of the emergency room and avoiding hospitalization and delaying placement in skilled nursing facilities. thank you. sen. scott: ms. sawyer, what's the biggest will challenge to

caregivers when assessing benefits from the v.a.? ms. sawyer: i assume you mean caregiver benefits which are actually caregiver benefits fall on the health care side. some of the biggest problems really have to do with the evaluation itself. i'll tell you the law itself doesn't have many problems. the regulation itself has many problems, implementing regulation. and one of those problems is the language that v.a. created around each and every time with a.d.l. assistance. it prevents the veteran from showing any independence at all should they be able to toilet by themselves once in the entire six months, that prevents them from being eligible for a.d.l. assistance for that a.d.l.

because it doesn't meet the standard of each and every time. so one of their requests has been that the regulation be changed from each and every time. however, each and every time is actually in the regulation, not the law, but it was upheld by the court because we've seen v.a. change this regulation multiple times and actually asked that congress codify it be regular instruction instead of how it's broadly worded in the law now. for supervision, protection, and instruction, that care with also continuous daily care, the veteran lawyer lawsuit actually overturned that and created than forced it back to regular instruction which is the standard in the law. we would ask that once again be

codified within statute so v.a. cannot make that change again regulatoryily. there's also a standard v.a. has put in the regulation in order to be the higher standard, a veteran must be unable to sustain in the community. we ask that congress make a little bit of a change to that wording though it's regulatory language, because currently v.a. employees don't interpret that correctly. we've asked it to be evaluated multiple times and what we keep finding is that it continues to be -- isn't able to perform those duties or needs assistance because, let's say you have a

veteran who needs 24-hour a daycare, your caregiver, it's impossible to provide 168 hours of care per week. so the best thing to do would be to have c.d.c. care, respite care, a combination of such for those hours. it's a continuing maze for what's available and to top it off, those hours differ between

regional communities within the v.a. to go back to an earlier question for just a second, when someone was asking about caregiver wages, there is a mechanism within the v.a. for your local v.a. to request an increase in home health care workers reimbursement rates. most v.a.'s, however, do not know how to engage that mechanism. but one way you can eliminate or lower the shortage of home health care workers is to increase that reimbursement rate so that more people would be willing to take those jobs. if you look at the current reimbursement rates around v.a., in the state of alabama, the current reimbursement rates are $30.50 an hour -- sen. scott: to

wrap up because we're over time. we'll turn next to senator murray. sen. murray: thank you very much to our chairman and ranking members for holding this really important hearing today and i appreciate the testimony from everyone. mr. townsend, i want to particularly thank you. your story was my family's story. my dad was a world war ii veteran diagnosed with m.s. when i was a young teenager, seven kids in our family, and our family went through what your family is. i want to thank you for your service and sacrifice for our country and i want to thank lisa for what she, i know, does every single day for your family as well and tell you, that's why i worked so hard to get the family caregivers act passed personally because i know what so many people struggle with and it is a real challenge.

and as chairman of the veterans committee at the time i worked very hard to implement it to make sure it was in line with what our congressional intent was. so this hearing is really important as we evaluate it now and what all of you do is really important. mr. townsend, you answered senator casey a little bit. just tell me, while the v.a. continues its review of the program, what do you think we need to particularly focus on? mr. townsend: particularly with regard for the eligibility for the comprehensive program. once again, i'd go back to my previous statement that the v.a.'s current interpretation of the openliagibility -- the eligibility criteria and requiring assistance of daily activity each time that activity is performed is unrealistic and as a result excludes a number of veterans and caregivers from myself which otherwise is a very, very valuable resource, a

very valuable program. sen. murray: i totally understand that and that is really helpful. so again thank you for being here and sharing your story and what your family's done. i want to turn to ms. nieskens. thank you for what you do for your husband and your family and your community and everything and being a caregiver. i wanted to really ask you something that doesn't get talked about a lot and that is the high level of stress and depression from caregivers who i know is especially true for post 9/11 caregivers. 40% have met criteria for major depressive disorder and is twice the amount of pre9/11 caregivers and four times the rate of that of noncaregivers and is a heartbreaking statistic and i really think it's something we

need to focus on. can you talk a little bit about what services are currently available for caregivers who need mental health treatment and what we need to do to really address that? ms. nieskens: i agree that's a startling statistic and is a reported statistic but in my experience just being in the caregiver community, i think the rate is actually higher than that. one of the things i think is important to the ptsd is the support they give to caregivers. there are community functions where they host abilities for caregivers to interact with each other to meet other caregivers and that allows caregivers to feel less isolated. being a caregiver at a young age i think is something most people don't expect. that greatly is in contrast to people caring for someone who is

geriatric and we expect people of a certain age to have mobility needs or supervision protection and instruction needs. however, to care for someone in their 20's who has those same needs just is difficult when you're in your 20's yourself. so that certainly is kind of something that the ptsd does attempt to do is support caregivers in learning how to become a caregiver and connect with each other to provide educational resources. there's also outside foundations like quality of life and elizabeth dole foundation who also provides caregiver communities and resources and educational calls, so on and so forth for these caregivers. but ultimately they're really, i guess, something that mr. townsend spoke to was the

v.a. benefits that is allowable if you are a caregiver through ptsd would be your resource to getting mental health therapy as a caregiver. and if you're just in the program of general care and you do not have 100% permanently and totally disabled person you don't have access to perhaps the insurance that would allow you to see those mental health therapists. sen. murray: mr. chairman, my time is up but want to mention something i personally know well is 2.3 million children live in a household with a disabled veteran and they provide really unique challenges and responsibilities and nor bowsman and i have a act to support kids to live with a disabled veteran and give them the support they need and i hope we look at that as well.

sen. moran: thank you, for the first time i know of we've had this joint meeting and the witnesses and their testimony is among the most compelling of the many hearings i've had with veteran issues and aging issues, so thank you. i want to comment, mr. sganga, i share your view. president biden's most recent budget submission requests $125 million for state construction grant programs. the current list of projects that's in waiting totals $1.2 billion. so this request barely scratches the surface. and i now face this in my own state as we are waiting for new construction project in northeast kansas. i just would highlight for the administration and my colleagues, this not only delays the care for veterans but puts the state who is putting money in this project in a difficult

situation, planning and financing projects. mr. sganga, i'm sure my colleagues will work to find other resources beyond the president's request in funding for the state home construction grant program. so thank for you highlighting that. let me ask a couple questions. ms. sawyer, i appreciate you working closely request me and senator sinema on the reeducation, re-employment and retirement act. tell me why you think and tell my colleagues why you think it's important to consider this legislation and what impact it would have on caregivers community? ms. sawyer: thank you, senator. we appreciate your involvement in creating that act. that is certainly something that's been a long time coming. most post-9/11 caregivers are in

a situation where the income in their home is unearned, if their veteran was injured and medically retired, they may receive 100% from the total v.a. pay and social security disability as well as the p.c.a. caregiver stipend. all that is unearned and caregivers cannot contribute to social security or any type of retirement account. that leaves those caregivers in a very precarious financial state for when their care giving years end and they reach retirement. the act, the reeducation, reimplement and retirement act that you and senator sinema introduced would study whether or not caregivers would be allowed to contribute to social security and their retirement accounts where there would be a mechanism that could be created for that to take place.