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“Dignity Denied: The Case for Reform at State Veterans Homes”

House Veterans Affairs Committee, Health Subcommittee Hearing

April 29, 2025 (recording here)

HEARING INFORMATION

Witnesses & Written Testimony (linked) (Panel One):

• Ms. Sharon Silas: Director, Health Care, U.S. Government Accountability Office, Washington, D.C.

• Dr. Scottie R. Hartronft M.D.: Executive Director, U.S. Department of Veterans Affairs, Washington, D.C.

Witnesses & Written Testimony (linked) (Panel Two):

• Mr. Ed Harries: President, National Association of State Veterans Homes

• Colonel Charlton J. Meginley (Ret.): Secretary, Louisiana Department of Veterans Affairs

Keywords mentioned:

• Veteran care, aging veterans, long-term care, oversight, state veterans homes, mental health, suicide prevention, Medicaid cuts, construction grants, high-cost medications, regulatory compliance, geriatric psychiatry, rural transportation, quality of care

IN THEIR WORDS

OPENING STATEMENTS FROM THE SUBCOMMITTEE

• Chairwoman Mariannette Miller-Meeks described the growing need for long-term care among aging veterans, especially those from the Vietnam and Cold War eras. She noted that many older veterans face physical and mental vulnerabilities, social isolation, and difficulties accessing care. She raised concern over the lack of attention and research around veteran suicides later in life, referencing a recent case involving a 77-year-old veteran. The Chairwoman underscored the importance of state veterans homes in providing long-term care and expressed a desire to ensure the VA supports these homes effectively, including through funding for essential medications and construction grants.

• Ranking Member Julia Brownley highlighted that approximately 80% of veterans will need long-term care services, with many preferring to age at home. She praised the Elizabeth Dole Act for expanding home- and community-based services but acknowledged that institutional care, such as state veterans homes, remains essential. Ranking Member Brownley criticized proposed Medicaid cuts, warning that they would strain the VA and state homes by reducing other long-term care options. She claimed that recent improvements in oversight, including those mandated by the Cleland-Dole Act, were critical to ensuring transparency and safety in veterans' care and shared her concern that federal budget cuts could undermine these efforts.

SUMMARY OF KEY POINTS (PANEL ONE)

• Dr. Scottie Hartronft began by stating that state veterans homes must comply with VA survey and certification processes to qualify for per diem payments and construction grants. He noted that the VA’s oversight structure mirrors Centers for Medicare & Medicaid Services (CMS) standards and allows homes to enter sharing agreements for clinical services and pharmaceuticals. As of 2025, CMS-certified state veterans homes scored higher on average than the national CMS ratings. Dr. Hartronft affirmed the VA’s commitment to improving oversight and supporting the homes through staffing grants and infrastructure reimbursements.

• Ms. Sharon Silas reviewed the Government Accountability Office’s (GAO) 2022 report on oversight of state veterans homes, saying that about 15,000 veterans lived in these facilities at an annual cost of $1.5 billion. She explained that oversight is provided by the VA, CMS, and in some cases, the states, with the VA being the only agency overseeing all state veterans homes. Ms. Silas mentioned deficiencies in the VA's enforcement tools, noting a reluctance to withhold per diem payments and a lack of scaled enforcement options. She recommended that the VA seek legislative authority to adopt a broader range of penalties, similar to CMS, to better ensure compliance and improve the quality of care provided to veterans.

• Ranking Member Brownley asked whether the VA had assessed how proposed Medicaid cuts would impact veterans' reliance on VA long-term care. Dr. Hartronft responded that while no specific analysis had been done, the VA could adapt by expanding the use of contract nursing homes. He acknowledged that Medicaid cuts would likely have some impact but deferred specifics to CMS.

• The Ranking Member then questioned why the VA had stopped pursuing legislative authority for additional enforcement tools as recommended by GAO in 2022. Dr. Hartronft explained that the VA had since centralized its survey process and introduced an escalation plan, which improved corrective action compliance. He said that the VA was reconsidering whether additional penalties were needed but had not ruled them out. Ms. Silas agreed that the VA's recent steps improved oversight but reiterated the need for enforcement tools with "teeth," including a range of penalties aligned to deficiency severity.

• Ranking Member Brownley also asked about concerns from state veterans homes regarding lack of access to specialty care. Dr. Hartronft acknowledged this ongoing issue and reported that local VA liaisons coordinate to bridge gaps between basic care covered by per diem and specialty services.

• Rep. Sheila Cherfilus-McCormick criticized partisan attacks on state veterans homes and illustrated their efficiency. She asked whether the VA had enough staff to fulfill its oversight mission. Dr. Hartronft claimed that the office was adequately staffed and mentioned that centralization improved follow-through on corrective actions.

• Rep. Cherfilus-McCormick noted ongoing deficiencies and asked if staffing or funding cuts would worsen the issue. Ms. Silas replied that GAO had not studied funding cuts but confirmed that centralization allowed four to five staff to consistently monitor specific homes, improving follow-up on deficiencies.

• Rep. Herb Conaway asked whether the VA conducted in-person inspections during the pandemic at troubled facilities like those in New Jersey. Dr. Hartronft stated that responses varied by facility and were determined by coordination between local VA offices and state homes, but he offered to follow up with specific data.

• Rep. Conaway then asked whether the VA lacked the authority it needed to enforce care standards. Dr. Hartronft confirmed that the VA operated within limited regulatory authority and was in discussions about potential next steps. Ms. Silas added that without the ability to impose fines or partial per diem withholdings, the VA could only take internal process-based actions. She underscored the need for externally enforceable penalties.

• Rep. David Taylor raised concern about the backlog of state veterans home construction projects, noting that some have secured state funding but may wait 5–10 years for matching federal dollars. Dr. Hartronft explained that the VA ranks projects annually based on priority and carries them over as needed. He said that while some projects were moving forward, the VA responded to state-submitted applications and was limited by available funding. Rep. Taylor argued that construction backlogs were unacceptable and that veterans should take precedence over overseas spending. He cited his Veterans First Act (H.R. 2083) as a solution to reallocate funding to clear the backlog.

• Chairwoman Miller-Meeks asked whether state-run veterans homes also received oversight from their respective state inspection departments. Ms. Silas responded that most homes did, but seven homes were overseen only by CMS or the VA.

• Chairwoman Miller-Meeks then inquired about suicide among older veterans and the services available to them. Dr. Hartronft said that the VA was working with the Office of Mental Health to expand suicide prevention education in state homes, with a focus on geriatric psychiatry. He noted that recent life events, such as widowhood, could be contributing factors and emphasized subtlety in symptoms among the elderly.

• The Chairwoman commended the VA for the progress made through process modernization. She asked whether state homes cited for deficiencies still receive funding. Dr. Hartronft answered that it was rare for facilities to have no deficiencies due to the large number of standards, but the VA focused on supporting homes through education and oversight to achieve compliance. When asked if more enforcement tools would help, he replied that current efforts were producing positive outcomes, but the VA remained open to future changes based on external feedback.

SUMMARY OF KEY POINTS (PANEL TWO)

• Mr. Ed Harries claimed that state veterans homes provide half of all VA-supported skilled nursing care but receive only 18% of the associated budget. He underlined that state homes are consistently safer and of higher quality than community nursing homes, with more rigorous oversight from the VA, CMS, and state agencies. Mr. Harries warned that excessive regulation can burden staff, reduce innovation, and divert focus from patient care, and he advocated for a balance between oversight and operational flexibility. He expressed strong support for legislation to fund high-cost medications, address VA non-payment for specialty and psychiatric care, and expand mental health services in state homes.

• Mr. Charlton Meginley testified that Louisiana's five state veterans homes provide compassionate, high-quality care through dedicated staff who treat residents with dignity and respect. He spoke on the rigorous oversight from multiple federal and state bodies and said that internal quality assurance processes have led to a 36% reduction in VA survey deficiencies. Mr. Meginley highlighted Louisiana’s low pressure ulcer rates and strong CMS star ratings as evidence of excellent care, while also acknowledging ongoing challenges in meeting rising mental health and behavioral care needs. He urged Congress to support pilot studies in geriatric psychiatric care and stated that Louisiana is ready to lead such efforts.

• Ranking Member Brownley asked Mr. Harries whether he supported Rep. Taylor’s proposed bill to reallocate $2 billion from the United States Agency for International Development (USAID) to VA state veterans home construction grants. Mr. Harries responded that while he could not weigh in on funding sources, he strongly supported the need for more state veterans homes to serve aging veterans with increasingly complex conditions.

• The Ranking Member voiced concern that Rep. Taylor’s bill posed a false choice between global security and veterans' care, arguing that the U.S. could fund both through fair tax policy. She then asked both witnesses whether their states had analyzed how proposed Medicaid cuts might impact demand for state veterans homes. Mr. Harries replied that while no formal analysis had been completed, cuts to Medicaid—especially as 75% of state veterans homes are CMS-certified—could significantly affect care access and finances. Mr. Meginley agreed that such cuts could be devastating and shared that many local healthcare providers were in “wait-and-see” mode due to the potential impacts.

• Chairwoman Miller-Meeks asked Mr. Harries how the VA could improve reimbursement for high-cost medications at state veterans homes. Mr. Harries stated that the VA should treat state veterans homes the same as private sector nursing homes and reimburse for life-saving medications already covered elsewhere. He shared that some facilities had turned veterans away due to $100,000 medications they could not afford, and called for updated reimbursement policies in light of increasing toxic exposure-related diagnoses.

• Chairwoman Miller-Meeks asked whether the CHIP IN Act model could be adapted for veterans home construction grants. Mr. Harries supported the idea, calling it "fantastic" and suggesting that it could help modernize infrastructure.

• The Chairwoman then asked about limitations in current regulations that prevent grants for starting new adult day healthcare programs. Mr. Harries explained that current rules only allow grants to expand existing programs, preventing homes from launching new adult day services unless they fully self-fund.

• Chairwoman Miller-Meeks turned to transportation and staffing challenges at rural Louisiana state veterans homes. Mr. Meginley noted that staffing in rural areas like Jennings was a key issue and that Louisiana worked with its civil service to ensure competitive pay. He also discussed transportation solutions for homes located near VA hospitals or Community-Based Outpatient Clinics (CBOCs), but he emphasized that rural transportation remained a concern requiring coordination with VA administrators.

• Rep. Kelly Morrison asked about the importance of data collection in evaluating and improving care at state veterans homes. Mr. Meginley described close collaboration with VA administrators and shared that strong partnerships enabled quick responses and continuous improvements, especially for rural veterans. He stressed that his department lived "by data," using it to identify trends and apply those best practices system-wide. Mr. Harries added that as a Six Sigma Black Belt, he deeply valued data-driven approaches and urged the VA to better utilize its vast healthcare datasets to improve outcomes.

• Ranking Member Brownley praised the relationship described between Louisiana’s state veterans homes and their local VA medical centers. She wondered how such strong partnerships could be replicated nationwide. Mr. Meginley responded that being both a veteran and a patient at the New Orleans VA helped him build that relationship and that regular contact with VA administrators was central to his success.

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