Last May, veterans attended a Memorial Day ceremony where President Joseph Biden and Vice President Kamala Harris took part in a wreath-laying ceremony at the Tomb of the Unknowns at Arlington National Cemetery.VA photos by Eugene Russell.

WASHINGTON — As the baby boomer generation begins to reach the age where they will require regular, long-term care, VA will be required to shift a huge portion of its resources to care for them. What many in Congress and VA have referred to as the “silver tsunami” has already begun and will crest over the next two decades, as the largest portion of VA patients (4.3 million) move from the 65-74 age group into 75 and over.

By 2037, VA expects to spend $14.3 billion annually on long-term care, nearly double its current spending. VA also projects that institutional care will take up a much lower percentage of that funding as more Americans choose non-institutional care models and look to spend their last years at home. 

“[These baby boomers] will live longer than any generation before them but with more-complicated health needs than any system has ever had to deal with,” explained Rep. Julia Brownley (D-CA), chair of the House VA Subcommittee on Health during a hearing last month. “These veterans will ultimately make up half of VA’s patient population. Over the next 17 years, VA will have doubled its spending on long-term care. There aren’t enough beds, staff or institutional settings in this country to meet the projected needs. And it’s not what veterans want. Ninety percent of Americans want to age in place. They want to stay in their homes and receive the care they need.” 

An effort was made during President Barack Obama’s administration to balance VA long-term care between institutional and non-institutional care, Brownley explained. That effort peaked in 2017 when non-institutional spending accounted for 36% of the long-term care budget at VA. Over the last few years, that balance has shifted back, and non-institutional spending sat at 30% in 2020. 

“Expansion of home- and community-based programs have also stalled,” Brownley declared. “At-home care is not uniformly available at all [VA] facilities or regions. [Veterans spend] months or years on a wait list.” 

According to Scotte Hartronft, MD, MBA, director of VA’s Geriatrics and Extended Care Program, most non-institutional care options are available nationwide. Those include adult day healthcare, home-based primary care, home health aide care, as well as palliative and hospice care. 

The newest programs in VA’s portfolio are still being rolled out. That includes medical foster homes—a private residence where a trained caregiver provides services for a small number of individuals. Also, not available nationwide is VA’s Veteran Directed Care Program. This program is for veterans who need personal care services and help with daily living. These veterans are given a budget for services and VA works with them to hire their own workers to meet those needs. 

Currently, the program is available at 68 sites, but VA hopes to expand it, Hartronft explained.

Once such programs are in place, however, there are not always enough caregivers to staff them, leading to the years long waitlists that Brownley noted.

 A Government Accountability Office report released in February 2020 found that 80% of VA community living centers had vacancies for nursing assistant or health technician positions and that staffing challenges were the key factor in the creation of a waitlist of 1,780 veterans for the Home-Based Primary Care Program. 

VA officials did not have 2021 hiring numbers, but Hartronft said, “I think it’s safe to say with some certainty that it’s still an issue.” 

The issue frequently comes down to money and the limits put on VA by government spending caps.

“Many times, we’re not the leading payer by any means and there’s a pay cap we have for current RNs,” Hartronft explained. “It leaves us at a real disadvantage many times, especially in high cost of living areas.”

A number of studies, looking at VA, Medicaid and other stakeholders in long-term care have found there is a cost savings when patients are able to be cared for in their home rather than moved to an institutional setting. 

“It does take an upfront investment in home care, but then it does have long-term cost savings,” Hartronft declared.

When asked whether that savings would still exist if VA raised salaries for caregivers to a level where they can fill the existing vacancies, Hartronft admitted that he did not know.

“I think that’s something we need to look at better,” he said. “We haven’t modeled using salary changes. We just know that with our current model, there’s a cost savings.”

Inequities in Assistance?

Another issue that has arisen with VA long-term care programs is whether they are equally beneficial to all veterans.

A recent study published in the journal Health Services Research looked at possible inequities in access to VA’s aid and attendance enhanced pension benefit to help veterans pay for long-term care.1

The study was led by researchers from the Providence, RI, VAMC and the School of Public Health at Brown University, also in Providence. Also participating were investigators from the Durham, NC, VAMC, Duke University, the Louis Stokes Cleveland VAMC and Case Western Reserve University in Cleveland.

The study team sought to examine characteristics that are associated with receipt of Aid and Attendance (A&A), an enhanced benefit for veterans who already receive pensions but need additional help with daily assistance.

The observational study used secondary data analysis of 2016-2017 national VA administrative data linked with Medicare claims to examine sociodemographic, medical and healthcare utilization characteristics associated with receipt of A&A among veterans receiving pensions.

Results indicated that, in 2017, 9.7% of veterans with pension newly received the A&A benefit. The probability of receiving A&A among black and Hispanic pensioners was 4.6% lower than for white pensioners (95%CI = -0.051, -0.042), however.

The study also found that married veterans receiving pensions had a 4.4-percentage point higher probability of receiving A&A (95%CI = 0.039, 0.048).

The authors pointed out that most indicators of need for assistance, including home health utilization, dementia and stroke were associated with significantly higher probabilities of receiving A&A.

“Notable exceptions” were the following, according to the researchers—pensioners with a diagnosis of post-traumatic stress disorder (marginal effect = -0.029 95%CI = -0.037, -0.021) or those enrolled in Medicaid (marginal effect = -0.053, 95%CI = -0.057, -0.050).

In addition, unadjusted and adjusted rates of receiving A&A among veterans receiving pension were found to vary by VAMC.

“This study identified potential inequities in receipt of the A&A enhanced pension among a sample of veterans receiving pension,” the authors included. “Increased veteran outreach, provider education and VA office coordination can potentially reduce inequities in access to this benefit.”


  1. Thomas KS, Corneau E, H Van Houtven C, Cornell P, Aron D, M Dosa D, M Allen S. Inequities in access to VA’s aid and attendance enhanced pension benefit to help veterans pay for long-term care. Health Serv Res. 2021 Jun;56(3):389-399. doi: 10.1111/1475-6773.13636. Epub 2021 Feb 25. PMID: 33634467; PMCID: PMC8143693.