The VHA, the largest and most visible operating unit, is predominantly a direct service provider of primary and specialty care, similar in many ways to a large private sector health care system. In addition to providing inpatient, outpatient, and a range of other medical care services, the VHA has been authorized by Congress since the 1960s to provide nursing home care to eligible veterans in VA facilities, private nursing facilities contracted by the VA, and state veterans homes. These services include programs of care directly provided by the VA, such as home-based primary care and geriatric evaluation, as well as services purchased by the VA, such as home health aide and home respite care. P.L. P.L. 91-101, enacted in 1969, amended P.L. Based on recommendations of the Federal Advisory Committee on the Future of VA Long-Term Care, Congress began to examine the VA's long-term care programs, which led to the enactment of the Veterans Millennium Health Care and Benefits Act ( P.L. VHA Eligibility, Enrollment, and Long-Term Care

In general, eligibility for VA long-term care services depends on several factors, including veterans' need for the service, as determined by the VA; whether the service is institutional or non-institutional; and, for certain programs, veterans' service-connected status. VHA Enrollment

The size and scope of the VA health care system are influenced by several factors, including the size of the veteran population, the number of veterans eligible for VA health care, veterans' decisions about whether to enroll, and once enrolled, whether to utilize VA health care services, including long-term care services. An estimated 9.1 million veterans (43% of all veterans) were enrolled in the VA health care system in FY2016. While overall the number of veterans in the United States has declined since FY2000, the number of veterans enrolled in the VA health care system has increased significantly. As shown in Figure 2 , just over 4.9 million veterans (19% of all veterans) were enrolled in the VHA in FY2000; by FY2016, that number was estimated to have increased 86%, to 9.1 million enrollees. Each VAMC/HCC offers certain mandatory programs and may offer several optional programs as well. VHA Long-Term Care Services

The VA offers long-term care in both institutional and non-institutional settings. Institutional settings may include both inpatient acute care and nursing home care, although the majority of long-term care the VA provides in institutional settings occurs in a nursing home setting, which is the primary focus in this report. Non-institutional care includes outpatient or ambulatory care settings, as well as care that occurs in the home or another community-based setting. Some long-term care services are provided directly by VA staff, while other services are purchased from providers outside the VA. 106-117 ) requires the VA to provide nursing home care to the following veterans: 
any veteran in need of such care for a service-connected disability; or to any veteran who is in need of such care and who has a service-connected disability rating of 70% or more; or any veteran who has a service-connected disability rated 60% or more and unemployable; or any veteran who has a service-connected disability rated 60% or more and who has been rated permanently and totally disabled. VHA Long-Term Care Expenditures

Long-term care expenditures are a small but not insignificant part of the VHA medical care budget, at just over one-tenth of the VHA's total medical care budget. In FY2015, the VHA spent $7.4 billion, just over 13% of its total medical care spending ($55.8 billion), for veteran's long-term care (see Table 5 ). Institutional care accounted for almost $5.3 billion, or 71% of VA's total long-term care spending, while non-institutional care accounted for $2.1 billion, or 29%. Institutional Care

The majority of VHA institutional care spending (64%) is for VA Community Living Centers (CLCs), which are nursing facilities owned and operated by the VHA (see Table 6 ). Issues for Congress

Three broad issues emerge for Congress when considering VA long-term care eligibility, financing, and delivery. The second issue is the setting where long-term care services are provided and the appropriate balance between home and community-based versus institutional services. Further, the number of veterans who have disabilities that are rated as 70% or more service-connected, and therefore are eligible for VA-paid nursing home care, has increased. One issue that may affect the balance of long-term care services offered is VA's statutory requirement to provide nursing home care to veterans with 70% or more service-connected disability, as well as the requirement to provide nursing home care to veterans who are service-connected and need care for their service-connected disability.
The Veterans Health Administration (VHA), an operating unit of the Department of Veterans Affairs (VA), is a direct service provider of health care, similar in many ways to a large private sector health care system. In addition to providing inpatient, outpatient, and a range of other medical care services, the VHA provides and purchases long-term care services. The VA is one of two federal payers of long-term care services (the other being Medicaid).
Since the 1960s, the VA has been authorized to provide nursing home care to eligible veterans in various settings, including VA facilities, private nursing facilities contracted by the VA, and state veterans homes (P.L. 88-450). These nursing home benefits were further expanded in subsequent legislation (P.L. 91-101 and P.L. 93-82). In 1999, the Veterans Millennium Health Care and Benefits Act (P.L. 106-117) required the VA to provide such benefits to veterans needing nursing home care due to one of their service-connected conditions, as well as veterans who overall have a service-connected disability rating of 70% or more, who need the care for any condition, service-connected or not. In addition, the law required the VA to maintain staffing and level of services for institutional care not less than the FY1998 level; the law also required non-institutional long-term care services as part of the VA medical benefits package.
About 9.1 million veterans (43% of all veterans) were estimated to be enrolled in the VHA in FY2016. Although the overall number of veterans in the United States has declined since FY2000, the number of veterans enrolled in the VHA has increased significantly in that same time period. In FY2000, just over 4.9 million veterans were enrolled in the VHA; by FY2016 that number was estimated to have increased 86%, to 9.1 million enrollees. This increase is due, in part, to the growing number of veterans with service-connected disabilities, as well as more liberal enrollment policies. Among veterans with a service-connected disability, the proportion who have a disability rated as 70% or more service-connected (and therefore eligible for VA paid nursing home care) has also increased.
VA long-term care programs are administered at the VA facility level, with some variability in how programs are administered. Each VA facility offers certain mandatory programs and may offer several optional programs as well. Eligibility for VA long-term care programs depends on eligibility for VA health care, which is based primarily on "veteran status" resulting from military service. Once enrolled, veterans' eligibility for long-term care services depends on several factors, including veterans' need for the service (as determined by the VA), whether the service is institutional or non-institutional, and (for certain programs), veterans' service-connected status.
Institutional settings may include both inpatient acute care and nursing home care. However, the majority of VA long-term care provided in institutional settings occurs in nursing home facilities, such as VA Community Living Centers (CLCs), community nursing homes, and state veterans homes. Non-institutional care includes outpatient and ambulatory care settings, as well as care that occurs in the home or another community-based setting. Non-institutional services include
home-based primary care, community residential care, geriatric evaluation, palliative care, adult day health care, homemaker/home health aide care, respite care, home skilled care, home hospice, and veteran-directed home and community-based services and medical foster homes (at some facilities).
Some long-term care services are provided directly by VA staff, whereas others are purchased from providers outside of the VA. Long-term care expenditures are a small but not insignificant part of the VHA total medical care budget, at just over one-tenth of the VHA's budget. In FY2015, the VHA spent $7.4 billion (13% of its total appropriated funding for medical care, which was $55.8 billion) for veterans' long-term care. Institutional care accounted for almost $5.3 billion, or 71% of VA's total long-term care spending, while non-institutional care accounted for $2.1 billion, or 29%. The majority of VHA institutional care spending (64%) was for VA Community Living Centers (CLCs), nursing facilities owned and operated by the VA.
This report provides an overview of VA long-term care services, including legislative highlights, eligibility, organizational structure, descriptions of services (both institutional and non-institutional care), and expenditures. The report also describes three key issues for Congress when considering the VA and its long-term care financing and delivery system:
1. Veterans' access to long-term care services. 2. Settings where services are provided and the appropriate balance between institutional and non-institutional care. 3. Veteran's health coverage options and federal coordination.