By the time they cut her from the program, Alishia Graham was angry, but not surprised. Her postman delivered the news in February.
"The letter was sitting at the top — and my stomach dropped because I knew what it was," she says.
The letter from the Department of Veterans Affairs informed Graham that her husband Jim, who sustained a brain injury on his third deployment to Iraq, no longer qualified for a caregiver to help with his daily life.
"It's not even like ... 'We think he doesn't need as much help.' No — 'We think he's totally fine and he doesn't need any help,' " says Graham. "I'm insulted for him. Because I know what he struggles with."
The VA's comprehensive caregiver support program pays a stipend to family members of veterans with disabilities, often wives who have had to leave their own careers to help their veteran with daily living.
At its outset in 2011, families of veterans overwhelmed the VA with applications to become official caregivers. A program designed for 4- to 5,000 has now grown to nearly 23,000 approved caregivers. Alishia Graham had been on the program for six years, but she'd been hearing rumors from around the country of veterans getting dropped without experiencing improvements in their disability.
"I was watching as all these caregivers were going up to their re-assessment. And one by one ... they were dropped," says Graham.
The VA denies any cuts to the size or funding of the caregiver program.
"The program is not cutting back in any way," says Meg Kabat, director of the VA Caregiver Support Program. "We've been able to expand the number of caregiver support coordinators and really continue to monitor that. We also train our staff on a regular basis."
But the VA is infamous for lacking consistency from station to station. And while the program has added 6,300 caregivers since 2014, according to VA data, NPR discovered that 32 out of 140 VA medical centers were cutting their programs during the same period — some drastically.
That included the VA in Fayetteville, N.C., which used to send Alishia Graham a monthly stipend of about $2,000 and offer her health insurance, respite and support.
Fayetteville cut more than half of its caregivers, dropping 314 families from the rolls between May 2014 and February 2017. And while data from the VA in Washington showed seven staff at Fayetteville were coordinating caregivers (a ratio of 37/1), the Fayetteville VA shows only two staff are doing that job, meaning that each coordinator is actually overseeing more than 125 veterans.
Graham's husband, Jim, was a Navy corpsman — a combat medic — for 13 years. In December 2006, on his third tour in Iraq, a mortar blast killed his best friend. Jim Graham was standing nearby and suffered a brain injury, as well as debilitating post-traumatic stress disorder.
The brain injury left him forgetful and in persistent pain for nearly 11 years.
"I've had a headache ever since I got hurt," says Jim, who wears dark Terminator-like sunglasses indoors, even with the blinds drawn, to prevent triggering an even worse pain.
"I get migraines on top of it. When I get one it lasts for days, months. If I'm someway able to get rid of the migraine, I'm lucky to get a week off before another one hits me," he says.
It's hard to separate which condition causes what symptom, but Jim's PTSD is probably what gives him anxiety about breaking his daily routine, about leaving the house, or about getting personal care from anyone outside his family. Alishia was studying to become a nurse when Jim got hit. She hasn't been able to work outside the house since then, because Jim needs help with everything from cooking to bathing — mostly just reminders not to let things burn on the stove, or help to get in or out of the shower.
That made the caregiver program a great fit for them, and VA rated Jim at the highest tier of need, which meant VA paid Alishia a stipend of nearly $2,000 per month. The stipend is based on 75 percent of what a professional caregiver would make for 40 hours a week in their town of Jacksonville, N.C. Jim says it's much better care than a stranger would give him. Alishia says 40 hours a week isn't the half of it.
NPR spoke with 10 couples who'd been cut from the program even though the husbands' condition hadn't improved.
The Portland, Ore., VA cut 66 percent of its caregivers in three years. Seattle cut 49 percent; the South Texas VA cut 48 percent; and Charleston, S.C., went from 197 caregivers in 2014 to just 11 in February of 2017 — a 94 percent reduction. The Charleston VA told NPR some of those vets improved and didn't need the program, and said that others probably never should have qualified at the start.
Congress and veterans organizations are aware of the problem, says Adrian Atizado of DAV, an advocacy nonprofit for veterans.
"We don't have a good idea about how many caregivers are in the same situation we're talking about. ... We know some have appealed, but we don't have enough reliable information, which we need," says Atizado.
He says the VA is promising to get better data and to look into the way clinical decisions about these veterans are made.
Atizado adds that the program is a great first step toward recognizing the millions of family members, doing billions of dollars' worth of work the VA might otherwise have to pay for, taking care of America's veterans. For the moment, however, caregivers like Alishia Graham are not feeling that recognition and support.
"It means my family is — um, nicer word, hold on — is janked out of $2,000 per month," she says.
Alishia says their financial situation is not exactly dire, though. She says made sure to never live paycheck to paycheck, and that Jim still has a pretty high disability check from VA. Plus, Jim hates leaving the house, she says, so it's not like they were saving up for a big vacation.
But Jim says the problem is more about Alishia's hard work no longer being recognized.
"It's insulting. Cause I know how much she does do. And how much help I do need with everything. I gave everything I have to what I was doing. Always did. To not get back the same or equivalent to I gave up is a slap to the face, basically," he says.
The Fayetteville VA told NPR that Jim is no longer clinically eligible for the program, and that the Grahams are welcome to appeal. The VA also says it "can't thank Caregivers enough for the vital role they play in helping Veterans recover from injury and illness."
RACHEL MARTIN, HOST:
Even with all the VA clinics and hospitals, that $180 billion budget for the U.S. Department of Veterans Affairs, even with all those resources, the day-in-and-day-out care of disabled veterans often falls to their own family members. Congress recognized that. And finally, in 2010, created the VA Family Caregiver Program. The program offers support and, in some cases, a little financial help for those family members. Veterans have signed up in huge numbers. NPR's Quil Lawrence reports that family caregivers in some cities say they are now being dropped from that program without any explanation.
QUIL LAWRENCE, BYLINE: Jim Graham wears thick, "Terminator" sunglasses indoors, even with the blinds drawn. Light is a big deal.
JIM GRAHAM: Light's a very big deal, actually.
LAWRENCE: Graham got knocked out by a mortar blast on his third deployment as a combat medic to Iraq in 2006.
J. GRAHAM: Part of my brain injury, one of the things is that I'm light-sensitive. So I have to wear the darkest sunglasses I can find all day, every day.
LAWRENCE: Otherwise, he gets migraines - not just headaches. Those he has all the time.
J. GRAHAM: I've had a headache ever since I got hurt.
LAWRENCE: You've had a headache for 11 years, almost.
J. GRAHAM: Yes. And then I get migraines on top of it. When I get one, it lasts for days, months. If I'm some way able to get rid of a migraine, I'm lucky if I get a week off before another one hits me.
LAWRENCE: The brain injury means he can't remember to turn off the kitchen stove or turn off the shower once he gets in it, or drive or pay bills. Graham also has post-traumatic stress disorder, which gives him panic attacks and makes it hard to leave his house in Jacksonville, N.C. The two-hour drive to the VA in Fayetteville is almost unbearable. Alishia, Jim's wife, takes care of him around the clock.
ALISHIA GRAHAM: I have not been able to work outside of our home since he was injured.
LAWRENCE: The VA's Family Caregiver Program was designed for people like Alishia, mostly wives, sometimes parents, who've had to leave their careers to help their veteran with daily living. Jim got rated at the highest tier in the program, which meant VA paid Alishia a stipend of nearly $2,000 per month. But I got in touch with Alishia Graham because of something I'd been hearing for over a year, caregivers claiming they'd been dropped from the program without cause.
A. GRAHAM: I was watching as all of these caregivers were going up to their reassessments. And one by one, they were sharing that they'd gone to their re-assessment, and they were dropped.
LAWRENCE: Alishia said around Fayetteville, everyone was scared. And she'd heard similar things around the country. Before I could make it down to see her, something came in the mail.
A. GRAHAM: The letter was sitting on the top. And my stomach dropped because I knew what it was.
LAWRENCE: Nothing about her case had changed. If anything, Jim's condition was a little worse. But the Fayetteville VA said he no longer qualified for a caregiver.
A. GRAHAM: And it's not even like, oh, we dropped you a tier because we think he doesn't need as much help. No, we think he's totally fine, and he doesn't need any help. I'm insulted for him because I know what he struggles with.
LAWRENCE: They're not the only ones stymied about why they were dropped. From the Graham's house, I drove down the road to visit another veteran couple, Brianna and Josh Schaudi.
JOSH SCHAUDI: Fourteen years in the Marine Corps, them just to say, OK, well here you go.
BRIANNA SCHAUDI: Met with the doctor for about 10 minutes and a few weeks later, got the letter saying bye-bye.
LAWRENCE: Then, on the phone, Drew and Kari Evans in Idaho Falls said the same thing.
KARI EVANS: Nothing changed from the time we were put on to when we were kicked off. And that's what I got frustrated about.
LAWRENCE: So did Chrissy Hogan, who takes care of her Army vet husband Sean in Cincinnati.
CHRISSY HOGAN: Yeah, I mean, it was a nice program. It helped, you know. I just got cut. I got the letter December 19.
LAWRENCE: And Jenn Wilmot and her husband George, who use the VA in Charleston, S.C.
JENN WILMOT: Home nurse came out. She didn't know anything changing or anything like that. So I'm thinking, OK, we're good. And then, seven days later, after her report went in...
LAWRENCE: NPR spoke with 10 couples who'd been cut from the program. But the VA says overall, the numbers have grown, not shrunk.
MEG KABAT: The program is not cutting back in any way.
LAWRENCE: Meg Kabat is director of the VA Caregiver Support Program. The program had a rocky start in 2011. VA expected to serve four or 5,000 caregivers. It's now serving over 22,000. Kabat says initially there were too few coordinators at some VA's.
KABAT: We've been able to expand the number of caregiver support coordinators and really continue to monitor that. We also train our staff on a regular basis because this is such a unique program and focuses in on family members of the veteran, which is very different than what anybody else is doing in the medical center.
LAWRENCE: Kabat says there's been no pressure nationally to push people off the program, though the eligibility requirements have gotten clearer. VA data does show it added 6,300 caregivers in the past three years. But the same data show it hasn't been consistent. The VA is infamous for inconsistency from station to station. Of 140 medical centers, most added caregivers. But 32 of them cut their numbers, some drastically. At Charleston, S.C., where Jenn and George Wilmot get care, there were 197 caregivers in 2014. Now there are only 11. So 95 percent of their caregivers have been dropped.
The Charleston VA says some of those vets improved and don't need the program; others probably never should have qualified. The Portland, Ore. VA cut 60 percent of its caregivers in three years. Seattle cut 50 percent. The South Texas VA cut half. To repeat, most VA's are adding caregivers. But if you're Alishia Graham taking care of your disabled Iraq-vet husband Jim out of Fayetteville and it seems like half the caregivers you know have been cut, that's because Fayetteville cut half its caregivers in the past three years.
A. GRAHAM: That means my family is - oh, nicer word, hold on - is janked (ph) out of $2,000 a month.
LAWRENCE: Alishia says she made sure never to live paycheck to paycheck. And she knows there were some people in the program who shouldn't have qualified. And Jim has a pretty high disability check from VA, so they're not starving. And she says Jim hates leaving the house, so it's not like they were going to save up for a big vacation anyway. But Jim says it's more about Alishia's hard work no longer being recognized.
J. GRAHAM: It's insulting because I know how much she does do, how much help I do need with everything. I gave everything I had to what I was doing, always did. To not get back the same or equivalent that I gave up is a slap to the face, basically.
LAWRENCE: The Fayetteville VA says Jim is no longer clinically eligible for the program and that the Grahams are welcome to appeal and that the VA, quote, "can't thank caregivers enough for the vital role they play in helping veterans recover from injury and illness." Quil Lawrence, NPR News. Transcript provided by NPR, Copyright NPR.