Federal Response to COVID-19: Department of Veterans Affairs

Summary: The Department of Veterans Affairs (VA) provides a range of benefits to eligible veterans and their dependents. The department carries out its programs nationwide through three administrations and the Board of Veterans' Appeals (BVA).

Summary: With a vast integrated health care delivery system spread across the United States, the VHA is statutorily required to serve as a contingency backup to the Department of Defense (DOD) medical system during a national security emergency and to provide support to the National Disaster Medical System and the Department of Health and Human Services (HHS), as necessary, in support of national emergencies. These functions are known as VA's "Fourth Mission."

Summary: Since the onset of the Coronavirus Disease 2019 (COVID-19) pandemic, Congress has passed a number of relief measures affecting the VA and its Fourth Mission.

Summary: T he Families First Coronavirus Response Act ( P.L. 116-127 ), enacted on March 18, 2020, provides $60 million for the VHA in emergency supplemental appropriations. Among other things, the act also prohibits the VA from charging any copayment or other cost-sharing payments for COVID-19 testing or medical visits during any period of this public health emergency.

Summary: P.L. 116-128 , enacted on March 21, allows the VA to continue to provide GI Bill benefits from March 1, 2020, through December 21, 2020, for courses at educational institutions that are converted from in-residence to distance learning by reason of an emergency or health-related situation.

Summary: T he Coronavirus Aid, Relief, and Economic Security Act (CARES Act) ( P.L. 116-136 ), enacted on March 27, provides a total of $19.6 billion in emergency supplemental appropriations for FY2020 for certain VA accounts, as well as temporary statutory relief for various VA programs and services during the COVID-19 public health emergency.

Summary: The Student Veteran Coronavirus Response Act of 2020 ( P.L. 116-140 ), enacted on April 28, 2020, is intended to mitigate the disruption to VA educational benefits, including Vocational Rehabilitation & Employment (VR&E), when schools, programs of education, and work are suspended or closed from March 1, 2020, to December 21, 2020.

The Department of Veterans Affairs (VA) provides a range of benefits and services to veterans who meet certain eligibility criteria. These benefits and services include, among other things, hospital and medical care; disability compensation and pensions; education; vocational rehabilitation and employment services; assistance to homeless veterans; home loan guarantees; administration of life insurance, as well as traumatic injury protection insurance for servicemembers; and death benefits that cover burial expenses.

The department carries out its programs nationwide through three administrations and the Board of Veterans' Appeals (BVA). The Veterans Health Administration (VHA) is responsible for health care services and medical and prosthetic research programs. The Veterans Benefits Administration (VBA) is responsible for, among other things, providing disability compensation, pensions, and education assistance. The National Cemetery Administration (NCA) is responsible for maintaining national veterans cemeteries; providing grants to states for establishing, expanding, or improving state veterans cemeteries; and providing headstones and markers for the graves of eligible persons, among other things.

In addition to providing health care services to veterans and certain eligible dependents, the VHA must, by statute, serve as a contingency backup to the Department of Defense (DOD) medical system during a national security emergency and provide support to the National Disaster Medical System and the Department of Health and Human Services (HHS) as necessary in response to national crises. The department must also take appropriate actions to ensure VA medical centers are prepared to protect veteran patients and staff during a public health emergency.

On December 31, 2019, the World Health Organization (WHO) learned of a cluster of pneumonia cases in Wuhan City, Hubei Province of China. The WHO has since linked these illnesses to a disease, called Coronavirus Disease 2019 or COVID-19, caused by a previously unidentified strain of coronavirus, designated SARS-CoV-2. On January 30, 2020, an Emergency Committee convened by the WHO Director-General declared the COVID-19 outbreak to be a Public Health Emergency of International Concern (PHEIC). On January 31, the Secretary of Health and Human Services declared a public health emergency under Section 319 of the Public Health Service Act (42 U.S.C. Â§247d). On March 11, 2020, the WHO characterized the COVID-19 outbreak as a pandemic. Two days later, on March 13, the President declared the COVID-19 outbreak a national emergency, beginning March 1, 2020.

The VHA plays a significant role in the domestic response to a pandemic. The VHA is one of the largest integrated direct health care delivery systems in the nation, caring for more than 7.1 million patients in FY2020 and providing 123.8 million outpatient visits at approximately 1,450 VA sites of care. The VHA employs a workforce of 337,908 full-time equivalent employees (FTEs), largely composed of health care professionals. In addition, the VHA has a statutory mission to contribute to the overall federal emergency response capabilities.

This report provides an overview of VA's and Congress's response thus far to the rapidly evolving COVID-19 pandemic. The report does not provide an exhaustive description of all of the department's activities, and it is based on publicly available information and daily updates provided from the VA.

first, it provides details on VHA's, VBA's, and NCA's response activities; second, it provides details on VA's emergency preparedness ("Fourth Mission") activities to provide support to the overall federal emergency response; and third, it describes congressional activity related to VA and veterans programs and services.

The COVID-19 pandemic is a rapidly evolving situation and information changes on a daily, or often hourly, basis. The Appendix provides a summary of VHA's emergency authorities.

Medical Care for Veterans During the COVID-19Â Outbreak

VHA's provision of medical care to veterans in response to the COVID-19 outbreak includes implementing mitigation strategies at VHA sites of care, as well as testing and treating veterans diagnosed with or suspected of having COVID-19. (A general description of medical care to veterans is provided in other CRS reports. )

In late February 2020, the VA provided information to congressional oversight committees on the number of positive and presumptive positive cases of COVID-19. On March 13, 2020, the department began publishing this information publicly on its website, which it updates on a regular basis. The VA has been providing regular updates to congressional oversight committees since that time.

The VA has published two public documents that provide valuable information to patients and the public regarding the response to COVID-19: (1) a COVID-19 response plan that provides operational details for both medical care for veterans, as well as other VHA missions, and (2) Coronavirus Frequently Asked Questions (FAQ) for patients. The VA COVID-19 response plan is summarized in more detail in the " Emergency Preparedness ("Fourth Mission") " section of this report.

This section describes current health system capacity (including staffing changes), guidance for patients, mitigation at VHA sites of care (including limitations to community care), and testing and treatment for COVID-19.

This subsection reflects point-in-time information provided by the VA to reflect the current capacity of the system.

As of April 14, 2020, veterans and VHA employees at sites of care spanning the United States have been diagnosed with COVID-19. The vast majority of COVID-19-positive veterans are being treated in outpatient settings, with a minority in VA inpatient intensive care unit (ICU) and acute care settings. The COVID-19 pandemic is a rapidly evolving situation and information changes on a daily, or often hourly, basis.

In response to the pandemic, the VA increased the number of ICU and acute care beds that are typically available. As of April 29, 2020, bed capacity across the health system is 12,215, with far less than half occupied. No regional or local level occupancy data have been reported. The VA started deploying Vet Centers, which provide a range of counseling services, in locations facing large COVID-19 outbreaks.

The VA is reporting that the health system has adequate levels of personal protective equipment (PPE), including N95 respirators. Earlier media reports, citing internal VA memoranda, stated that the VA has a shortage of PPE and hospitals are being directed to decide which employees get certain supplies. The media reports suggested that only employees that work directly with COVID-19 patients are to be provided N95 respirators.

An April 16, 2020, memorandum to Veterans Integrated Service Networks (VISN) directors from the VA Deputy Under Secretary for Health for Operations and Management confirmed that the VA received a significant number of N95 respirators and is working to secure additional facemasks and surgical masks. The memo specified that facilities have enough masks and respirators to follow CDC-based contingency strategies for supply management. The memo provides system-wide guidance for staff use of respirators and masks.

Staff providing direct care should use N95 respirators. If N95 respirators are in short supply, staff are directed to use surgical masks for low-risk care on suspected or confirmed COVID-19 patients. Staff providing care for patients in specified institutional settings will be provided with one facemask or surgical mask per day.

It goes on to provide guidance to VISN directors on how to support medical facility directors in implementing contingency and crisis strategies based on the referenced CDC guidelines. Medical facility directors have authority to determine allocation and crisis standards of care, in the event that resources become scarce.

The VA is allocating equipment within VISNs, as needed, and it has increased pharmaceutical inventories from 8 days to 10 days and is utilizing certain medications needed for hospitalized COVID-19 patients as national system-wide resources.

As described below, the VA has taken a number of actions to ensure that there is adequate staffing and that safeguards are in place to protect frontline employees. These actions are described in the next section.

Employment Actions Related to the Pandemic Response

Actions related to employment can be separated into two categories: (1) actions to increase the capacity of the health system during the pandemic response and (2) actions to protect current employees from contracting the COVID-19 virus.

Employment Actions to Increase Health System Capacity

The VA submitted a request to the Office of Personnel Management (OPM) and received approval to waive a requirement that retiree' salaries be reduced when rehired to reflect the retirement annuity they already receive, otherwise known as a dual compensation reduction waiver. The VA is asking retired clinicians to register online to join the workforce and to act as surge capacity if needed. The registration form adds the reemployed retirees to VHA's national provider database and matches them to opportunities based on their specialties.

The VA has indicated that it is exploring the use of existing hiring authorities to make 30-day appointments where a critical need exists, one-year appointments in remote/isolated areas, and temporary not-to-exceed 120-day appointments. VA on-boarded 3,107 new hires in the period between April 22 and April 28, 2020.

In addition, activation of the Disaster Emergency Medical Personnel System (DEMPS) allows the VA to deploy personnel from areas that are less impacted by COVID-19 to reinforce staff levels at other facilities as needed (e.g., facilities in New York City and New Orleans). Under DEMPS, movement of personnel must be approved by the VISN and the originating medical center's director.

A number of VHA employees have been diagnosed with COVID-19 or are being monitored for COVID-19. As of April 29, 2020, over 2,200 employees have been diagnosed with COVID-19 and 20 employees have died from the disease. The VA has taken specific actions to protect employees, which, in turn, increases health system capacity by reducing the need for front-line employees to take leave during the pandemic.

The VA is following CDC precautions to reduce the likelihood of transmission of COVID-19 among employees. According to the VA, staff have been given guidance to remain home if symptoms develop, to obtain health checks for symptoms associated with COVID-19 while at work, and to report symptoms through the correct process. Employees are also being encouraged to develop personal and family disaster plans that enable them to continue working. Employees are encouraged to telework, if their work can be accomplished remotely.

Sites of care are encouraged to use alternative treatment methods wherever possible, such as telemedicine and telehealth. To prevent the spread of infection, the VA has dedicated specific treatment areas for COVID-19 patients. This and other mitigation efforts at VHA sites of care are discussed below.

The VHA operates care settings with varying levels of patient risk for developing severe symptoms if COVID-19 is contracted. Each VA medical center is implementing a two-tiered system to mitigate the potential for spread of the virus, with one zone for active COVID-19 cases and a passive zone for care unrelated to COVID-19. The VA has canceled all elective surgeries and limited routine appointments to only those with the most critical need.

This section describes mitigation efforts at community living centers (CLCs; nursing homes) and spinal cord injury/disorder (SCI/D) centers, which are high-risk settings, separate from other care settings. The VA has implemented different screening processes and other pandemic responses depending on the care setting.

On March 26, 2020, the VA Office of Inspector General (OIG) published the results of inspections of VA facilities for implementing the enhanced screening processes and pandemic readiness, which took place between March 19 and March 24. The findings of those inspections for each care setting appear in the appropriate sections below.

On March 10, 2020, the VA announced safeguards to protect nursing home residents and spinal cord injury patients. As of that date, no visitors are allowed at either VA nursing homes or spinal cord injury/disorder centers. The only exception to this policy is if a veteran is in the last stages of life, in which case the VA allows visitors in the veteran's room only. The VA is not accepting any new admissions to nursing homes and is limiting new admissions to SCI/D centers.

The OIG tested the no-access policy at 54 CLCs and found the majority to be in compliance with the policy. Nine of the 54 CLCs tested were prepared to allow OIG staff to enter, despite the no-access policy.

The VA implemented enhanced screening procedures at all sites of care to screen for respiratory illness and COVID-19 exposure. Because each facility determines its own enhanced screening procedures, those procedures vary at the local level. However, the VA has designed standardized screening questions for each facility. Screening consists of the following three general questions:

Do you have a fever or worsening cough or shortness of breath or flu-like symptoms? Have you or a close contact traveled to an area with widespread or sustained community transmission of COVID-19 within 14 days of symptom onset? Have you been in close contact with someone, including health care workers, confirmed to have COVID-19?

The VA's COVID-19 response plan provided specific potential questions that sites of care can implement in different care settings. Those screening questions also include screening scenarios for virtual triage via phone, telehealth, or secure messaging.

If screened individuals are determined to be at risk, staff are instructed to isolate them immediately. If critically ill, individuals are transferred to the emergency department. If stable, individuals are sent home with printed instructions to isolate and contact their primary care providers.

The OIG evaluated screening procedures at 58 medical centers and 125 community-based outpatient clinics (CBOC). The OIG found that 41 of 58 (71%) of medical centers' screening processes were generally adequate, 16 (28%) had some opportunities for improvement, and one medical center had inadequate screening procedures. The OIG found that the vast majority of CBOCs (97%) had screening processes in place. Four CBOCs had no screening process in place.

The VA instituted several changes to community care guidance during the COVID-19 pandemic response on community care access under the Veterans Community Care Program (VCCP). Under normal circumstances, veterans generally are eligible for access to medical care from non-VA community providers if they meet certain criteria, including wait time and drive time access standards and if the veteran elects to receive community care.

The eligibility criteria are mandated by law, and the VA has no authority to waive them. However, as many non-VA providers are postponing or canceling routine care to mitigate the spread of COVID-19, wait times may be just as long or longer in the community. In addition, the VA indicated that community providers should not have veterans attend routine appointments in-person except where the urgency of in-person treatment outweighs the risk of contracting COVID-19.

VA issued the following guidance to providers:

convert routine in-person appointments to telehealth; follow CMS, CDC, state, and local guidance regarding screening, testing, case reporting, and PPE; plan for increased high acuity demand; communicate with local VA medical center regarding any veteran cases or exposure to COVID-19; episodes of care ordered through the VA can be extended by 60 days; and work with the third-party administrators of the community care network (CCN) to expand enrollment where possible.

The VA is promoting the Coronavirus FAQ document as the main source of guidance for veterans. This document includes answers to broad questions about COVID-19, VA's role, testing, access to care, mental health, and visiting patients. A fact sheet with similar information is also available to patients.

The VA is advising veterans who may be sick or who are exhibiting flu-like symptoms not to come to a VA facility. Instead, patients are asked to send a secure message through the VHA online portal, My HealtheVet, or to schedule a telehealth appointment. The VA is experiencing high call volumes at some facilities and call centers, so it is advising veterans to use online tools first. However, patients can call their health care providers instead of using the online tools available from the VA.

In addition, the VA is advising patients to budget additional time for appointments due to enhanced screening measures at VA facilities. These enhanced screening measures, as well as other mitigation strategies at VHA facilities, are described below.

This section describes the current VA policy on testing patients for COVID-19 and treatment following a COVID-19 diagnosis.

On March 13, 2020, the department began publishing the number of positive cases of COVID-19, and the number of tests conducted, on its public website, which it updates on a regular basis. Individual medical centers have discretion on where to send samples for testing. Samples can be tested at the Palo Alto VA Medical Center, state public health labs, or private labs.

Individual providers decide whether to test for COVID-19 on a patient-by-patient basis. However, the VA has advised providers that to be tested, patients must be exhibiting respiratory symptoms and have another factor, such as recent travel or known exposure to someone who tested positive.

Generally, diagnostic testing is a covered service under VA's standard medical benefits package, which is available to all veterans enrolled in the VA health care system. Some veterans are required to pay copayments for care that is not related to a service-connected disability. However, routine lab tests are exempt from copayment requirements.

The Families First Coronavirus Response Act ( P.L. 116-127 ), enacted on March 18, 2020, does not allow the VA to charge any copayment or other cost-sharing payments for COVID-19 testing or medical visits during any period of this public health emergency. (For a discussion of P.L. 116-127 , see the " Congressional Response " section of this report.)

The VA has not indicated whether it has developed a specific treatment plan for patients diagnosed with COVID-19. Treatment depends largely on the severity of symptoms that each patient experiences.

The VA is handling coverage and cost of treatment for COVID-19 as it would for any other treatment for a condition that is not service-connected. Treatment for COVID-19 is a covered benefit under the VA standard medical benefits package. However, some veterans may have to pay copayments for both outpatient and inpatient care.

Normal coverage rules apply for veterans who report to urgent care or walk-in clinics. To be eligible, a veteran must be enrolled in the VA health care system and must have received VA care in the past 24 months preceding the episode of urgent or walk-in care. Eligible veterans needing urgent care must obtain care through facilities that are part of VA's contracted network of community providers. These facilities typically post information indicating that they are part of VA's contracted network. If an eligible veteran receives urgent care from a noncontracted provider or receives services that are not covered under the urgent care benefit, the veteran may be required to pay the full cost of such care. Certain veterans are required to pay copayments for care obtained at a VA-contracted urgent care facility or walk-in retail health clinic.

In addition, normal rules apply for veterans who report to non-VA emergency departments. To be eligible for VA payment or reimbursement, a veteran's non-VA care must meet the following criteria:

The emergency care or services were provided in a hospital emergency department or a similar facility that provides emergency care to the public. The claim for payment or reimbursement for the initial evaluation and treatment was for a condition of such a nature that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health. A VA or other federal facility or provider was not feasibly available, and an attempt to use them beforehand would not have been considered reasonable by a prudent layperson. At the time the emergency care or services were furnished, the veteran was enrolled in the VA health care system and had received medical services from the VHA within the 24-month period preceding the furnishing of such emergency treatment. The veteran was financially liable to the provider of emergency treatment for that treatment. The veteran had no coverage under a health plan contract that would fully cancel the medical liability for the emergency treatment. If the condition for which the emergency treatment was furnished was caused by an accident or work-related injury, the veteran is required to first pursue all claims against a third party for payment of such treatment.

In the event that a vaccine is approved by FDA and brought to market, it is unclear whether certain veterans would be charged copayments for administration of the vaccine. Under current regulations, the VA is prohibited from charging copayments for "an outpatient visit solely consisting of preventive screening and immunizations (e.g., influenza immunization, pneumococcal immunization)."

Veterans experiencing homelessness live in conditions that could make them particularly vulnerable to COVID-19. Those who are unsheltered lack access to sanitary facilities. For those sleeping in emergency shelters, conditions may be crowded, with short distances between beds, and there may be limited facilities for washing and keeping clean.

The VA administers programs to assist veterans experiencing homelessness and also manages several grant programs for nonprofit and public entities to provide housing and services to homeless veterans. These include the Homeless Providers Grant and Per Diem program (GPD), for transitional housing and services; the Supportive Services for Veteran Families program (SSVF), for short- to medium-term rental assistance and services; and Contract Residential Services (CRS), for providing housing for veterans participating in VA's Health Care for Homeless Veterans program. In addition, the Department of Housing and Urban Development (HUD), together with VA, administers the HUD-VA Supportive Housing program (HUD-VASH), through which veterans who are homeless may receive Section 8 vouchers to cover the costs of permanent housing and VA provides case management services.

VA General Guidance for Homeless Program Grantees

The VA released guidance on March 13, 2020, for its grantees that administer programs for veterans who are homeless. The guidance suggests grantees take a number of actions:

Develop a response plan, or review an existing plan, and coordinate response planning with local entities, including health departments, local VA medical providers, and Continuums of Care. Plans should address staff health, potential staff shortages, and acquisition of food and other supplies, as well as how to assist veteran clients. Prevent infection through methods recommended by the CDC, such as frequent handwashing, wiping down surfaces, and informing clients about prevention techniques. In congregate living facilities, such as those provided through VA's Grant and Per Diem program, keep beds at least three feet apart (preferably six, if space permits), sleep head-to-toe, or place barriers between beds, if possible. Develop questions to ask clients about their health to determine their needs and how best to serve them. For new clients, interviews should occur prior to entry into a facility (such as over the phone), if possible, or in a place separate from other clients. If a client's answers to questions indicate risk of COVID-19, separate them from other program participants (have an isolation area, if possible), clean surfaces, and reach out to medical professionals. If isolation is not practical, reach out to other providers who might be able to isolate.

Supportive Services for Veteran Families (SSVF)

The VA has released additional specific guidance and flexibilities for SSVF providers.

SSVF regulations allow funds to be used for emergency housing, including hotels and motels; however, this use of funds may occur only when no other housing options, such as transitional housing through GPD, are available. In response to COVID-19, however, grantees may use funds for high-risk veterans to live in hotels and motels instead of congregate settings. Due to Public Housing Authority (PHA) closures and remote work, veterans who have HUD-VASH vouchers, but who have not yet moved into a housing unit, may face delays in receiving rental assistance. This delay may occur if a PHA cannot conduct a housing quality standards (HQS) inspection or complete other administrative tasks that allow move-in to occur. In these cases, SSVF grantees may use funds to cover rental assistance until a PHA has completed the tasks allowing the voucher to be used.

HUD-VA Supportive Housing program (HUD-VASH)

For veterans residing in rental housing using HUD-VASH vouchers, HUD has waived certain requirements pursuant to CARES Act ( P.L. 116-136 ) waiver authority to address situations that may arise due to COVID-19. For example, ordinarily HUD will not approve a unit for Section 8 rental assistance (which includes HUD-VASH vouchers) unless it has passed an HQS inspection. However, HUD has waived this requirement and will accept an owner certification that there is "no reasonable basis to have knowledge that life threatening conditions exist in the unit." PHAs must conduct inspections of units as soon as reasonably possible, and no later than October 31, 2020. PHAs may also accept alternative inspection results rather than HQS inspections and allow families to move into units in these cases. For existing tenants, PHAs may change from an annual unit inspection schedule to a biennial schedule without updating their administrative plan.

If resident income changes due to an inability to work, or other reason, residents should report the change to their local PHA and rent should be adjusted accordingly. HUD has waived the requirement that PHAs obtain third-party verification of an income change for these income recertifications. In addition, as part of the CARES Act ( P.L. 116-136 ), residents receiving Section 8 rental assistance cannot be evicted for nonpayment of rent for 120 days from the date of the bill's enactment (March 27, 2020).

The VA administers both guaranteed and direct loans for veterans through the Veterans Benefits Administration. Prior to enactment of the CARES Act, VA encouraged lenders to establish a foreclosure moratorium for borrowers with VA loans, but a moratorium was not required. However, the CARES Act provides for both forbearance (i.e., allowing borrowers to reduce or suspend mortgage payments) and a foreclosure moratorium for federally backed single-family mortgages, including guaranteed VA loans. Direct VA loans do not appear to be included in the CARES Act definition of federally backed mortgage.

Borrowers may request forbearance from their loan servicer for up to 180 days, with another 180-day extension, due to financial hardship caused directly or indirectly by COVID-19. The foreclosure moratorium is in effect for 60 days beginning March 18, 2020. For more information about these provisions, see CRS Insight IN11334, Mortgage Provisions in the Coronavirus Aid, Relief, and Economic Security (CARES) Act .

The Veterans Benefits Administration has taken several actions to assure continued delivery of disability compensation, pensions, and education assistance.

On March 18, 2020, the Veterans Benefits Administration announced via Facebook and Twitter that all regional offices would be closed to the public starting March 19. The regional offices are to remain open to ensure the continuity of benefits, however, the offices are longer accepting walk-ins for claims assistance, scheduled appointments, counseling, or other in-person services. The VBA is directing veterans who have claims-specific questions or any other questions to use the Inquiry Routing & Information System (IRIS) or to call 1-800-827-1000.

In a March 26 interview, VA Under Secretary for Benefits, Dr. Paul Lawrence, assured veterans and their families that benefits were still being processed thanks in part to the large telework capability in place for the VBA. Lawrence stated that about 90% of all VBA employees, approximately 22,500 individuals, are set up and teleworking to retain the continuity of processing claims.

Dr. Lawrence also addressed the issue of veterans who need a compensation and pension exam completed as part of their benefits application. Due to travel restrictions and social distancing policies, Lawrence explained VBA's attempt at still providing the exams but without in-person contact. He stated:

So we're trying to do more, a lot more through telehealth, You know phone call or a Skype session or something. We can get these exams done that we're flexing in new ways. Where once things were done in person â¦ now they're being done electronically.

Following Dr. Lawrence's interview, on March 31, the VA issued a press release announcing changes to several in-person meetings and programs to ensure the safety of both the staff and veteran/dependent during this time. Some of these changes included

providing educational counseling through online and telephone services; using teleconferencing and VA Video Connect for case management, general counseling and connecting veterans to VR&E services; conducting informal conference hearings by telephone or video conferencing; providing virtual briefings and individualized counseling for transitioning servicemembers; and conducting examinations for disability benefits using tele-compensation and pension (Tele-C&P) exams. If an in-person examination is required, veterans will be notified for scheduling.

However, on April 6, the VBA announced via email that it is "suspending in-person C&P examinations until further notice and will continue to conduct C&P exams through ACE and Tele-C&P, when possible." The email also provided guidance on filing claims and information to assist veterans with submitting medical documentation without appearing in person. On April 3, the VA announced that claimants who need an extension in filing their paperwork "can simply submit [the request] with any late-filed paperwork and veterans do not have to proactively request an extension in advance."

In FY2020, over 900,000 individuals are expected to receive veterans educational assistance from the GI Bills (e.g., the Post-9/11 GI Bill), Vocational Rehabilitation & Employment (VR&E), Veteran Employment Through Technology Education Courses (VET TEC), Veterans Work-Study, Veterans Counseling, and VetSuccess on Campus (VSOC). As a result of COVID-19, some participants' training and education may be disrupted, and some participants may receive a lower level of benefits, or none at all. These concerns may directly affect beneficiaries in several ways, including the following:

Some students may be required to stop out, discontinue working, or take a leave of absence as a result of their own illness. Some training establishments, educational institutions, and work-study providers may close temporarily or permanently. Some training establishments, educational institutions, and work-study providers may be required to reduce participants' hours, enrollment rate, or rate of pursuit. Some educational institutions may transition some courses to a distance learning format. Some educational institutions may require students living on campus to move off campus. Individuals receiving benefits in foreign countries may encounter any of the above circumstances while residing in a foreign country whose COVID-19 situation may differ from that in the United States, or may stop out, discontinue working, or take a leave of absence and return to the United States.

Since mid-March, the VA has sent direct emails to GI Bill participants and school certifying officials (SCOs) and held webinars for SCOs to explain its authority and payment processing procedures that are directly relevant to COVID-19 disruptions.

On March 13, 2020, the VBA Education Service requested that school-certifying officials "temporarily refrain from making any adjustments to enrollment certifications" if resident courses transitioned to distance education pending subsequent VA guidance and/or legislative action. The VBA Education Service administers VA educational assistance programs. Prior to the COVID-19 emergency, educational institutions were required to receive approval before transitioning any courses to a distance learning format for the courses to remain GI Bill-eligible. GI Bill benefits could not be paid for the pursuit of online courses that had not been previously approved as online courses. This limitation was alleviated by recently enacted legislation (for a discussion of P.L. 116-128 , see the " Congressional Response " section of this report).

In addition, on April 3, 2020, the VA announced that it was suspending for sixty days the collection of institutions' and veterans' debt, including for debts under the jurisdiction of the Department of the Treasury. Individuals with an existing repayment plan must request a suspension if they are unable to make payments. In 2019, the VA indicated that approximately 25% of GI Bill participants must resolve an overpayment-related debt at some point.

The VBA Education Service has announced that it is moving away from paper correspondence, including faxes. In an effort to accomplish this transition, VBA has requested that GI Bill participants provide or update their email addresses. On-the-job training (OJT) and apprenticeship training establishments must submit certifications electronically.

The National Cemetery Administration has provided information for the survivors and dependents of veterans who have passed away and are scheduled to be buried in a National Cemetery during this national emergency. Effective March 23, 2020, the NCA announced that all "committal services and the rendering of military funeral honors, whether by military personnel or volunteer organizations, will be discontinued until further notice at VA national cemeteries."

VA National Cemeteries will remain open to visitors and for interments, but visitors should follow their local communities' restrictions on visitations and travel. In addition, visitors should be prepared for certain areas of the cemetery typically open to the public to be closed. These areas include public information centers, visitor centers, and chapels. For direct interments, the NCA is limiting attendance to immediate family of deceased family members, up to 10 individuals. In addition, the NCA is to work with families to schedule a committal or memorial service at a later date.

On Friday, March 27, the NCA informed funeral directors of a change in the floral arrangement policy, stating that national cemeteries will no longer accept floral arrangements with direct interments.Â If families want to place a floral arrangement at the gravesite, they may do so after 4:30 pm on the day of interment or any time after. In addition, the NCA limited floral arrangements to two per gravesite.

The NCA announced that the National Cemetery Scheduling Office in St. Louis will continue to provide scheduling services. The NCA has set up an "Alerts" web page for the public to check cemetery operating status and is directing the public to its Facebook and Twitter pages for the most recent operating information.

Emergency Preparedness ("Fourth Mission")

In 1982, the Veterans Administration and Department of Defense Health Resources Sharing and Emergency Operations Act ( P.L. 97-174 ) was enacted to serve as the primary health care backup to the military health care system during and immediately following an outbreak of war or a national emergency. Since then, Congress has provided additional authorities to VA to "use its vast infrastructure and resources, geographic reach, deployable assets, and health care expertise, to make significant contributions to the Federal emergency response effort in times of emergencies and disasters."

Among other authorities, the VHA may care for nonveterans, as well as veterans not enrolled in the VA health care system. The VA also has authority to provide certain health services such as medical counter measures to VA employees. The authority to care for care for nonveterans, applies in situations where the President has declared a major disaster or emergency under the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act), or where the HHS Secretary has declared a disaster or emergency activating the National Disaster Medical System established pursuant to Section 2811(b) of the Public Health Service Act (42 U.S.C. Â§300hh-11(b)). The President's March 13, 2020, declaration of a national emergency under Section 501(b) of the Stafford Act allows VA to use this authority.

On March 27, 2020, the VA released its COVID-19 Response Plan. The plan defines the VA's national level roles and responsibilities:

VHA will provide [personal protective equipment] PPE fit-testing, medical screening, and training for [Emergency Support Function #8] ESF #8 and other Federal response personnel. Provide VHA staff as ESF #8 liaisons to [Federal Emergency Management Agency] FEMA the Incident Management Assistance Teams deploying to the state emergency operations center. Provide VHA planners currently trained to support ESF #8 teams. VHA provides vaccination services to VA staff and VA beneficiaries in order to minimize stress on local communities. VHA furnishes available VA hospital care and medical services to individuals responding to a major disaster or emergency, including active duty members of the Armed Forces as well as National Guard and military Reserve members activated by state or Federal authority for disaster response support. VHA provides ventilators, medical equipment and supplies, pharmaceuticals, and acquisition and logistical support through VA National Acquisition Center. [NCA] provides burial services for eligible veterans and dependents and advises on methods for interment during national security emergencies. VHA designates and deploys available medical, surgical, mental health, and other health service support assets. VHA provides one representative to the National Response Coordination Center (NRCC) during the operational period on a 24/7 basis.

According to the VA, during declared major disasters and emergencies, service-connected veterans receive the highest priority for VA care and services, followed by members of the Armed Forces receiving care under 38 U.S.C. Section 8111A, and then followed by individuals affected by a disaster or emergency described in 38 U.S.C. Section 1785 (i.e., individuals requiring care during a declared disaster or emergency or during activation of the National Disaster Medical System [NDMS]). In general, care is prioritized based on clinical needâthat is, urgent, life-threating medical conditions are treated before routine medical conditions (see the Appendix ). The Coronavirus Aid, Relief, and Economic Security Act (CARES Act; P.L. 116-136 ), provided funding for the Public Health and Social Services Emergency Fund to reimburse the VHA to respond to COVID-19 and to provide medical care for nonveterans. However, prior to reimbursing the VHA, the HHS Secretary is required to certify to congressional appropriations committees that funds available under the Robert T. Stafford Disaster Relief and Emergency Assistance Act are insufficient and that funds provided under the CARES Act are necessary to reimburse the VHA for expenses incurred to provide health care to nonveterans .

Generally, if a state, tribal, or territorial government needs resources, it can request assistance from the federal government through its local HHS regional emergency coordinator (REC), which is a part of FEMA's NRCC. The VA cannot receive direct requests for assistance from state and local governments. In addition, the VA does not support providing VA medical personnel to nondepartment facilities. The VHA has accepted several "fourth mission" assignments from FEMA/HHS. For example, the VHA has responded and provided assistance to New York and New Jersey. On March 29, VA New York Harbor Healthcare System's Manhattan and Brooklyn VA medical centers admitted nonveteran, non-COVID-19 patients, and on April 1, East Orange, New Jersey VA Medical Center, admitted nonveteran critical and noncritical COVID-19 patients. Furthermore, the VHA is providing laboratory services, pharmaceutical and medication supply through the National Acquisition Center (NAC), and mobile pharmacy units, among others, as requested by FEMA/HHS.

In response to the COVID-19 pandemic, Congress passed several measures to provide the VA with supplemental appropriations and provided temporary statutory changes to enhance veterans' benefits and services during this public health emergency.

Families First Coronavirus Response Act (P.L. 116-127)

Supplemental Appropriations and Cost-Sharing

On March 18, 2020, the President signed into law the Families First Coronavirus Response Act ( P.L. 116-127 ). The act provides $30 million for VHA's medical services account to fund health services and related items pertaining to COVID-19, and $30 million for VHA's medical community care account (see Table 1 ). These funds are designated as emergency spending and are to remain available until September 30, 2022. Among other things, the act does not allow the VA to charge any copayment or other cost-sharing payments for COVID-19 testing or medical visits during any period of this public health emergency.

P.L. 116-128 , as enacted on March 21, 2020, allows the VA to continue to provide GI Bill benefits from March 1, 2020, through December 21, 2020, for courses at educational institutions that are converted from in-residence to distance learning by reason of an emergency or health-related situation. P.L. 116-128 further permits the VA to pay the Post-9/11 GI Bill housing allowance as if the courses were not offered through distance learning throughout the same period. With the exception of those participants covered under this P.L. 116-128 exemption, Post-9/11 GI Bill participants enrolled exclusively in distance education are eligible for no more than one-half the national average of the housing allowance.

Coronavirus Aid, Relief, and Economic Security Act, "CARES Act" (P.L. 116-136)

On March 17, 2020, the Administration submitted to Congress a supplemental appropriations request. The Administration sought $16.6 billion for FY2020 for VA's response to the COVID-19 outbreak. This amount included $13.1 billion for the medical services account. According to the request, this additional amount would provide funding for "healthcare treatment costs, testing kits, temporary intensive care unit bed conversion and expansion, and personal protective equipment." The request also included $2.1 billion for the medical community care account to provide three months of health care treatment provided in the community in response to COVID-19. The VA assumes that about 20% of care for eligible veterans will be provided in the community, since community care facilities would be at full capacity with nonveteran patients.

Furthermore, the emergency supplemental appropriations request included

$100 million for the medical support and compliance account to provide 24-hour emergency management coordination overtime payments, to cover costs associated with travel and transport of materials, and to enable VHA' s Office of Emergency Management to manage its response to COVID-19; $175 million for the medical facilities account to upgrade VA medical facilities to respond to the virus; and $1.2 billion for the information technology systems account to upgrade telehealth and related internet technology to deliver more health care services remotely.

On March 27, the President signed into law the CARES Act ( P.L. 116-136 ). Division B of this act included an emergency supplemental appropriations measure. Title X of Division B provides supplemental appropriations for FY2020 for certain VA accounts totaling $19.6 billion, and is designated as emergency spending. Unless otherwise noted below, funds remain available until September 30, 2021. Funding provided in the CARES Act is broken down as follows (see Table 1 ):

VBA, general operating expenses account, $13 million, for enhancing telework support for VBA staff and for additional cleaning contracts. VHA, medical services account, $14.4 billion, for increased telehealth services; purchasing of additional medical equipment and supplies, testing kits, and personal protective equipment; and to provide additional support to homeless veterans, among other things. VHA, medical community care account, $2.1 billion, for increased emergency room and urgent care usage in the community. VHA, medical support and compliance account, $100 million, for the provision of 24-hour emergency management coordination overtime payments, and for costs associated with travel and transport of materials. VHA, medical facilities account, $606 million, for the procurement of mobile treatment facilities, improvements in security, and nonrecurring maintenance projects. VA, general administration account, $6.0 million, for maintaining 24-hour operations of crisis response and continuity of operations plans at VA facilities, among other things. VA, information technology systems account, 2.2 billion, for increased telework capacity, purchasing additional laptops for telework and telehealth-enabled laptops for VHA providers to work from home, and to increase bandwidth and IT infrastructure needs, among other things. VA, Office of Inspector General account, $12.5 million, for increased oversight of VA's preparation and response to COVID-19 (funds remain available until September 30, 2022). VA, grants for construction of state extended care facilities account, $150 million, to assist state homes to renovate, alter, or repair facilities to respond to COVID-19.

General CARES Act Provisions Affecting VA Programs and Services

This section allows the VA to transfer funds between the medical services, medical community care, medical support and compliance, and medical facilities accounts. The VA can make any transfer that is less than 2% of the total amount appropriated to an account and may follow after notifying the congressional appropriations committees. Any transfer that is greater than 2% of the total amount appropriated to an account or exceeding a cumulative 2% for all of the funds appropriated to the VA in the CARES Act requires Senate and House Appropriations Committee approval.

This section requires the VA to provide monthly reports to the Senate and House Appropriations Committees detailing obligations, expenditures, and planned activities for all the funds provided to the VA in the CARES Act.

This section defines a public health emergency as an emergency with respect to COVID-19 declared by a federal, state, or local authority.

Section 20004. Short-Term Agreements or Contracts with Telecommunications Providers to Expand Telemental Health Services for Isolated Veterans During A Public Health Emergency

The VHA provides telehealth services to veteran patients in their communities from any location in the United States, including U.S. territories, the District of Columbia, and the Commonwealth of Puerto Rico. Section 20004 defines telehealth as "the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration." Examples of telecommunications technologies include the internet, videoconferencing, streaming media, and terrestrial and wireless communications. This section allows the VA Secretary to enter into short-term agreements or contracts with telecommunications companies to expand veteran patients' access to telemental health care services . The goal of the short-term agreements and contracts is for the telecommunications companies to provide temporary, complimentary, or subsidized fixed and mobile broadband services to veteran patients. The Secretary is allowed to enter into short-term agreements or contracts with telecommunications companies only during the period of the COVID-19 outbreak. During this period, covered veteran patients can assess VA telemental health care services through telehealth and the VA Video Connect (VVC) mobile application, which the act refers to as the VA program that connects veteran patients with their health care teams using encryption. Veteran patients can access the VVC on their mobile devices, such as laptops and smartphones.

The short-term agreements or contracts with telecommunications companies must address the telemental health care needs of isolated veterans; therefore, the VA Secretary must prioritize eligibility to veterans who either have low-incomes, live in unserved and underserved areas, reside in rural and highly rural areas, or are considered by the Secretary as having a higher risk of committing suicide and mental health care needs while being isolated during the COVID-19 outbreak. The VA, however, may expand eligibility for telemental health care services to veteran patients who are currently receiving VA care but who are ineligible to receive mental health care services and other health care services through telehealth and/or the VVC.

Section 20005. Treatment of State Homes During Public Health Emergency

The state veterans' home program is a federal-state partnership to construct or acquire nursing home, domiciliary, and adult day health care facilities. VA provides assistance to states in three ways: First, VA provides states with up to 65% of the cost to construct, acquire, remodel, or modify state homes. Second, VA provides per diem payments to states for the care of eligible veterans in state homes. VA may adjust the per diem rates each year. A state home is required to meet all VA standards in order to continue to receive per diem payments. Third, VA is required to support states financially to assist state homes in the hiring and retention of nurses to reduce nursing shortages at state veterans' homes.

This section modifies the treatment of state homes during the public health emergency by (1) waiving requirements for per diem reimbursements for state homes under the VHA State Home Per Diem Program and (2) authorizing the Secretary to provide equipment to state homes. The section waives the occupancy rate requirement under 38 C.F.R. Section 51.40(c), authorizing a state home to receive per diem payments for veterans who are temporarily absent from nursing home care regardless of the state home's occupancy rate. In addition, the section waives the requirement under 38 C.F.R. Section 51.210(d) that a state home must maintain a certain percentage of veteran residents. Lastly, the section authorizes the Secretary to provide state homes with medication, personal protective equipment, medical supplies, and any other equipment, supplies, and assistance available to VA. The personal protective equipment may be provided through the All Hazards Emergency Cache in addition to any other source available.

Section 20006. Modifications to Veteran Directed Care Program of Department of Veterans Affairs

The Veteran Directed Care Program helps isolated veterans who need assistance with activities of daily living or instrumental activities of daily living, and who are at high risk of nursing home placement, to live in their own homes. Veterans in this program are provided a budget for services that can be managed by the veteran or a family caregiver.

This section modifies the Veterans Directed Care Program during the public health emergency to require that the Secretary (1) accept telephone or telehealth enrollments and renewals; (2) stop all suspensions or disenrollments unless requested by a veteran or representative, or the veteran and provider make a mutual decision; (3) waive paperwork requirements and penalties for late paperwork; and (4) waive any requirement to stop payments under the program if the veteran or caregiver is out of state for more than 14 days.

Section 20007. Provision by Department of Veterans Affairs of Prosthetic Appliances through Non-Department Providers During Public Health Emergency

In general, VHA prosthetics staff are responsible for providing and fitting prosthetic appliances that meet the best medical needs of the veteran patient. This provision requires the Secretary to ensure that eligible veterans receiving or requiring prosthetic appliances and services are able to obtain them from contracted non-VA providers during this emergency period.

Section 20008. Waiver of Pay Caps for Employees of Department Of Veterans Affairs During Public Health Emergencies

Under existing regulations, certain VA employees may not receive any combination of premium pay, including overtime pay, that, when added to their base pay, results in total pay above the higher of two rates: GS-15, step 10, or the rate payable for Level V of the Executive Schedule on a biweekly basis. This provision allows the Secretary waive any limitation on pay for any employee of the VA during a public health emergency for work done in support of the emergency. The Secretary is required to provide reports on a monthly basis to the Senate and House Committees on Veterans' Affairs detailing the waivers.

Section 20009. Provision by Department of Veterans Affairs of Personal Protective Equipment for Home Health Workers

This section requires the Secretary to provide VA home health workers with personal protective equipment from the All Hazards Emergency Cache or any other available source.

Section 20010. Clarification of Treatment of Payments for Purposes of Eligibility for Veterans Pension and Other Veterans Benefits

Under ordinary circumstances, eligibility for a VA pension is, in part, based upon the annual income of the individual. Generally, "all payments of any kind or from any source (including salary, retirement or annuity payments, or similar income, which has been waived, irrespective of whether the waiver was made pursuant to statute, contract, or otherwise) shall be included" when calculating a veteran's annual income.

This provision of the CARES Act excludes the recovery rebate from a veteran's annual income, thereby preventing it from counting towards the income limit associated with pension eligibility. It explicitly states that the rebate "shall not be treated as income or resources for purposes of determining eligibility for pension under chapter 15 of title 38." Consequently, the direct individual payment included in the CARES Act will not affect a veteran's eligibility for a VA pension.

Section 20011. Availability of Telehealth for Case Managers and HomelessÂ Veterans

Formerly homeless veterans participating in the HUD-VASH program are assigned VA case managers to assist with their health and other needs. This section requires the VA to ensure that telehealth capabilities are available to veterans and case managers participating in HUD-VASH.

Section 20012. Funding Limits for Financial Assistance for Supportive Services for Very Low-Income Veteran Families in Permanent Housing During A Public Health Emergency

The SSVF program, which provides short- to medium-term rental assistance and supportive services to homeless veterans and their families, is authorized at $380 million through FY2021. Without legislative authority, the VA cannot obligate additional funding for the program. This provision removes the SSVF funding limitation in cases of public health emergencies.

Section 20013. Modifications to Comprehensive Service Programs for Homeless Veterans During A Public Health Emergency

The Homeless Providers Grant and Per Diem (GPD) program provides grants to public entities and private nonprofit organizations for the capital costs associated with developing facilities to serve homeless veterans and also makes per diem payments to grantees for the costs of providing housing and supportive services to homeless veterans. Together, grant and per diem funding is authorized at approximately $258 million per year. In addition, grant costs are limited to 65% of the costs of acquisition, construction, expansion, or remodeling of facilities, and per diem payments are limited to the VA domiciliary care per diem rate, which, for FY2020, is $48.50 per day. This section allows additional appropriations for the GPD program in cases of public health emergencies notwithstanding the FY2020 authorization level, and it also allows the Secretary to waive statutory limitations on grant and per diem payments to grantees.

Generally, VA, under GPD guidance, requires providers to discharge veterans residing in GPD housing who are absent for more than 14 days. In addition, VA will not make per diem payments after a veteran has been absent for more than 72 consecutive hours. This section requires the VA Secretary to waive the discharge requirement and allows the Secretary to reimburse providers for veterans who have been absent for more than 72 hours.

Student Veteran Coronavirus Response Act of 2020 (P.L. 116-140)

The Student Veteran Coronavirus Response Act of 2020 ( P.L. 116-140 ), as enacted on April 28, 2020, responds to concerns that abrupt and temporary closures or suspensions of educational institutions, programs of education, and employment could negatively impact the short-term finances of eligible beneficiaries and their continued pursuit of educational programs. Eligible beneficiaries include participants in several VA educational assistance programs and Vocational Rehabilitation and Employment (VR&E). The act provides special authorities for the period beginning on March 1, 2020, and ending on December 21, 2020, including academic terms beginning prior to December 21, 2020. Selected sections of the bill are discussed below.

Section 3. Payment of Work-Study Allowances During Emergency Situations

The Veterans Work-Study Program allows GI Bill and VR&E participants to receive additional financial assistance through the VA in exchange for employment. Provisions in this section permit Work-Study payments in accordance with an existing Work-Study agreement or at a lesser amount despite the participant's inability to perform work by reason of an emergency situation. These provisions further require the VA to extend an existing agreement for a subsequent period beginning during the covered period if requested by the Work-Study participant.

Section 4. Payment of Allowances to Veterans Enrolled in Educational Institutions Closed for Emergency Situations

The VA has authority under 38 U.S.C. Section 3680(a)(2)(A) to pay GI Bill and VR&E allowances for up to four weeks when an educational institution temporarily closes under an established policy based on an Executive order of the President or due to an emergency situation. The provisions in this section permit GI Bill and VR&E payments for up to four weeks, in addition to any payments under 38 U.S.C. Section 3680(a)(2)(A), if an educational institution closes or the program of education is suspended due to an emergency situation.

Section 5. Prohibition of Charge to Entitlement of Students Unable to Pursue a Program of Education Due to an Emergency Situation

In general, the GI Bills provide eligible persons a 36-month entitlement to educational assistance. GI Bill entitlement is restored in the following instances:

for an incomplete course if an individual is unable to receive credit or lost training time as a result of an educational institution closing; for an incomplete course if an individual is unable to receive credit or lost training time because the course or program is disapproved by a subsequently established or modified policy, regulation, or law; and for the interim (through the end of the academic term but no more than 120 days) Post-9/11 GI Bill housing allowance paid following either a closure or disapproval.

The provisions in this section require that the VA restore entitlement for an incomplete course if an individual is unable to receive credit or lost training time as a result of a temporary closure of an educational institution or the temporary termination of a course or program of education by reason of an emergency situation.

Section 6. Extension of Time Limitations for Use of Entitlement

Many GI Bill participants must use their educational entitlement within a specified time period beginning upon discharge or release from active duty or eligibility. There are notable exceptions to the time limitation. For example, Post-9/11 GI Bill participants whose last discharge or release from active duty was on or after January 1, 2013, are not subject to a time limitation. The provisions in this section exempt from the time limitation, the period during which an individual is prevented from pursuing a program of education because the educational institution closed (temporarily or permanently) under an established policy based on an Executive order of the President or due to an emergency situation until the individual is able to resume pursuit. The provisions are applicable to the Montgomery GI Bill-Active Duty (MGIB-AD) 10-year limitation, the Post-9/11 GI Bill 15-year limitation and age limitation for children using transferred benefits, the VR&E 12-year limitation and the period of a veteran's vocational rehabilitation program, and the Montgomery GI Bill-Selected Reserve (MGIB-SR) limitation.

Section 7. Restoration of Entitlement to Rehabilitation Programs for Veterans Affected by School Closure or Disapproval

Typically, programs under VR&E are limited to 48 months of entitlement and veterans pursuing an education program under VR&E must be enrolled to receive a subsistence allowance. For the covered period, the provisions in this section extend protections from entitlement charges following school closures that are established for the GI Bills to veterans participating in education programs under the VR&E program. The provisions further allow the VA to (1) continue paying subsistence allowances to VR&E participants through the end of the academic term but no more than 120 days following either a closure or disapproval and (2) prohibits VA from charging the impacted term against a veteran's VR&E entitlement if the veteran did not receive credit for classes.

Section 8. Extension of Payment of Vocational Rehabilitation Subsistence Allowances

The provisions in this section provide two additional months of subsistence allowance to veterans who were following a program of employment services under the VR&E program during the covered period.


The Charitable Deduction for Individuals: A Brief Legislative History

Summary: This report provides a brief history of the major legislative changes to the charitable deduction that have occurred over the past 100 years, focusing on changes to the amount that taxpayers could deduct. Over the past 100 years, Congress has generally increased the amount that eligible taxpayers can deduct for their charitable donations. These changes are summarized in the below table.

Summary: As Congress has expanded the amount that can be deducted by those who claim the deduction, policymakers have debated the deduction's effectiveness at increasing charitable giving and the broader role of government subsidies for the philanthropic sectorâa discussion that continues to this day.

This report provides a brief history of the major legislative changes to the charitable deduction for individuals, from its enactment in 1917 through the recent changes enacted at the end of 2017. Policymakers considering changes to this tax benefit may find it helpful to understand how this benefit has evolved over the past 100 years. This report does not address all the legislative changes made to this tax benefit, nor does it provide a broad overview of charitable giving in general, charitable giving tax incentives, their economic effects, or policy options to modify them. Those issues are discussed in CRS Report R45922, Tax Issues Relating to Charitable Contributions and Organizations , by Jane G. Gravelle, Donald J. Marples, and Molly F. Sherlock, and CRS In Focus IF11022, The Charitable Deduction for Individuals , by Margot L. Crandall-Hollick and Molly F. Sherlock.

This report begins with a brief overview of the current charitable deduction for individuals. It then describes major legislative changes made to the deduction from 1917 through the present day, with the most recent changes being those made in 2017. For the purposes of this report, major legislative changes include those that changed the amount that taxpayers could deduct. The bills summarized in this report do not include those that temporarily modified the charitable deduction in response to a disaster. Laws that modified definitions or changed substantiation requirements for taxpayers claiming the deduction are also generally excluded. This report will be updated as necessary to reflect future legislative changes.

Current Tax Benefit for Individual Charitable Donations

Under current law, taxpayers who itemize their deductions canâsubject to certain limitationsâdeduct charitable donations to qualifying organizations. (Individuals who take the standard deduction may not deduct their charitable contributions.) Deductions that cannot be claimed in the current tax year can be carried forward for up to five years, subject to certain limitations.

Under current law, charitable contributions are tax deductible when made to qualifying Section 501(c)(3) organizations, governmental units, veterans' organizations, fraternal organizations, and cemetery companies. A Section 501(c)(3) organization is either a public charity or private foundation.

Private foundations often are tightly controlled, receive significant portions of their funds from a small number of donors or a single source, and make grants to other organizations rather than directly carry out charitable activities. Most private foundationsâ91% of all private foundations in 2015 âprimarily make grants to other charitable organizations and to individuals. These foundations are referred to as nonoperating foundations . Foundations that directly operate their own charitable programs are referred to as operating foundations .

In contrast, public charities tend to have broad public support and provide charitable services directly to beneficiaries. Public charities include organizations "organized and operated exclusively for religious, charitable, scientific, testing for public safety, literary, or educational purposes, or to foster national or international amateur sports competition â¦ or for the prevention of cruelty to children or animals."

Tax-deductible donations to qualifying organizations can be in the form of cash, securities, or property. Properties or securities held for more than a year are often referred to as long - term capital gain properties . Properties or securities held for less than a year are often referred to as short - term capital gain properties. (For more information on general valuation rules of noncash property, see Appendix B .) Depending on (1) the type of property donated and (2) the type of qualifying organization that receives the donations, there are limitations on the total dollar amount that the taxpayer can deduct, as illustrated in Table 1 . The limitations are defined as a percentage of the taxpayer's adjusted gross income (AGI).

Enacted in 1917, the deduction for charitable giving has changed over the years from "a short statutory provision into a complex set of rules." Below is a brief legislative history of the major legislative changes to the charitable deduction that have occurred over the past 100 years, focusing on changes to the amount that taxpayers could deduct. Table 2 summarizes these changes.

Over the past 100 years, Congress has generally increased the amount that eligible taxpayers can deduct for their charitable donation. The history of the charitable deduction illustrates two main policy objectives of this benefit. In its early years, the charitable deduction served to ensure that resources given to charity would not be treated as income for the purposes of taxation. When the charitable deduction was created, the income tax was in its early years, and applied only to the very top of the income distribution. Thus, when the deduction was created, it could be viewed as having been designed to "protect voluntary giving to public goods by rich industrialists who had made their fortunes in business." Today, many policymakers are focused on the charitable deduction's impact on giving, and its efficacy at inducing additional giving. As the deduction has changed over time, policymakers have continued to discuss its effectiveness at increasing charitable giving, the broader role of the government in the philanthropic sector, and reform proposalsâa discussion that continues to this day.

The charitable deduction was initially enacted to offset the potential negative effects of increased income taxes on charitable giving among the wealthy. The federal income tax, enacted four years earlier as part of the Tariff Act of 1913, generally applied a top rate of 7% to only the wealthiest Americans. The War Income Tax Revenue Act of 1917 (P.L. 65-50) increased federal income tax ratesâthe top rate on individuals rose to 67% by 1917 âas a way to pay for the costs of the United States' involvement in World War I. According to the Joint Committee on Taxation (JCT), some

[l]egislators feared that the [tax] increase would reduce individuals' income "surplus" from which they supported charity. It was thought that a decrease in private support would create an increased need for public support and even higher rates, so the [charitable] deduction was offered as a compromise.

In short, some policymakers were concerned that without the charitable deduction, wealthy taxpayers subjected to these higher tax rates would no longer contribute to charities or institutions of higher education (or would contribute less). As Senator Hollis stated,

Usually people contribute to charities and educational objects out of their surplus. After they have done everything else they want to do, after they have educated their children and traveled and spent their money on everything they really want or think they want, then, if they have something left over, they will contribute it to a college or to the Red Cross or for some scientific purposes. Now when war comes and we impose these very heavy taxes on income, that will be the first place where wealthy men will be tempted to economize, namely in donations to charity. They will say, "Charity begins at home." I should not favor allowing any man to deduct all of his contributions to these objects from his income-tax return, but if we limit it to 20 percent of his income we cannot be doing much harm to the Public Treasury. Look at it this way: For every dollar that a man contributes for these public charities, educational, scientific, or otherwise, the public gets 100 percent; it is all devoted to that purpose.

And since "many believed charities could deliver social services better than the government," a drop in funding to charitable groups could have led to what many may have perceived as the inefficient provision of social services and public goods by the government.

The law allowed a deduction for cash or gifts made to organizations operated for religious, charitable, scientific, or education purposes, or for the prevention of cruelty to animals or children. The overall amount that could be deducted was limited to 15% of net taxable income "to ensure that individual taxpayers could not eliminate their tax liability through the deduction."

Several years later, Congress waived the 15% limitation for taxpayers who made consistently large charitable donations. Specifically, as a result of the Revenue Act of 1924 (P.L. 68-176), taxpayers who donated "more than 90% of their net taxable income in the current year and in each of the previous 10 years" were not subject to the 15% net taxable income limitation. This provision was often referred to as the "Philadelphia nun" provision, after Mary Katherine Drexel, a wealthy Philadelphia native who became a nun and underwrote her charitable activities from her sizable inheritance. (In later years, it was also referred to as the "unlimited charitable deduction" (UCD), or "unlimited charitable contribution deduction.")

In 1944, Congress changed the limitation of the charitable deduction, which effectively increased the maximum amount that taxpayers could deduct. As previously discussed, for most taxpayers the charitable deduction was limited to 15% of net taxable income. The Individual Income Tax Act of 1944 (P.L. 78-315) changed the measurement of this limitation from net taxable income to adjusted gross income. Since AGI was generally larger than net taxable income, the maximum amount that could be deducted in dollar terms was larger.

This law also created a standard deduction, which some charities worried would result in a reduction in charitable giving. The federal income tax, which before the early 1940s had been levied only on high-income Americans, was expanded to apply to most working-age Americans by the end of World War II. According to the IRS,

In 1939 only about five percent of American workers paid income tax. The United States' entrance into World War II changed that figure. The demands of war production put almost every American back to work, but the expense of the war still exceeded tax-generated revenue. President Roosevelt's proposed Revenue Act of 1942 introduced the broadest and most progressive tax in American history, the Victory Tax. Now, about 75 percent of American workers would pay income taxes.

This expansion was driven by increasing needs for revenue to finance World War II expenses. As more Americans became subject to the federal income tax, Congress became interested in simplifying tax preparation for these new taxpayers, which motivated the creation of a standard deduction. However, some worried that among those who used the standard deduction, there would be a reduction in charitable giving since there would be no additional tax benefit for these donations.

Others who advocated for the standard deduction contended that charitable contributions were made for more than just financial reasons, and that especially among lower- and middle-income taxpayers (who were most likely to claim the standard deduction), the tax benefit for giving was not an important factor in their decisions to give. According to Senator Walter George, Chairman of the Senate Finance Committee,

The committee does not believe that it can be proved that a tax incentive has been an important factor in the making of such gifts by individuals having less than $5,000 of adjusted gross income, and certainly the $500 standard deduction will not remove the tax incentive for persons in the higher brackets, upon whom the charities depend for contributions in substantial amounts.

Acts Increasing the AGI Limitations: 1952-1964

In 1952, as part of P.L. 82-465, Congress further increased the maximum amount taxpayers could deduct, raising the limitation to 20% of AGI.

In 1954, Congress further increased the maximum deduction limit to 30% of AGI (P.L. 83-591) for any contributions to certain charitable organizations ânamely churches, educational institutions, or hospitals. The 10% of additional AGI that taxpayers could deduct was allowable only for contributions made to one of these eligible organizations. Deductible donations to other eligible organizations were still limited to 20% of AGI. One commentator noted that this was "the first time that Congress encouraged certain charitable giving by granting more generous deductions for donations to certain charitable organizations than to others â¦ [to] encourage additional contributions to these organizations to offset their rising costs and modest returns on endowment funds."

Congress expanded the list of organizations for which taxpayers could claim the 30% charitable deduction as part of the Revenue Act of 1964 (P.L. 88-272) to include those that "receive a substantial part of [their] support from a governmental unit â¦ or from direct or indirect contributions from the general public." This effectively expanded the 30% AGI limitation to most charitable organizations except private nonoperating foundations, which were still subject to the 20% limitation. In addition, the law included a provision that allowed for charitable contributions in excess of the AGI limits to be carried forward up to five years. This five-year carryforward allows taxpayers who contributions exceed the AGI limit in a given year to still potentially receive a tax benefit from that contribution in future years.

The Tax Reform of 1969 (P.L. 91-172) made several modifications to the charitable deduction, including increasing the maximum AGI limits, phasing out the "Philadelphia nun" provision, and creating certain limitations on donations of appreciated property. Many of the current parameters of the charitable deduction for individuals were enacted as part of this law.

At the time that Congress was debating this legislation, there was increased concern that taxpayers were using tax benefits like the charitable deduction to avoid paying income taxes. In particular,

â¦ the unlimited charitable contribution deduction (UCD) had become a sanctuary in which many of the very wealthy were sheltered from the income tax. Prior to its repeal, the UCD was being used by an estimated 100 taxpayers who generally had economic income in excess of one million dollars. Since the UCD had a particular appeal to taxpayers having large amounts of appreciated capital which could be donated to charitable institutions, with the deduction based on the full market value rather than acquisition value, it not surprisingly became a prime target for reformers.

The Tax Reform Act of 1969 phased out the "Philadelphia nun provision" over five years while also raising the maximum AGI limitation to 50% of AGI for donations of cash/short-term capital gain property to public charities. The increase in the AGI limit was intended to "offset any decreased incentive resulting from the repeal of the unlimited charitable contributions deduction." In addition, the increased AGI limitation was intended to

[s]trengthen the incentive effect of the charitable contributions deduction for taxpayers.â¦ It is believed that the increase in the limitation will benefit taxpayers who donate substantial portions of their income to charity and for whom the incentive effect of the deduction is strongâprimarily taxpayers in the middle- and upper-income ranges.

The new 50% limitation generally did not apply to gifts of property that had appreciated in value (e.g., capital gains), which were still generally subject to the 30% AGI limitation. In addition, the 20% AGI limitation for donations to private nonoperating foundations (irrespective of the form of the donation) was unchanged by the law.

Under the Economic Recovery Act of 1981 ( P.L. 97-34 ), taxpayers who did not itemize their deductionsâi.e., those who took the standard deductionâcould claim a new deduction for charitable giving. This was a temporary provision that went into effect in 1982 and was scheduled to expire at the end of 1986. (The law made no change to the itemized deduction for charitable giving.) The amount that nonitemizers could deduct was limited to a percentage of the contributed amount, subject in some years to an additional fixed dollar cap. In 1982 and 1983, 25% of contributions could be deducted, subject to a $100 cap. In 1984, the contribution percentage remained unchanged (25%), but the dollar cap rose to $300. In 1985, 50% of contributions could be deducted, and the contribution cap was eliminated, and in 1986 100% of contributions could be deducted with no contribution cap. In addition to these caps, the amounts that could be deducted were also subject to the AGI limits applicable to the itemized deduction for charitable giving.

This temporary provision was opposed by the Treasury Department and some economists at the time. For example, Donald Lubick, Assistant Secretary for Tax Policy at the Treasury Department, argued that the main beneficiaries of the above-the-line deductionâlower- and moderate-income taxpayersâwould be less responsive than higher-income taxpayers in terms of additional giving. Lubick argued that the above-the-line deduction "would go, in very large measure, to those who are already giving with respect to their existing gifts," providing them with a windfall gain. He testified that an above-the-line deduction "would result in a large revenue loss to the Treasury and little increased giving for the charities."

But according to JCT, Congress disagreed.

The Congress believed that allowing a charitable deduction to nonitemizers stimulates charitable giving, thereby providing more funds for worthwhile nonprofit organizations, many of which provide services that otherwise might have to be provided by the Federal government.

In addition, supporters of this provision believed that "[p]eople ought not be taxed on money they contribute to charitable causes. This should be true whether or not their other economic actions make it advantageous for them to itemize their deductions."

This tax benefit expired as scheduled at the end of 1986, and was not extended as part of the Tax Reform Act of 1986. According to one commentator, "The big idea of the '86 Act was to pare away deductions and credits to broaden the base so you could bring the top rates down. And that was a pretty powerful tide and the nonitemizer [deduction] just wasn't strong enough to swim against that current."

As part of the Deficit Reduction Act of 1984 ( P.L. 98-369 ), Congress increased the contribution limits on donations of cash or ordinary income property to private nonoperating foundations from 20% of AGI to 30% of AGI. (Donations of long-term capital gain property to private nonoperating foundations remained limited to 20% of AGI.) In explaining this increase, JCT noted the following:

Because as a general rule public charities and operating foundations directly carry out charitable function and programs, expend charitable donations more promptly and have public involvement, support, and supervision, the Congress concluded that a tax preference for contributions to public charities and operating foundations [50% AGI limitation] continues to be appropriate. However, acknowledging the substantial role of many grant making foundations in private philanthropy, the Congress believed that the extent of this tax preference should be narrowed by increasing to 30 percent the deduction limitation for gifts by individuals of cash and ordinary-income property to nonoperating foundations.

At the end of 2017, President Trump signed into law P.L. 115-97 , often referred to as the Tax Cuts and Jobs Act (TCJA), which made numerous changes to the federal income tax for individuals and businesses. Among the many changes, the law temporarily increased the AGI limit for cash donations made to public charities from 50% to 60%. This change went into effect in 2018, and is scheduled to expire on December 31, 2025.

According to the House Ways and Means Committee report that accompanied H.R. 1 (the House-passed version of P.L. 115-9 ):

The Committee believes that a robust charitable sector is vital to our economy, and that charitable giving is critical to ensuring that the sector thrives. For this reason, the Committee believes that it is desirable to provide additional incentives for taxpayers to provide monetary and volunteer support to charities. Increasing the charitable percentage limit for cash contributions to public charities will encourage taxpayers to provide essential monetary support to front-line charities.

While this change to the charitable deduction may increase the amount that some taxpayers can deduct and hence may encourage more charitable giving, other changes made by the law are expected to result in an overall reduction in charitable giving. TPC estimates that even after including the increased 60% limitation, the changes TCJA made to the tax code could result in charitable donations falling by 5%.

Appendix A. Definitions of Commonly Used Terms

Appendix B. Valuation of Noncash Donations for the Charitable Deduction

For noncash donations, there are certain rules on how to value the property. Depending on the type of property and the recipient organizations, the property is generally valued either at its basis (i.e., what the taxpayer originally paid for the property) or its fair market value (how much the taxpayer would receive in an open market for the property at the time it is donated), as summarized in Table B-1 . For an overview of these and other terms often used in the context of the charitable deduction, see Appendix A . If a property increases or appreciates in value, its fair market value when sold will be greater than its basis. If property decreases or depreciates in value, its fair market value when sold will be less than its basis. Hence, deducting the fair market value of an appreciated (depreciated) property results in a larger (smaller) deduction for the taxpayer than the basis value of that same property.


Democracy in Latin America and the Caribbean: A Compilation of Selected Indices

Summary: This report provides a regional snapshot of the political climate in Latin America and the Caribbean, based on the U.S. Department of State's description of each country's political system and selected nongovernmental indices that measure democracy trends worldwide. Using tables and graphs to illustrate regional trends, this report provides a snapshot of democracy indicators from the following sources: (1) the U.S. Department of State's 2018 Country Reports on Human Rights Practices ; (2) Bertelsmann Stiftung's 2018 Bertelsmann Transformation Index (BTI); (3) the Economist Intelligence Unit's (EIU's) Democracy Index 2018 ; (4) Freedom House's Freedom in the World 2019 ; and (5) the Varieties of Democracy Institute's (V-DEM's) Liberal Democracy Index in its Democracy Report 2019 . A bibliography at the end provides sources for further information.

The current trajectory of democracy around the world is an issue of interest for Congress, which has contributed to U.S. democracy promotion objectives overseas. For decades, U.S. policy has broadly reflected the view that the spread of democracy around the world is favorable to U.S. interests. This report provides a regional snapshot of the political climate in Latin America and the Caribbean, based on the U.S. Department of State's description of each country's political system and selected nongovernmental (NGO) indices that measure democracy trends worldwide.

For additional information on democracy in the global context, see CRS Report R45344, Global Trends in Democracy: Background, U.S. Policy, and Issues for Congress , by Michael A. Weber.

For related information about democracy in Latin American and the Caribbean, see the following products:

CRS In Focus IF10460, Latin America and the Caribbean: U.S. Policy Overview , by Mark P. Sullivan; CRS Report R45547, U.S. Foreign Assistance to Latin America and the Caribbean: FY2019 Appropriations , by Peter J. Meyer and Edward Y. Gracia; CRS Report 98-684, Latin America and the Caribbean: Fact Sheet on Leaders and Elections , by Carla Y. Davis-Castro; and CRS Report R45733, Combating Corruption in Latin America: Congressional Considerations , coordinated by June S. Beittel.

CRS also publishes reports on specific Latin American and Caribbean countries.

This report compiles information from the U.S. State Department and data from four nongovernmental (NGO) indices. For a discussion about definitions of democracy and critiques of democracy indices, see CRS Report R45344, Global Trends in Democracy: Background, U.S. Policy, and Issues for Congress , by Michael A. Weber. CRS does not endorse the methodology or accuracy of any particular democracy index.

In parentheses following the country name in the tables below is the nature of the country's political system, as described in the U.S. State Department's 2018 Country Reports on Human Rights Practices . While the publication focuses broadly on human rights conditions in each country, the first sentence of each country report provides a characterization of the country's political system. This U.S. government information is included here for comparison with findings from the democracy indicators published by NGOs.

Bertelsmann Stiftung, a private foundation based in Germany, has published the Bertelsmann Transformation Index (BTI) biannually since 2006. Key regional findings and country reports are available in English (BTI publishes the full regional report in German). BTI 2018 evaluates the quality of democracy, a market economy, and political management in 129 developing and transition countries. For political transformation specifically, BTI ranks countries using 18 indicators grouped into five criteria: (1) stateness, (2) political participation, (3) rule of law, (4) stability of democratic institutions, and (5) political and social integration. Based on the criteria, BTI assigns a category: democracy in consolidation, defective democracy, highly defective democracy, moderate autocracy , and hardline autocracy . In its regional report, BTI notes that since 2008, it "has recorded a decline in the quality of democracy in Latin Americaânot dramatic, but continual." BTI evaluates all Central and South American nations. With the exception of Cuba, the Dominican Republic, Haiti, and Jamaica, BTI does not evaluate Caribbean nations.

The Economist Intelligence Unit (EIU), based in London and New York, has offices and analysts in various countries. Since 2006, EIU has produced a democracy index that provides an annual snapshot of the state of democracy for 165 independent states and two territories. The EIU classifies countries as full democracies , flawed democracies , hybrid regimes , or authoritarian regimes based on an aggregate score of 60 indicators in five categories: (1) electoral process and pluralism, (2) civil liberties, (3) the functioning of government, (4) political participation, and (5) political culture. According to the EIU's Democracy Index 2018 , the Latin America and Caribbean region's overall score went down from 6.26 in 2017 to 6.24 in 2018 (on a 0 to 10 scale). The two countries in the region classified in 2018 as full democracies are Uruguay and, new to the group, Costa Rica. EIU's Democracy Index 2018 identified three countries in the region as authoritarian regimes: Nicaragua moved to join Venezuela and Cuba. EIU evaluates all Central and South American nations. With the exceptions of Cuba, the Dominican Republic, Guyana, Haiti, Jamaica, Suriname, and Trinidad and Tobago, EIU does not evaluate Caribbean nations.

Freedom House is a U.S.-based NGO that conducts research on democracy, political freedom, and human rights worldwide. It has published Freedom in the World since 1978, and the current report covers 195 countries and 14 territories. Freedom House assigns each country 0 to 4 points on 25 indicators (10 political rights indicators and 15 civil liberties indicators) for a total of up to 100 points. The scores determine numerical ratings for political rights and civil liberties freedoms on a scale of 1 (most free) to 7 (least free). The political rights and civil liberties ratings are averaged to produce an overall status of free, partly free , or not free. Freedom House's report covering 2018 found that Nicaragua was the country with the greatest decline in the world regarding conditions for political rights and civil liberties as compared to 2017. Venezuela had the third-greatest decline; Brazil, El Salvador, and Guatemala also made the top 20 for steepest declines. The report's analysis is based on data that are detailed in full on the Freedom House web page on "Countries," which ranks the state of democracy for 197 countries and 15 territories. This web page lists the top three aggregate scores in Latin America and the Caribbean: Uruguay, Barbados, and Chile; the region's lowest aggregate scores are those for Nicaragua, Venezuela, and Cuba. Freedom House evaluates democracy in all Central and South American and Caribbean nations.

The Varieties of Democracy Institute (V-DEM), headquartered at the University of Gothenburg in Sweden, collects democracy data through its research team in collaboration with country experts. In 2017, V-Dem published its first global report measuring the status of democracy with an index. Democracy Report 2019 includes the Liberal Democracy Index, which examines 71 indicators included in the Liberal Component Index and the Electoral Democracy Index. V-Dem groups 179 countries into four categories: liberal democracy , electoral democracy , electoral autocracy , and closed autocracy . The current report notes "the regional average for Latin America is down to 0.51 in 2018, bringing the region back to about 1996-levels." V-DEM evaluates all Central and South American nations. With the exceptions of Barbados, Cuba, the Dominican Republic, Guyana, Haiti, Jamaica, Suriname, and Trinidad and Tobago, V-DEM does not evaluate Caribbean nations.

Table 1 looks at Caribbean countries' global democracy rankings according to EIU's Democracy Index 2018 , Freedom House's Freedom in the World 2019 , V-Dem's Democracy Report 2019 , and Bertelsmann Stiftung's 2018 Transformation Index. Table 2 compares the same reports for Mexico and Central America, as does Table 3 for South America. Each report evaluates a different number of countries, so there are missing rankings for some countries. Countries are listed alphabetically in each table.

Figure 1 shows the global rank and classification of all Central and South American and Caribbean countries according to the Political Transformation Rank, a component of the 2018 Bertelsmann Stiftung Transformation Index (BTI).

Figure 2 shows the global rank and classification of Central and South American and Caribbean countries according to the EIU's Democracy Index 2018 .

Figure 3 shows the aggregate scores of all Central and South American and Caribbean countries according to the Freedom House country web page for Freedom in the World 2019 . Countries receive 0 to 4 points on 25 indicators (10 political rights indicators and 15 civil liberties indicators) for a total of up to 100 points.

Figure 4 shows the political rights and civil liberties scores of all Central and South American and Caribbean countries according to Freedom House's Freedom in the World 2019 . The scale used is 1-7, with 1 indicating the most free conditions and 7 the least free.

Figure 5 shows the liberal democracy index rank and classification of all Central and South American and Caribbean countries according to the Varieties of Democracy Institute's Democracy Report 2019 .

Table 4 provides resources for further information about democracy indicators in Central and South America and the Caribbean, although many cover other geographic areas as well. The sources are organized alphabetically by title. This is not an exhaustive list.