America's Military and Veteran Caregivers: Hidden Heroes Emerging from the Shadows

Military and Veteran Caregivers: The Need for a New Examination

Military and veteran caregivers are hidden heroes. This term was coined by RAND and the Elizabeth Dole Foundation in 2014, when the organizations partnered to produce Hidden Heroes: America's Military Caregivers. That study provided the first national portrait of American people who care, mostly uncompensated, for wounded, ill, and injured service members and veterans. Hidden Heroes shed light on a new class of caregivers: spouses, friends, and neighbors caring for service members and veterans with wounds, illnesses, and injuries—including mental health conditions—and how caregiving disproportionately affected them.

Guided in part by the 2014 Hidden Heroes study, the Elizabeth Dole Foundation and others created programs and advocated for policies designed to better support military and veteran caregivers. These changes call for a new examination of military and veteran caregivers. This study, America's Military and Veteran Caregivers: Hidden Heroes Emerging from the Shadows, presents this new examination of America's hidden heroes.

Key Findings

Military and Veteran Caregivers: Who They Are and What They Do

Approximately 40.5 percent of the U.S. adult population provides some form of caregiving support. The authors found that there are 14.3 million military/veteran caregivers, which is 5.5 percent of the U.S. adult population. There are an additional 91.3 million civilian caregivers (35.0 percent of U.S. adults) caring for wounded, ill, or injured civilian adults. The number of caregivers per state varies but likely exceeds 1 million veteran caregivers in each of Texas, California, and Florida.

These estimates are much higher than those presented in the 2014 study. In part, this is because the 2023 RAND Caregiving Survey asked people about the caregiving tasks they did rather than just whether they saw themselves as caregivers (as in the earlier study).

An additional 3.9 percent of American adults are former military/veteran caregivers, one-third of whom served in this role within the past two years. Almost three-quarters of former military/veteran caregivers are no longer serving as caregivers because the person they were caring for died. On measures of stress, depression, and financial security, former military/veteran caregivers more closely resemble non-caregivers than current military/veteran caregivers.

Differences in military and veteran caregiving experiences are driven by the age of the care recipient. The authors found that the age of the care recipient often influences the conditions and symptoms the care recipient has, their caregiving needs, and the relationship of the caregiver to the care recipient. Because of this, the research team took a closer look at caregivers and their roles in two large groups: those who care for individuals over age 60 and those who care for individuals age 60 and younger. Figure 1 lists the similarities and differences of both groups.

Military and Veteran Caregivers: Who They Are and Who They Help

Care recipients 60 years old and younger

26 percent of caregivers care for military persons or veterans 60 years old and younger.

Nontraditional caregivers

Twenty-seven percent of military/veteran caregivers are nontraditional caregivers such as neighbors and friends. 31 percent are nontraditional caregivers such as relatives, such as siblings, aunts, and uncles.

Care recipients

• 84 percent were diagnosed with a chronic condition
• 62 percent were diagnosed with a mental health condition or substance use disorder
• 61 percent need help with at least one activity of daily living

Care recipients over 60 years old

74 percent of military and veteran caregivers

Family

Between 65 and 75 percent are caring for parents or are individuals caring for their spouse.

Nontraditional caregivers

Friends and neighbors account for over 20 percent of caregivers for this group.

Care recipients

• Most have been diagnosed with a chronic condition or hearing or sight impairment
• 40 percent have been diagnosed with a mental health condition or substance use disorder
• 51 percent need help with at least one activity of daily living

Caregivers helping with at least one activity of daily living (ADL) spend more time caregiving, on average. Even after accounting for medical diagnoses, caregiver characteristics, and care recipient characteristics, caregivers who assisted with at least one ADL spent more time caregiving than those who provided other types of care. The distribution of time spent caregiving for military/veteran caregivers, by the age of the care recipient for whom they provide care, is provided in Figure 2.

Hours per week	Military/veteran caregiver to someone 60 or under	Military/veteran caregiver to someone over 60
Under 1 hour	8%	6%
1 to 8 hours	39%	48%
9 to 20 hours	22%	21%
21 to 30 hours	18%	9%
31 to 40 hours	4	5
Over 40 hours	9%	11%

The Mental and Physical Health of Military and Veteran Caregivers

Military and veteran caregivers to those over 60 tend to have the same health outcomes as non-caregivers. Health in this case refers to both mental health outcomes (e.g., depression, stress) and physical health (e.g., overall health, physical functioning). However, 16 percent of military and veteran caregivers to those over 60 needed mental health treatment but did not access it. Cost was the primary barrier in this case.

Military and veteran caregivers to those 60 and under are at higher risk of depression and are less likely to seek care than non-caregivers. The authors found that 43 percent of military and veteran caregivers to those 60 and under met probable criteria for depression; this is almost four times the rate of non-caregivers. About 20 percent of military and veteran caregivers in this group had thoughts in the past year about taking their own lives. This is also four times the rate of non-caregivers. Thirty-six percent felt that they needed mental health care but did not seek it. More than three-quarters of this group reported that they “didn't have time for treatment,” and 70 percent were concerned about hospitalization or taking medications.

Only around half of military/veteran caregivers to those 60 and under had seen a doctor for any reason in the past year, compared with around three-quarters of non-caregivers.

Nine percent of military/veteran caregivers were “very concerned” or “somewhat concerned” that the person for whom they are caring was at risk of suicide. Compared with military and veteran caregivers not concerned about suicide risk, a greater proportion of military/veteran caregivers concerned about suicide risk met criteria for excessive caregiver burden (65 percent versus 28 percent), probable depression (55 percent versus 19 percent), and hazardous drinking (65 percent versus 24 percent).

Children of military and veteran caregivers are more likely to have problems at school but are also more aware of others' feelings. Thirty-nine percent of children under 18 living in military/veteran caregiving households assume some caregiving responsibilities. The study found that, when compared with children of non-caregivers, military/veteran child caregivers were more likely to miss school because of illness. They also scored higher on emotional symptoms and conduct problems. However, they scored higher on prosocial behaviors as well, such as empathy, based on their parents' reports. Almost a quarter of military/veteran caregivers reported that their caregiving children needed mental health treatment in the past year but did not receive it.

The Costs of Caregiving and Economic Well-Being of Caregivers

Military and veteran caregivers incur an estimated $8,583 in annual out-of-pocket costs associated with their caregiving responsibilities. There is no evidence of differences in annual costs between military/veteran and civilian caregivers. In addition, military/veteran caregivers forgo an estimated $4,522 in annual household income, on average. Again, there is no evidence of a difference in forgone income between military/veteran and civilian caregivers.

The estimated economic value generated by military/veteran caregiving activities ranges from $119 billion to $485 billion per year. The range is explained by the different activities that caregivers perform, some of which would earn them the state's minimum wage and others of which can be performed only by licensed registered nurses. Table 1 shows the range of estimated values, which, for this group of caregivers, are largely uncompensated.

Assumed Caregiver Hourly Wage	Estimated Value of Military/Veteran Caregiving
State minimum wage	$119 billion
2022 median hourly wage: home health aide	$162 billion
2022 median hourly wage: nursing assistant	$201 billion
2022 median hourly wage: registered nurse	$487 billion

Thirty-five percent of military/veteran caregiving households have incomes below 130 percent of the federal poverty level, but some are not using benefits to which they are entitled. Many households in this group are not taking advantage of available benefits, even those that are based on assets. Civilian caregivers in households with incomes below 130 percent of the federal poverty level outpace their military/veteran counterparts in the use of the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Among those who are food insecure, only one-quarter to one-third of military/veteran caregivers use SNAP.

Fewer than half of military/veteran caregivers are offered workplace accommodations that could help them more easily perform their caregiving responsibilities. Although not different from non-caregivers, more than half of military/veteran caregivers are unable to telecommute or work from home, about half cannot take paid family leave, and about one-third do not have flexible work hours. Perhaps because of the lack of workplace accommodations, 27 percent of military/veteran caregivers experience workplace disruptions, such as cutting back on their work hours or thinking they are being discriminated against. The study's results suggest that these disruptions are driving income losses associated with caregiving.

Military and Veteran Caregiver Support and Care Networks

Military and veteran caregivers find that support can be hard to come by. The authors found that around half of military/veteran caregivers to those 60 and under had no one else to turn to in their caregiving network. In addition, over half in this group felt that they had no one to call for emotional support. Those caring for someone over 60 fared slightly better; 40 percent of that population felt that they were going it alone.

Between half and two-thirds of military/veteran caregivers use common support programs. Those caring for individuals 60 and under were the greatest users of such programs. Table 2 compares the use of support programs by military/veteran caregivers of those 60 and under and military/veteran caregivers to those over 60.

	Military/Veteran Caregivers to Those 60 and Under	Military/Veteran Caregivers to Those over 60
In-person support groups	30%	10%
Online support groups	15%	8%
Respite	19%	12%
Training	38%	10%
Structured wellness	46%	34%
Case manager	27%	20%
No participation in support services	38%	48%

Military/veteran and civilian caregivers have preferences for types of support programs. Caregivers to those 60 and under indicated a preference for programs they can do with the person for whom they are caring. Those caring for individuals over 60 wanted programs that help keep the recipient safe and help with filling out forms. All caregivers indicated a preference for programs for reducing stress.

Religion helps ease burdens for some caregivers. Among all caregivers, those for whom religion is an important part of their lives reported less caregiver burden than other caregivers, even after accounting for characteristics of caregiving, characteristics of the care recipient, and characteristics of the caregiver.

Military and Veteran Caregivers' Experiences in Health Care Settings

Many military and veteran caregivers and civilian caregivers feel unvalued or hassled by health care providers. The authors found that only approximately one-third of military/veteran or civilian caregivers felt that health care providers often sought their input or listened to them about the care recipient. Also, one-third of military/veteran caregivers reported experiencing hassles in health care, such as having to remind staff to do things for the care recipient or experiencing delays in completing paperwork. Among those who experienced hassles, between 25 percent and 30 percent of 18- to 44-year-old caregivers felt that the hassle was due to age discrimination.

There were modest differences in military and veteran caregivers' perceptions of being hassled or undervalued among military/veteran caregivers whose care recipients used U.S. Department of Veterans Affairs (VA) facilities most commonly for their health care and those whose care recipients received care outside of VA. A greater proportion of caregivers who were caring for someone who received most of their care at VA, compared with those who did not receive most of their care at VA, reported staff delays in completing paperwork (22 percent versus 14 percent), feeling excluded from decisions regarding the care recipient's care (20 percent versus 7 percent), and difficulty interacting with the care recipient's physicians (23 percent versus 8 percent). Differences in care recipients who receive care at VA—who tend to be younger, have lower household incomes, are more likely to have mental health and substance use disorders, and have higher disability ratings—may explain some of this variation.

Military and Veteran Caregivers' Families and Locations

The challenges of caregiving can be exaggerated and complicated by distance. While 39 percent of military/veteran caregivers to those 60 and under provide all of their care in person, 28 percent provide half or more of their caregiving remotely. In contrast, 70 percent of military/veteran caregivers to those over 60 provide care exclusively in person, and 12 percent provide half or more remotely. A greater proportion of military/veteran caregivers who provide most care remotely met criteria for excessive burden, high stress, and depression, compared with those who provide most care in person.

Military/veteran caregivers tend to live in areas where most Americans live. This means that over half live in either Southern or Western states and in urban areas. The only notable difference that location had on military/veteran caregivers concerns access to mental health care. Specifically, those in Western states were more likely to access that care but were also more likely to report needing but not accessing that care than caregivers living elsewhere.

Military/veteran caregivers residing in lower-income areas reported reduced caregiver burden and depression. It may be that neighbors in lower-income neighborhoods are more likely to offer support or that these communities have concentrations of similar individuals (such as older people who have had to provide care before) who understand caregiver needs. The research on low-income areas and support networks is inconclusive, however, and the authors found no single reason for this finding.

Urban and rural military/veteran caregivers differ most on internet access. Nearly one-quarter of rural military/veteran caregivers did not have reliable broadband internet access at home, compared with 16 percent of urban military/veteran caregivers.

Recommendations

Based on these findings, the authors make nine broad recommendations:

1. Increase access to mental health and substance use treatment for caregivers and their children. Up to 42 percent of military/veteran caregivers could have likely benefited from mental health treatment but did not access it. They reported time constraints, concerns about prescription medications or being hospitalized, and cost as barriers to treatment. Novel mental health care delivery models, including telehealth, asynchronous counseling, mobile health applications, task shifting, and Collaborative Care (which integrates evidence-based mental health care into primary care), may help meet the unmet mental health needs of caregivers and their children.
2. Increase opportunities for caregivers to access available financial support, and offer additional financial compensation to caregivers for the work they perform. Military/veteran caregivers provide services valued at a minimum of $119 billion, but they spend approximately $8,500 in out-of-pocket expenses because of their caregiving, forgo $4,522 in earnings, and are mostly not accessing benefits that they are likely entitled to receive. Organizations that serve caregivers should inform them about programs that provide financial assistance and help them apply; policymakers should continue to explore tax credit options for caregivers.
3. Tailor caregiver support programs to reflect caregivers' diverse preferences and needs. While there has been an expansion of programs to support caregivers, 38 percent to 48 percent of military/veteran caregivers are not using those programs. To increase uptake, organizations that serve this population should consider the following actions:
   • Change the way they conduct outreach to caregivers. The approach that RAND researchers used to define caregivers in the 2023 RAND Caregiving Survey identified individuals performing caregiving duties but who do not necessarily identify as caregivers. Programs could take a similar approach to conducting outreach.
   • Modify the content of some programs. Military/veteran caregivers are a diverse group with different preferences: Caregivers to those 60 and under want activities to do with the person for whom they are caring, while those caring for veterans over 60 want help keeping the person they are caring for safe at home. Programs should consider the diversity of the population and how needs may differ.
   • Expand the ways in which programs are delivered. Many caregivers who wanted but did not receive mental health care suggested that time constraints were a significant barrier. Technology-driven solutions (for example, telehealth and mobile applications) may be attractive to some caregivers who face time pressures. However, more military/veteran caregivers reported participating in in-person groups than in online support groups, suggesting that an exclusive focus on technology may not meet some caregivers' preferences.
   • Partner with diverse entities and organizations. Military/veteran caregivers who felt that religion was important to them had lower levels of caregiver burden. Partnerships between caregiver support programs and religious organizations could expand the numbers of those who are served and the ways in which caregivers are supported.
4. Expand and promote home health care considering how caregivers will be affected. Caregivers who reported having a medically trained person come to the care recipient's home to help (i.e., caregivers who used home health care) reported lower caregiver burden, and current and proposed policies are aiming to expand such services. However, other research has raised issues (most of which need further study) related to the ways in which home health care could add more burdens to caregivers. Caregivers may need to coordinate and train home health care teams and providers, have increased out-of-pocket costs associated with keeping care recipients at home, and face additional work disruptions negotiating home health care teams. Residential options should continue to be pursued and made accessible, particularly for those care recipients who will be safest in residential placement.
5. Focus programmatic and social support within the context of local conditions in which military/veteran caregivers live. Military/veteran caregivers live in less resourced areas compared with non-caregivers; however, there were nuanced findings around associations between neighborhood conditions and military/veteran caregiver outcomes. Policies and interventions aimed at military/veteran caregivers should take local resources, such as housing, food access, and economic conditions, into account. Additional investigation into the mechanisms linking neighborhood conditions to caregiver outcomes is warranted.
6. Encourage health care systems to better integrate caregivers into health care teams. Health systems need to be incentivized to better include caregivers into health care teams. To do this, evaluation research should test whether efforts to integrate caregivers into health care environments improve patient outcomes, create cost savings, and increase demand. Additionally, policymakers should create new mechanisms that incentivize health care systems to integrate caregivers into health care teams, expanding on recent efforts that compensate providers for providing training or education to caregivers.
7. Promote work environments that are supportive of caregivers. Although employers are increasingly offering temporal and spatial flexibility to workers, among working military and veteran caregivers, only one-half to two-thirds are offered temporal flexibility, and fewer than one-half are offered telework options.
8. Continue to conduct rigorous evaluations of those initiatives designed to support military and veteran caregivers. Many caregivers participating in programs exhibit high levels of burden, which may suggest that programs are attracting caregivers in need of support or that these programs are not adequately helping reduce caregiver burden. Evaluation is key to ensuring that programs are achieving their intended outcomes and worth the resources and time that caregivers devote to participating in them.
9. Continue to conduct research that fully captures the breadth of caregiving and those who serve as caregivers. Defining caregivers based on descriptions of the caregiving activities they perform, instead of based on their identity as a caregiver, identifies many more individuals who are taking on caregiving roles. However, further describing these caregiving activities, particularly for caregivers to those with mental health conditions, substance use disorders, and neurocognitive conditions (such as traumatic brain injury and dementia), is necessary to fully support caregivers to individuals with these conditions.

The 2023 RAND Caregiving Survey and the 2022 RAND Veterans Survey

The information in this study is derived from two sources. First, RAND researchers administered the 2023 RAND Caregiving Survey, a probabilistic survey of U.S. households that collected detailed information from caregivers and non-caregivers alike. It was designed to establish the number of military and veteran caregivers and to further understand their needs, service utilization, and outcomes. The final analytic sample size was 2,946 respondents, including 513 military and veteran caregivers, and, for comparison, 1,205 civilian caregivers and 1,228 non-caregivers. The 2023 RAND Caregiving Survey was linked to national data characterizing where caregivers live to better understand how rural, regional, and neighborhood characteristics affect caregivers and caregiving.

RAND researchers also administered the 2022 RAND Veterans Survey, a survey of 1,100 veterans residing in the United States. Data from this survey were exclusively used to produce state-level estimates of the numbers of military and veteran caregivers.