>> very good. i agree, we've got to put that infrastructure in if place. and then another problem, you might comment on this, crystal, is the fact that we do have stuff in place now. and yet families don't know about it, you know? the it's not readily accessible. be and if you can comment on that or ways that we can improve. but i see that as something that we really need to get aggressive with. >> no, i, um, like many have said the strides that have been made are amazing because many years ago you don't, you didn't have what we have now. but i think that as that being said what should be focused on now is these things and the improvements that are going to be there for the future because war's not going away, and people are still going to be wounded. so the accessibility to the things that the service members are needed, um, in my husband's case prosthetics are a big thing. so if we did move to a small

town or a small area, would we have to go further away from be our home due to they didn't have the technology or the things needed to be able to assist him with what he does need to make life easier on a daily basis? so those drives are amazing and -- the strides are amazing and great and improvement is always something to be proud about, but it's a problem that's not going away, and improvements will always be needed, so -- >> good. thank you, crystal. thank all of you for being here. we appreciate your testimony. >> thank you very much. ms. st. james, i wanted to ask you while you were here, i recently heard some very disturbing complaints from a female veteran. she told me she had a great deal of difficulty in accessing appropriate, safe care for herself. she'd had some exams from a doctor where he left the exam room open to a crowded hallway, had been harassed by male

veterans while trying to get mental health care and other concerns. and i'm concerned about the lack of separate women-only inpatient mental health care unit that we're hearing about as well. so i'm very concerned that the va is not strategically planning for the increasing number of women veterans, something mr. rieckhoff mentioned as one of the costs of this war. can you share with this committee how many of va's backlogged construction projects involve immaterial improvements -- improvements needed just to protect the privacy and safety of woman veterans? >> i really, excuse me, don't have that specific information be. i do know that there are initiatives that va includes in its planning process, but i don't know specifically if that -- >> is that something you can find out for us? >> we could certainly get back to you on that. >> okay. i'd really appreciate that. ms. golding, you testified that the medical costs for iraq and afghanistan veterans between 2011 and 2020 could total between $40 billion and $55

billion. that number, of course, doesn't take into account the costs of paying for previous generations of veterans that we're still responsible for. cbo did another report earlier this year on possible ways to reduce the deficit where they made a couple of recommendations about veterans' programs. i don't support those specific proposals because they negatively impacted benefits which i believe we shouldn't be touching. but i do believe there are some ways that we can be more effective, um, with taxpayer dollars by not diverting it from direct delivery of services in health care. i wanted to ask you this morning, do you believe there's enough excess and dupe hi case that can be addressed to make va more efficient without negatively impacting services? >> um, just one or two points that i want to make on that. and the first is that we also, um, had projection withs for the 2011-2020 time frame for vha for

all veterans. and the budget would grow -- well, not the budget, but the amount of the costs to treat those individuals would rise from the 48 billion in 2010 to under the one scenario 69 billion, and in the higher scenario which included higher medical inflation and so forth, i think it was 85 billion. so in the lower case we're talking about an increase of about 45% over the next ten years, um, which is a substantial increase in order to be able to provide the health care for all the enrolled veterans. now, we have not, we do not make policy recommendations, and we have not in that paper looked at options for cutting that growth. and we had not looked at efficiencies. so i cannot tell you about that specifically. i mean, you're aware of our

budget options, apparently, so we do have a couple of options in that. but it may also involve not just efficiencies, but it may involve shifting some costs or -- >> if we just do efficiency and shifting costs, will we meet that projection that you just met? >> i cannot tell you, you unfortunately. >> okay. mr. hosek, a 2008 rand study concluded that there's a possible connection between having ptsd, tbi and major depression and being homeless. last month admiral mullen expressed concern about repeating the mistakes we made after the vietnam war, and he said we are generating a homeless generation, many more homeless female veterans. and if we're not careful, we're going to do the same thing we did last time, unquote. can you walk we through the costs, both budgetary and human, of caring for veterans after they become homeless and using tools to prevent homelessness?

>> unfortunately, i can't give you -- >> want to turn on your mic? >> thanks. unfortunately, i can't give you estimates of the cost. my concern, which i foreshadowed in my testimony, is that there may be a value in being more proactive in guiding people as they leave the service. right now when service members leave the service, they receive an out brief, and that covers among other things the benefits they're entitled to and advises them, of course, if they'll have a postdeployment health assessment and a six month follow-up of that if they're still in the service and then leave later on. but this information comes at them very fast, and even though it's provided -- which is a good thing -- i'm afraid that many of them don't really absorb it at the time. and when they leave the military and go out and need care or need to learn about their va benefits or need to lesh about job -- learn about job search support, they really don't know where to, where to turn.

they haven't necessarily absorbed or remembered what they were told, and what our research indicates that there isn't readily available, cohesive, easily accessible sources of information. now, people absorb information in two ways, when it's pushed at them, or when they pull for it. and a lot of the discussion that we've received has to do with the push of information, that is just making it available. but the fact that there isn't readily available, cohesive sources of information, something that paul referred to, i think is important too. i mentioned it in my testimony that one thing we really don't know much about are people who leave the service, um, we don't know about their sort of joint seeking of educational benefits and further education or work and their health care. and we're particularly interested in, particularly concerned about -- >> are you looking at the costs of that? is that something -- >> these are simply ideas i'm

responding to you for your questions. these are not, to my knowledge, studies we have underway at rand. i realize the importance of this, and i wish i could give you a specific estimate. it is important, i think, to think about this sort of jointly occurring, um, set of concerns service members have. if they happen to be the roughly one in five, perhaps fewer, service members who leave with mdd, major depressive disorder, and they also want to find a job or they want to seek health care, um, we're finding a lot of them are having trouble finding jobs, a lot of them are not seeking, they're not going to seek care. we've talked about the barriers to care that's come up in several testimony this week and i know if your hearing last week. -- in your hearing last week. all of those things come together.

trying to make things easier for veterans to provide that information, this is something paul's outfit is particularly concerned with, but it's not only something, you know, that should be left to volunteer organizations. it's possible that more effective support could be provided by the services or by transition even for-contract transition outfits or simply by, um, more effective, um, web-based, um, services available. for example, the military one source of information has been a big boon to service members providing them information with many service-related resources for service members and their families before, during and after the deployment cycle. um, developments in that direction for veterans are likely to be helpful. as i mentioned in my testimony, veterans have reported difficulty knowing where services are offered, what kind of services are available, how to apply for them, who is

eligible. those are fundamental questions. um, the fact that half of those with probable ptsd or mdd have not seen a physician, have not been evaluated within the prior year to our survey was striking. these are individuals who, arguably, ought to be evaluated. there are certainly many veterans who leave who can do well on their own, but for people with these probable symptoms -- and sometimes individuals don't report their symptoms, so that's one of the reasons for this wide variance in the estimates -- but they should be incentivized and have the information to seek this. we clearly have in the va system an issue of surge capability. i mean, the va caseload itself is largely cissing of -- consisting of older veterans. and the va handles many individuals who need health care.

the immediate growth of the new generation of veterans as you've referred to it here in the hearing is a challenge for them because they need to adapt their provider mix, and that's, those are growth problems. but to the extent that there are also providers available in the private sector, i'll suggest without the basis of research that it's certainly worth thinking about trying to figure out how to make use of extent capacity in the private sector. >> and i appreciate that. and one of the points of this hearing is cost of war just providing it in the private sector is not free. it is still a cost, and we have to keep focused on that. senator brown? >> thank you. chris, i just want to go back to you, and i apologize. i had to go down to another hearing. and i have some questions, and so if you've answered this, i apologize. during your time going through what you were going through, did you ever go to any outside agencies outside the military, outside the va to get some additional assistance? if so, could you kind of explain

what you did and what that response was like? >> um, well, in the beginning, um, there wasn't, i really didn't know of what was available. but due to, um, me -- my case manager, jordan hall, he gave us some information in regards to some foundations that could help. and, um, when we seeked out the foundations, they were able to assist us like semper fi fund and operation home front, soldiers' angels. i mean, there's so many that, um, that do -- there are great foundations that help and assist, yes. >> great. thank you. >> uh-huh. >> mr. rieckhoff, infoáó your written testimony you state that long-term costs between 600 billion and a trillion to care for oef, oif veterans alone. i mentioned learning more about your estimate. is this a study conducted by you

folk or any other organization that would come up -- >> i think this is, actually, to the doctor's earlier point. estimates are all over the place. and in part because we don't have real good research on a lot of things. um, so, you know, these are high-end, low-end estimates that come from a variety of places ranging from, um, from rand to harvard researchers to veterans' groups. and i think two things we have to identify to earlier questions is on homelessness the va just released their new numbers of 10,000. those numbers are really fuzzy. places like veterans don't even count people when they go out to count homeless people. on suicide, specifically, we don't know how many veteran suicides there are. that is really troubling. we see anecdotally suicides from the community on a regular basis that aren't counted. if you separate from the military and you're a veteran, you're not even counted. so i think it's important that

we recognize that some of the best research that came there the rand study back in the 2008 is still the best research now. and be that was privately funded. so, you know, to answer your question, sir, we don't know. i mean, and i don't think anybody knows. and anybody who tells you they do know, you know, let's see the research. across this industry as you guys try to think in the next couple of years about how to spend money and how to support different program, we need much more research. and we all have a hard time, i think, finding really good data. um, and i think the suicide's the best example. we have no idea how many veterans have committed suicide since 9/11. nobody knows because there's nobody counting. and i think that's a major problem when we try to forecast any kind of cost. >> thank you. dr. hosek, did you notice at all a difference between active army, active military versus guard and reserve in terms of getting the materials? because you indicated that when somebody leaves, they have an out briefing, obviously.

i know being from massachusetts that not only do we as a guard and reservist not only do you get an out brief, you have to go through, basically, a total top to bottom exit interview, they give you the packet, they give you everything. so when you're saying they don't have anywhere to go, quite frankly, i would suggest that they look in the packet that they've been given as we do it in massachusetts be. what are your observations in that? >> well, first, to begin with the specific answer i haven't seen any research whatsoever comparing the outprocessing support for active versus reserve, so i'm not sure what that difference would be. um, i agree with you that individuals actually receive briefings, they receive materials. um, they basically should have a starting point on where to go, and that is good. at the same time, the recently

done rand new york state veterans' needs paper as well as the earlier paper on invisible wounds indicated that a number of respondents, veteran respondents, um, weren't sure where to turn, what to seek. this could reflect differences among individuals in their capacity to remember and recall information or to process complicated information. um, so i think as i said a minute or two ago, while i think what's being done right now is probably very helpful, it's not totally effective. there is a question about how to continue to reach people after they reach, after they leave the service and begin actively seeking some sort of support or assistance. health care, g.i. bill benefits, what have you. >> this thank you. and, ms. st. james, in your analysis of the va's capital plan from 2004 to 2009, excuse me, gao noted va's real property

portfolio changed with an increase in leases and lease spaces. this was va's efforts to adjust their real property portfolio to match the agency's overall mission to move the delivery of care toward more outpatient facilities. beyond cbocs and vet centers n. what ways can the veterans' health administration expand their inventory of leased buildings, and also is there any effort to have these buildings within already government-owned properties to, in fact, save money? >> the results of the space that was really looked as if those were improvements, and i believe there were 24-29 that were reported in our report indicated that there had been some improvements in that. so part of an initiative that's included in their planning is the need and the planning for community-based outpatient clinics which is directly tied to trying to give care to the

more rural, more rural community. so it is a factor in their planning, and there could be more that could be done in terms of that. i think it's an issue government wide of having more space than is actually needed, and the need to take care of historical properties that are quite expensive to take care of. so if there's any other, if i haven't answered your question, let me know, and i'll get back the you. >> thank you. >> thank you very much, senator brown. i have some questions that i will submit for the record if you have any -- i want to thank each of our witnesses for their testimony on the lifetime costs of caring for our newest generation of veterans. and i, again, especially want the thank you, crystal, and todd for your service to our country. you're really an example to a lot of other veterans and their

families who are traveling down this road to recovery, and i really believe that your testimony today will go a long way in helping us do a better job. as i said at the beginning of this hearing, caring for veterans is a cost of war that we have to account for. um, as today's hearing has really made clear, the cost of caring for this new generation of veterans is not going to end when they come home. it will be incurred over a lifetime. so as we are here today and the deadline for reaching a debt ceiling agreement quickly approaches and various proposals to cut or cap spending are out there, we've got to remember the sacred responsibility we have to care for our veterans and service members. we as a nation must honor our obligations in good times and in bad. so i appreciate all of you being here today to participate and share your perspectives on the lifetime costs of this war. thank you very much. this hearing is is adjourned. [inaudible conversations]

knox [inaudible conversations] [inaudible conversations] [inaudible conversations]

[inaudible conversations] >> the senate gavels in if at 9:t 30 a.m. eastern to continue debate on the house-passed debt ceiling bill. majority leader harry reid announced yesterday that a vote on final passage is scheduled for noon eastern. here's some of yesterday's remarks on the senate floor from the chairman and ranking member of the budget committee. the presiding officer: without objection. mr. conrad: mr. president, i have two unanimous consent requests for committees to meet during today's session of the senate. they have the approval of the majority and minority leaders. i ask unanimous consent these requests be agreed to and these requests be printed in the record. the presiding officer: without objection. mr. conrad: mr. president, i rise today to discuss the agreement that has been reached between leaders in the senate and the house, republicans and democrats, and the president of the united states with respect to an extension of the debt limit and certain deficit-reduction steps to be

taken in conjunction with that action. mr. president, i want to remind colleagues that if we fail to act, most economists believe we would face an interest rate spike and for everyone percentable point increase in interest rates, we would add $1.3 trillion to deficits and debt over ten years. mr. president, if there was only a 200 basis point increase, that would wipe out all of the deficit reduction that is in this package. so colleagues need to keep in mind the consequences of our actions and how critically important it is to prevent that interest rate spike. in addition, david beers of

standard & poor's global head of sovereign ratings said in an interview on cnbc on july 26 the following -- "to avoid a u.s. credit rating downgrade, the s&p wants to see bipartisan debt-reduction effort." mr. president, he said specifically, "we will measure this matter on a number of parameters. one is, is it credible? and credibility, among other things, means to us that there has to be some buy-in across the political divide, across both parties, because politics can and will change going forward. and if there's ownership by both sides of the program, then that would give us more confidence. it's not just about the number. it's about the all-in intent." mr. president, however imperfect this agreement is -- and it is imperfect; after all, it is a work of the hands of man, we are

all imperfect -- but it is critically important. it is important to demonstrate that we can work together it is important to demonstrate we can work together to achieve a result. this package contains these elements. first, it presents a default. it saves the nation from an immediate economic crisis. it creates a process to allow a debt ceiling increase in 2013. so we don't have to reenact this entire episode in a matter of months. it provides a $900 billion down payment on deficit reduction that is enforced with ten years of spending caps. it creates a joint select committee of congress on deficit reduction have refining $1 trillion in savings and to

bring us a report before thanksgiving. this select committee has a goal of $1.5 trillion in savings as a floor. it is not a ceiling. this committee could come back to us with a more ambitious proposal to get our fiscal affairs in order. let us hope that it be so. the overall package before us requires a vote on a balanced budget amendment. the debt ceiling increase is not contingent on its passage but there's a requirement to give colleagues in both chambers and opportunity to vote. the package before us protect held grants from near-term cuts and most of us understand how important held grant are to providing opportunities to young talented people all across

america to improve themselves through higher education. mr president the was raised by my grandparents. my grandmother was a schoolteacher. they called her little chief because she was only 5 feet tall but she commanded respect. she commanded respect because she had character. she told people there are three priorities in this house hold. number one is education. number 2 is education. number 3 is education. we got the message. i remember her telling us over and over would you put in your head no one can take away. they can take your property and your wealth but one thing nobody can take from you is what you have done to improve your mind. that ought to be taught in every household in our country because it is central to america continuing to be a world leader.

mr president, the proposal that will be before us create a joint select committee on deficit-reduction. they have a goal of finding an additional $1 trillion in savings but they are not limited to that level of savings. they could do more. it is bipartisan and bicameral. 12 members, six democrats, six republicans. congress is to have a report by thanksgiving on their work. no amendments are allowed at a simple majority vote to pass in the senate and house. mr president, this is closely follows recommendations of senator gregg and i from five years ago to create a commission empowered to bring to a vote in the senate and the house a plan to get our debt under control and to do it so that you

wouldn't have the endless process that our current situation requires. mr president, the idea was to create a system that a proposal could come before the senate and house to get the debt down. it is modeled in many ways after the reconciliation process that was designed for deficit reduction and requires a simple majority vote. there's a fail-safe. if this committee fails to produce a result the fail-safe is across-the-board cuts in defense and nondefense spending with exemptions for social security, veterans, low income people and it limits the medicare reductions to 2%. mr. president, i would prefer the medicare reduction not be there because there is no revenue in this plan.

but we do have to have a fail safe. we have to have some assurance that the savings are actually realize. this mechanism does that. i think all of us know that our current status finds us borrowing $0.40 of every dollar that we spend. we are in a condition in which the united states is borrowing more than we have ever borrow before. the congressional budget office, non-partisan has told us the long-term outlook is even more -- that we have debt held by the public that is 70%, 70%. our gross debt is approaching 100%. that our publicly held debt which is held by the pu