so i can see the end of the tunnel. i hope that in loss -- los cabos we can provide good news for the rest of the country, and even for the agenda in terms of the issues i want the which is food security and green economy. >> i think the cavalry's going to come for you soon, so let me just wrap up by saying a few things. first of all, you absolutely have the commitment of the u.s. chamber and our members in supporting your meetings in los cabos. we will be present, we will be active, we will be supportive of the agenda whether it's food security, whether it's dealing with financial risks and many other issues on your plate. so count on the commitment of the business community. ..

>> finally, this is a man of great courage, a man of great conviction, a man who is clearly led his country to greater prosperity. we congratulate you. we wish you good luck in the final period of your time as president. and, of course, you "king lear" as president-elect. you come there as president. we expect you back after you have been president. president. so thank you very much, and thank all of you for being here. >> thank you.

[applause] >> if everyone could stay seated as the president leaves the stage. and another round of applause, thank you. [applause] >> and we go now to a live eve event, house ways and means subcommittee hearing on controlling medicare costs. the committee will look at different proposals, including house budget committee chairman paul ryan's plan. he wants to give seniors a voucher to shop for the own private health insurance. he calls that plan premium support. congressman wally herger of california chairs the ways and means subcommittee on health. this is live coverage now here on c-span2.

>> the subcommittee will come to order. we are meeting today to examine proposals to reform medicare through premium support and the bipartisan support for such proposals. first, i think it should be made abundantly clear that despite what some on the other side might say, republicans support the medicare program. the program serves as a critical function in our society, ensuring that american seniors and people with disabilities have health care coverage. unfortunately, the program faces significant financial challeng challenges, and is slated to go bankrupt in 2024. we cannot keep tweeting here and tweeting there, hoping to kick the can down the road for a year or two. but the medicare trustees again stayed in the annual report,

congress must act sooner rather than later to reform the program to ensure its viability. the medicare program is in dire need of reform and improvement so that it meets the health care needs of its beneficiaries in the 21st century. the traditional medicare benefit was created in 1965, and it really hasn't been reform since, despite the fact that the delivery of health care and the private insurance markets have changed dramatically. the medicare fee-for-service benefit design, with its array of confusing coinsurance and deductible levels, and its five vote delivery system, has not kept pace with the rest of health care. can you imagine buying a hospital insurance des moines

insurance company, your doctor's office insurance from another insurance company, your prescription drug insurance from yet another company, and catastrophic spending protection from a fourth company? that's exactly what the majority of medicare beneficiaries do today. this outdated design breeds confusion, waste, and even fraud. medicare is an antiquated design also inhibits care coordination, incentivize his overuse, and has led to financial challenges throughout medicare's history. so what is to be done? simply hoping to make the medicare program solvent by cutting payments to providers is unrealistic. the chief medicare actuary has warned that the cuts already

enacted as part of the democrats health longwood drive medicare payments below medicaid levels, which could result in quote, severe problems with a beneficiary access to care, closed quote. further drastic provider cuts may make medicare a parasol and on paper, but it would do so at the expense of the millions of seniors and people with disabilities who depend on the program. instead, we should examine reforms that will protect and improve the medicare program, the premium support is one way to do that. the term wringing support was coined by henry aaron, one of our witnesses here today, and robert reischauer, both

democrats, it has received a bipartisan support. moving to a premium support model was advanced by the national bipartisan commission on the future of medicare, which was co-chaired by democrat senator breaux, another witness here today, writing in support of the proposal, senator breaux and former ways and means chairman bill thomas, stated that they believed medicare, quote, can be more secure only by focusing the government's powers aren't ensuring comprehensive coverage at an affordable price, rather than continuing the inefficiency, inequity and inadequacy of the current medicare program, closed quote. premium support was also a key component of the recommendation from the bipartisan policy

center, co-chaired by senator pete domenici, and former cbo director and clinton administration omb director, alice rivlin, who's also testifying today. it is in this vein that the 2013 house budget includes a premium support proposal. we have drawn upon the ideas that our witnesses have proposed over the past two decades, and put forward a plan to protect medicare for future generations. there certainly will be different opinions about how a premium support proposal should work. that is a healthy discussion. however, simply hiding our head in the sand is not. house republicans have made it abundantly clear that we will not simply watch medicare become

insolvent. my friends on the other side may not like our proposal to protect the medicare program, but where is yours? relying on 14 billion in savings from so-called delivery reforms and the health care law is not going to save the program. there are already built into the medicare trustees estimate that predict medicare's demise in just over 10 years. there is some time before medicare faces a dire shortfall that would jeopardize access to care. however, we would be wise to heed the charge given to us by the medicare trustees and begin to work together now the place -- to place the medicare program on solid ground. it is my hope that today's hearing we be the beginning of

this effort. before i recognize ranking member stark for the purposes of an opening statement i ask unanimous consent that all members written statement be included in the record. without objection so ordered. and now i recognize ranking member start for five minutes for the purpose of his opening statement. >> i'd like to thank chairman herger for holding this meeting. i think it's the first hearing the republicans have held in the ways and means committee to advance their plan to end medicare as we know it. basically, republicans want to take away medicare's guarantee benefits and replace it with a voucher and for the insurance companies back in charge. i don't like your plan. i appreciate your honesty and flying their flag to dismantle medicare high and proud. this year, they've modify their plan by saying a traditional

medicare would remain an option. that promise isn't worth very much. traditional medicare might be theoretically available, but we be out of reach of many because the voucher would not be guaranteed to cover costs. traditional medicare would undoubtedly attract syncopations and quickly enter into a death spiral. my republican colleagues don't like the sound of voucher to describe their plan, so they've made up a new term called premium support. they also just dislike being the sole owners of this plan, so they're holding this hearing today. they want to share the blame and try to overshadow the fact that every single democrat in the house of representatives voted against their budget, which includes their medicare voucher proposal. i got dashed i count on it would have the democrats who support vouchers or similar proposals.

dr. aaron actually has come to his honor of having coined the phrase wringing support. ideas written test and today makes clear he is no proponent of the divine plan. the only democrat i've heard say nice things about premium support is ron wyden, and he quickly disavowed the ryan budget, said he didn't write it and i can't imagine a scenario where i would vote for it. i'm going to go on record, again, make it clear, strong opposition the democrats have to the house republican proposal, by any name. it would be devastating to medicare beneficiaries, raising their costs, negating the gains made from medicare that ensure that all our seniors have quality, affordable health care. instead, they would return us to a time when private health insurers would control what your

seniors get, and what price they're forced to pay. cbo has said it would lead to an increase in overall national health spending, as seniors and people with disabilities are moved into less efficient, more costly private lands. it simply takes us in the wrong direction. now, i have to agree with my chairman that there are reform that we can and continue to make medicare. i'm proud of the provisions were included in the health reform bill that are already moving forward, payment and delivery system reforms. they are reducing over payments to private health insurers, and there are plans that cost taxpayers tens of billions of dollars each year. adding years of solvency to the trust fund through our recent legislation. we did this while preserving and even improving medicare

benefits, proving that you don't have to kill the patient to save it. with that, i look forward to hearing from our witnesses today. thank you, mr. chairman. >> thank you. today, we are joined by four witnesses, former senator john breaux, who chaired the 1999 national bipartisan commission on the future of medicare. alice rivlin, a senior fellow at the brookings institution, and co-chair of the bipartisan policy center's task force on debt reduction. joe and jo's and william h. taylor scholar, the william h. taylor scholar at american enterprise institute, and henry aaron, a senior fellow at the brookings institution. you each have five minutes to present your testimony. your anti-written statement will be made a part of the record. senator breaux, you are not

recognized for five minutes. >> thank you very much, mr. herger, for inviting me, ranking member stark, he and i've been involved in this for many, many, many years. thank you all for inviting me, the general who served with me and great capacity one of the national bipartisan commission on medicare reform, and many of you who i've had the privilege of working with in different capacities. thank all of you for inviting me to talk about one of the most important issues, and at the same time one of the most divisive issues that either party is going to have to face, and that is what do we do with medicare reform? let me say that i had the privilege of serving in this body for 14 years in the house, and 18 in the senate, or other bodies as we would like to call them over here in the house. so i think i fully understand the difficulty that each member from each party has in addressing the very difficult issue of how we continue to

provide quality health care for our nation's seniors. i have observed over the years that some democrats, not all, but sun, have taken the position that in health care the government should do everything, and the private sector should do nothing. on the other side there are some republicans are not all, but some comedy take the opposite position that the commission do nothing when it comes to health care. and that the private sector should do everything. my opinion is that in ever to reach an agreement between the two parties congress is going to have to combine the best of what government can do with the best of what the private sector can do, and put the two together. i would submit to this band that is exactly what we did in creating medicare part d. the best of what government can do in that legislation is one, help pay for the program, which government can do to the taxation system, second, government can help set up the mechanics and structure of the program which standards of the

government would put into place. and third, government can make sure that private sector and companies do not scan the system, they can actually deliver the product. government does those things fairly well but on the other and the private sector needs to be involved. the private sector can create competition along competing plans. government doesn't create competition. private sector can do that. secondly, private sector can bring innovation, and new products to the market. government doesn't do that very well. and third, the private sector can deliver beneficiaries choices to allow them to select best plan for themselves and their families. our current medicare program as all of you know was signed into law by president lyndon johnson back in 1965. the model chosen to deliver those health benefits 47 years ago was to be passionate the fee-for-service model. to control the cost the government fixes the price for everything from bedpans to brain

surgery. providers now get around the cost caps by simply doing more services, and the program has remained much the same as it has for 47 years. a former colleague of mine in the united states senate was harris wofford, a great guy from pennsylvania. he was a truly committed liberal who serve with great distinction in the kennedy administration as well as in the thing. he argued strongly that american citizen should have access to the same quality health care that his or her member of congress had. he argued it was good enough for many of congress issued be good enough for all americans. now, what each of you have come and your staffs, and millions of other federal employees, and myself included as a retired federal employee, is a health plan that does combine the best of what government can do with the best of what the private sector can do. the federal employees health benefit plan enacted in 1959 required the federal government

right to regulations that set up the program, and then face up to 75% of the cost of health benefits. the beneficiary then pays the rest based on a formula set by law. over 350 private health plans are offered under program, at 14 or so are fee-for-service, and the remainder of what are called premium support planes. premium support plans have a government paying 75%, and they improved a group the government does, improves a group of private plans that employees can choose from that are required on our government to deliver the services to all of this is implemented by the office of personnel management. when i chaired the national bipartisan commission on the future of medicare back in 1988-1999, we examined several options on how to improve medicare. no one, republican or democrat on that commission, wanted to end the federal medicare. and a strong majority, 10 of the 17, supported a new delivery

system based on market-based premium support system. where for most seniors the premium support would be set at about 80% of the standard plan. unfortunately, the statute created, our commission did not require a majority to report, but a supermajority so are commissions plan was never formally submitted to the president nor to congress. however, what happened next was the then republican leader bill frist and i developed complete statutory language. not an ally, not just a prank, not just talking point, but complete statutory legislation. it introduced s. 1895, which incorporated the fundamental principles that medicare commission proposed. before recommendations of our bill is not to medicare, but rather restructure medicare come using what each of you have today, the program as among the under our bill beneficiaries would be subsidized by the federal government for

participating in any competing private or government plan, offered under medicare, including the existing fee-for-service program. the contribution amount by the federal government would be base, this is important, on the national average of the premiums for a standard benefit package, weighted by plan and moment and adjusted for risk and for geography. not some arbitrary growth rate like gdp. that standard benefit package would be all services guaranteed under the existing medicare statute, part of the legislation. the overall contribution at 88% of the national average cost of a standard benefit package. and under our plan the amount of medicare's contribution would be guaranteed. also importantly under our plan for rural areas, many of you represent, where competition is less likely, beneficiaries would be protected for paying premiums that higher than the current part b been premium.

finally, with stylish the medicare board. this board would oversee competition among private and government sponsored fee-for-service plans and would be the equivalent of the office of personnel management which today manages the sth pp program. it would exercise its authority by regulation and negotiate with the planes. over all the commission estimate the proposal would reduce the medicare growth rate by 12%. one might ask a question, why can't do with medicare at all? why change the system that has worked well for 47 years. i used to drive a 1965 chevy come i'd really love that car but i would hate to be driving it today 47 years later and keeping up with the maintenance of the carpet and i think that he would want to do the same thing. perhaps better answer, why take a with it that is a statement made by red sauce, chief actuary for the medicare and medicaid services just this past week. mr. foster said in the 2012 trustees report on medicare

quote, without unprecedented changes in health care delivery systems, and payment mechanisms, the prices paid by medicare for health services are very likely to fall increasing the short of the cost of providing the services, uncle. so good news out there now is the in addition to the important changes made in a affordable health care act, obamnicare, made to those under 65 in the private insurance market through exchanges and other things, it also included promising reforms, moving away from traditional fee-for-service medicare but still under the fee-for-service program. things like value-based purchasing and bundled payment systems where cms will try to realign incentives and reimburse doctors and hospitals for the quality of the care they provide, and not just the quantity. under the accountability -- affordable care act, cms is over start testing new and innovative payment deliver programs through

the cmmi, the senate for medicare and medicaid innovation. the goal of all these payment reforms and a message projects is to improve patient outcomes while lowering the cost. in the event we move to a premium support model weather is more price competition between fee-for-service and the private plans, the whole system will be better off if these promising fee-for-service medicare reforms and -- >> if you could summarize. >> i am summarizing the last paragraph. i used to say that all the time. it never stopped. [laughter] the great challenge -- the great challenge today i would just suggest to both my democratic colleagues and my republican friends and colleagues, former colleagues, is how to both political parties bridge the gap between the different political philosophies and produce health care reform for america's seniors? 1965, a bipartisan congress said that fee-for-service was the best delivery system back then. let me suggest that in 2012 the

best delivery system was still what is contained in the pro-frisk proposal but if i could beat of a help to interview please call me and thank you very much for your attention. >> thank you. ms. rivlin? >> you are recognized for five minutes. >> thank you, chairman herger, and ranking member stark. i'm delighted to have the opportunity to testify on reforming medicare to a premium support model. medicare is a hugely successful program that has dramatically increased the availability of health care to seniors can increase the length and quality of life of older americans, and greatly reduced their fear of being unable to afford care when they need it. we need to preserve medicare's guarantee of affordable health care for older and disabled people, and make sure the program is sustainable as the number of beneficiaries explodes and upward pressure on health

care costs continues. medicare reform is not just about medicare. medicare plays a crucial role in two of the most daunting challenges facing american policymakers. the relentless increase in the proportion of total spending americans collectively devote to health care, and the unsustainable projected increase in publicly held federal debt. medicare reform represents an opportunity to turn this large publicly funded program into the leader and increasing efficiency of health care and private -- of health care delivery for all americans. i believe that a well-crafted bipartisan bill that introduces a premium support model while preserving traditional medicare can help achieve these goals. i will focus my remarks on the plan that former senator pete domenici and i devised a

bipartisan policy center, but it is very similar to the plan offered by chairman paul ryan, and senator ron wyden. our proposal would receive traditional medicare as the default option for all seniors permanently. it would also offer seniors the opportunity to choose among comprehensive private health plans offered on a regulated exchange. these plans would be required to cover benefits with at least the same actuarial value as traditional medicare. and would have to accept all applicants and which received a risk adjusted annual payment based on age and health status of their beneficiary. the regional exchanges would collect and manage the prices and terms of competing plans within a designated region. and those plans would include

traditional fee-for-service medicare as well as qualified private plan. the government's contribution would be set by the second lowest plan in the region, subject to their having sufficient capacity. with more accessible information about costs and patient outcomes, cost conscious consumer choice will lead providers to emphasize preventive measures, managed care coordination of people with multiple chronic diseases, and adopt more cost effective approaches to the delivery of care. however, we don't know in advance what consumer driven competition will do. so we have introduced, as a failsafe which we doubt will be necessary, a cap on per enrollee government contribution over time at the rate of growth of

per capita gdp, plus 1%. there are lots of questions about how well this would work. one is, can't medicare beneficiaries already choose among private plans under medicare advantage? they can come and a quarter of them do. but medicare advantage wasn't properly structured to give full competition among plans and our plan, we think, would structure the competition so that it actually lowers the rate of growth of costs. and people question whether there is evidence that competition leads to lower cost and better quality. actually, despite its perverse features, medicare advantage provides considerable evidence that competition works.

the impression that it is more expensive to rise from the fact that medicare often pays plans more than the cost of fee-for-service. but under our plan that would not be possible in the competition we think would hold plans down. finally, would older and sicker seniors end up in traditional medicare, and raise its costs? this fear is based on the assumption that risk of judgment passionate adjustment can't work in rules against terri ticking will not be enforced, but, in fact, we believe that these rules can were, that they working better in medicare advantage than they used to, and will work still better under a new system. we believe that health care policy is far too important to be driven by a single parties

ideology. no matter how the 2012 election turns out, the president and congressional leadership should try, should strive to find common ground on how to cover the uninsured, how to reform medicare and medicaid while stabilizing the debt. we believe that our plan contributes to that end. thank you very much for having -- for having given the opportunity. >> thank you very much. mr. antos, you're recognized for five minutes. >> thank you, chairman herger and ranking member stark. medicare is about import program, but it is living of our time to the trust fund will be depleted in 2024, as you said, and the program faces $27 trillion in unfunded liabilities over the next 75 years. with the retirement of 76 million baby boomers over the next two decades the program

will consume an ever-increasing share of the federal budget unless policies are adopted to been medicare's costs are. reform based on the principal premium support can respond to show the growth of medicare spending and help set this country on a sustainable fiscal path. such a reform relies on market competition among health plans to achieve high quality coverage, at low cost. that is the essential if we are to protect the medicare program for future beneficiaries. i will address four points about the design of a premium support reform. first, should traditional medicare be offered as a competing plan option under premium support? i think that the most reasonable course. are half as many as 57 million beneficiaries will be enrolled in traditional medicare 10 years from now, which is when most proposals would start competition under premium support. traditional medicare will not disappear. the premium support begins, even if we do not allow any new

enrollment. moreover, traditional medicare is likely to retain a strong hold in routers and other markets that are dominated by a few providers. for that reason we must find ways to reduce unnecessary spending in traditional medicare in the near term as well as after premium support is in place. premium support does not need to exclude traditional medicare. premium support lets consumers decide for themselves which plan provides the best value and gives them a clear financial stake in that provision. second, will premium support shift huge new cost to medicare beneficiaries? let's be clear, the affordable care act already shifts costs to beneficiaries are the law imposes unprecedented cuts in provider payment rates to generate $860 billion in medicare savings over the next decade. according to the medicare actuary, these payment reductions means that 15% of hospitals and other party providers would lose money on

their medicare patients by 2019. that figure rises to 25% in 2030. large across the board cuts in provider payment without change incentives threaten access to care. that is a real cost to patients that is not reflected in higher premiums. in contrast premium support changes the incentives that have driven up medicare spending. plans to help increase the profit margin need to seek more efficient ways to deliver necessary care, rather than adding another procedure. there's plenty of room to improve efficiency in health care and plans that ignore opportunities to cut costs will lose market shares and see the bottom line shrinkage is also the market test in premium support. if private plans fail to offer a good product at a good price, beneficiaries will move traditional medicare, which remains an option. this is an important safety and ensure that seniors will be protected. third, what index should be used?

an index that has medicare spending growth to the economy provides some budget discipline and helps with the cbo score, and let's not fool ourselves into thinking that the spending target is what produces the reductions in the cost of care. efficiency and innovation in health care come and help the delivery determined whether medicare savings can be sustained in the long term. finally, what other forms are needed? we need to modernize medicare. we need to make the program. we need to reduce unnecessary spending. that means we need better information, clear financial incentives to have reform structure that reinforces rather than undercuts efforts to slow spending. in my written statement i listed a number of reforms, there many that need to be done, certainly reforming the confusing structure of traditional medicare, make a more clear to people what they're paying, would be a good first step, and giving people good information about the health plans so that

they can make good choices is absolutely vital. so in conclusion, there is broad agreement we need to in the medicare cost curve. the argument is only over how to do. premium support is not an academic theory. it has been effective in lowering costs and enhancing value in a federal employees health benefit program for the past five decades, and intel for since 1990 to a well-designed premium support program continues to take full bench of market competition to drive our unnecessary spending and increase medicare's value to beneficiaries. it's about time we try to come and i think we can find bipartisan agreement about moving forward. thank you. >> thank you, mr. antos. mr. arun s. mechanize for five minutes. >> think you, mr. herger and ranking member stark. also special greetings to congressman price with whom i've had the privilege of working in the past. you have my written statement,

and i understand it's going to be entered into the record i'd like to begin with what i think is the central issue that divides those of us who are opposed to the premium support idea from those who are in favor of it. i think all of us recognize that there are reforms to the existing medicare program that could improve its operation, all of us would like to see cost competition played an enhanced role. all of us would like to see delivery system reforms that result in better quality and lower costs. and we hope they will work. but maybe they won't. if they don't, who bears the risk of costs rising faster than projections? under traditional medicare, those risks are pooled broadly

across the population and over time, across all america. under premium support, those risks are shouldered i medicare beneficiaries. who will be faced with higher out of pocket costs themselves. that is the choice i believe, the fundamental choice, that needs to be made in determining a position on this issue. now, some years ago bob reischauer and i, as you noted, coined this term, premium support, and we did so with respect to a particular plan which was more than vouchers, and actually incorporate one of the features that senator roe mentioned just now, that the index to which benefits are tied should be a health index, not an economic index. and i would note that none of the proposals now under discussion meet senator breaux's

standard in that respect. in the 17 years since bob reischauer and i put this idea forward, i have changed my mind, and i would like to just list a few of the reasons why i have changed my mind, and i think i would urge you to consider them as well. the whole in front of health care policy has been transformed. we wrote in the wake in the day of the clinton health reform effort, and at a time when projections of the insolvency of the medicare trust fund will become steadily worse, and were very near term. both of those elements has changed. and in particular, the passage of the affordable care act means that we have put in place a key element of the premium support idea for the rest of the population, namely, health insurance exchanges. we are funny those are difficult

to implement. they are politically controversial. i think they will succeed, and those problems are solvable. the medicare population is vast and more difficult to deal with than the population served under the affordable care act. we should prove that the medicare, the health insurance exchanges work, get them up and running before we take seriously, in my view, call to the medicare population through similar system. the regulatory climate has changed. it is far more hostile to the kinds of regulatory intervention, pretty aggressive regulatory interventions that bob reischauer and i thought were essential to the functioning of a premium support plan. we, at the time, said that no premium support plan should go

forward until risk adjustment was good enough to discourage competition based on risk selection. at the time, like alice, we thought oh, well, it's doable, sometime it will happen. alas, it hasn't happened yet picked a recent study has shown that the risk adjustment algorithm used under medicare advantage action has increased the degree of risk selection that occurs through medicare advantage. we are not there yet your when we are, that would be the time to consider whether premium support merits consideration. and finally the idea that competition is going to save money, as an economist i would want to believe that. i got my degrees in that. i was pledged to like markets. i really do. the evidence today is not encouraging. the higher cost of medicare advantage are not attributable

to the extra, solely to the extra costs, extra payments that are made to them, nor is it attributable to a selection of patients. after controlling for all of those factors, medicare advantage plans are more expensive than is traditional medicare. furthermore, even part d. drug benefits which have come in below cost, have come in below costs by less than other drug spending outside of the medicare system has come in below the projections that were made at about the same time. so i want to be that competition will work and save money. the evidence is not supported at this time. and given the risks involved, it seems to me important to continue to spread the risks from rapid growth in health care spending across the general population, rather than to impose them on a very vulnerable

group of people, the elderly and people with disabilities. thank you. >> thank you, mr. aaron. senator breaux, i think it's important to get this out of the way right at the beginning of this hearing. do you think premium support will, quote, and the medicare as we know it, as some have claimed? >> i think the whole debate politically about in the medicare as we know it, i think we are to change medicare. we want to keep medicare. i think we want to improve the delivery system. i think everybody is committed to having the federal government provide adequate quality health care for our nation's system, seniors. but we don't have to do it under a delivery system that was formed in 1965. just like my chevy, things have changed. things have improved, so what our recommendation is to keep medicare, of course but it's a great program, but change the way it is delivered to our nation's seniors so they get a better deal, a better product at

a better price. >> so then you would say that premium support does have the potential to improve the medicare program and shore up its long-term finances by harnessing private sector innovations? >> my answer would be yes, but you don't have to take my word for it. look at the things we've done in areas where we've implement premium support. medicare part b is a classic premium support system. the government helps pay for, and they help set it up, but the private sector compete for the right to deliver the product. let me suggest, it's a program that is more popular today than the congress that wrote it. and i include myself in that group because i was there. seniors love it. secondly, the second example is even better. every one of us out there, and me, have a premium support, federal employees health benefit plan. that is a classic premium support. people can choose from continue thibault service if you want to stay there, but the federal government since the bed premium

support. with office of personnel management guaranteeing that everybody participates can deliver the project and negotiate for the price. that combines the best of what government can do with the best of what the private sector can do. so don't take my word. look at the two times were able to do this, and i would think you would agree it works very well. >> mr. aaron, i think support for all of us to import him with the medicare program is facing today. the medicare trustees released their 2012 report -- 24 report uses we. would you expect the medicare hospital insurance trust fund to go bankrupt? >> i relied on the trustees who are the secretaries of treasury, labor, hhs, and two public trustees, and they relied on

mr. foster who is the chief actuary. if current law is actually implemented, which means major cuts in payments to hospitals and other party providers, and then their projection is that the party trust fund will run short of funds by 2024. however, under other assumptions it would be much earlier than that, and, in fact, under the so-called high-cost assumption that the trustees also present, it's 2016. >> so buy, even with the projections that we were to make these major cuts, which most doubt very much we would make to hospitals, what was the bankruptcy, you say 2024, what was the bankruptcy date in last year's trustees report? >> 2024. so we know some people say that we've held our ground it another

way to look at it is in the we are one year closer. >> in other words, we are one year closer, as you mentioned to this looming, addressing this looming problem. the trustees stated that congress and the executive branch quote, must work closely together with a sense of urgency, closed quote. in other words, now is the time to address significant reform, the medicare program. do you agree with this assessment speak was yes or. it is absolutely vital. >> ms. rivlin, the plan you worked on with senator domenici is similar to the 2013 house passed budget, as it has private plans that compete against traditional fee-for-service medicare. can you please explain how this competition will control costs? not only for the beneficiaries

enrolled in private plans, but also for traditional medicare. >> yes. on a structured exchange where you can really see, where the consumer can really see what the choices are, the plans that participate would offer their wares, and they would have to agree to take everybody who wanted to join their plan, and to give actuary only equivalent benefits to fee-for-service medicare. and they would be competing directly with fee-for-service medicare. there are lots of new innovations in how you treat people, including people with chronic diseases. and there's evidence that plants

can offer better services and bring down the cost of treating medicare beneficiaries. we believe that would happen, and that through the bidding process the cost of the plan would, maybe not come down, that not increase as rapidly as they otherwise would. and that fact that the government contribution would be slowed, would be a benefit to everybody, including those in fee-for-service medicare. >> in other words, quality could be higher, service could be higher, but the cost could be -- >> yes, we think that would be true but fee-for-service medicare would compete, and would probably get better over time, because otherwise people

would leave it. but there's a lot of evidence that fee-for-service doesn't coordinate care very well. i'm a medicare beneficiary. i watch this happening. and the coordination among providers is terrible. if you are looking at comprehensive capitated plans hoosiers possibility is to take care of everybody in the plan, you are likely to get better results. >> thank you very much. mr. stark is now recognized for five minutes. >> thank you, mr. chairman. mr. aaron, would the medicare trust fund become insolvent sooner under the republican plan to repeal a ca speak with the

aca contains many provisions that extend the life of the medicare trust fund. it was a major improvement in the financial status. they are can become is grounds for legitimate debate about whether every element of aca is going be enforced down the road, but there are additional revenues, and a host of payment reforms that are designed to lower cost, with scorable savings, and others that, while not scored by cbo, contain virtually every idea for payment reform that analysts have come up with. >> i have a letter from cms that indicates that without the aca the trust fund would expire eight years earlier, and i would ask the chairman to make that letter part of the record. >> without objection.

>> if we had vouchers, or whatever you want to call premium support things, medicare would stop being a defined benefit plan and become a defined contribution plan, would it not? >> that was exactly what i meant in my opening comment about what -- who bears the risk if costs rise more than is not anticipated. can i inject one comment which i think is important? >> please. >> the statement has made a couple times that medicare is the same as it was 47 years ago. that just isn't true. medicare -- >> you're right. >> it involved a number of very important ways, it has pioneered a payment reform within the drg system, respective payment. and as various people have

noted, it does contain in one form or another, we may like it or not, the options for individuals to choose among a large number of competing private plans. >> i've always suspected it was republicans, but, you know, these guys who marched outside with billboards over the and sync the world is going to come to an end, they now crossed that out and say that medicare is going to come to an end in 2024, or whatever, 12 years. i can remember when no sign said it was going to end in one year, and i can remember years when the trustees report said we had 20 years. but the fact is that to change the existence, the life of medicare, costs relatively so little to the population at large. i believe that the figure to

extend the solvency of medicare beyond the 75 year target that people are talking about, would cost less than, say, 3% total increase of the prime minister, or lifting the cap were doing a host of those types of things. so that it hardly seems, and she or so, stern is an object to anything that sounds like a tax or fee, which many of my colleagues do, but if you are willing to ask the public will benefit from this plan to pay a reasonable amount over their lifetime, i see no reason that it can't be extended for ever, without hurting job growth or putting this country further into deficit. does that make sense to you? >> yes, it does. but i would modify it in one

direction. i haven't a clue what's going to happen in the health care world in 50 or 75 years. what is science going to produce, what would be the impact on longevity? in my view trying to look 50 or 75 years ahead, with respect to health care, pensions are different, with respect to health care in my view is a fools game here and it was a bad day when the actuaries were required to look 75 years ahead in the case of health care. looked 25 years ahead. that's quite a long time, and there's a lot of uncertainty within that. over that carried you could close the part a trust fund gap with an increase in payroll taxes of .35% each on workers and employers, or more cost sharing on some medicare beneficiaries, or additional payment cuts through one would

hope backed up by improvements in delivery, which is one of the goals of the affordable care act. so i think the idea that medicare is standing on the brink of dangerous precedents, for us for a head as it is reasonable to look, is simply incorrect. >> thank you. 75 your target doesn't bother me much, but i will come back and ask. thank you, mr. chairman. >> well, i would agree, we have a tough time as doing what's going to happen next year, let alone five, 25, 75 years. but one thing we do know, 10,000 baby boomers are now going on medicare every day, and that is something we are aware of, and we have to, hopefully in a bipartisan way, work together to

solve this so that it does remain stable for our children and our grandchildren. with that, mr. ryan is recognized. >> thank you, mr. chairman. unit, i hesitate to say this, but dr. aitman, i think i agree with everything you said in your opening statement. and the reason i hesitated is every time i say something nice about a democrat, it gets them in trouble. they get viciously attacked. so in light of mr. stark's opening statement and colors on considering taking -- considering making nice comments about you, see if i contracted over from alice to you. [laughter] >> i will be working on the. look, there seems to be this attempt to undermine prime minister support and out came to be. leche member that it started as a democratic idea. we have the grandfather of the original idea here, the author in congress of his last generation your. and so, there's clearly room for the two parties to talk to each other about this issue.

if we could just calm down a little bit of we might able to say this program to recently i worked with ron white i know that by the name, i probably got him in trouble saying that. here's what ron wyden tells me. personal i think if you want real lasting medicare reform and my judgment it does has to be bipartisan. so here's what a democrat, ron wyden, to but he said democrats can't support a proposal that does not have an ironclad medicare guarantee. it must maintain traditional fee-for-service as a viable option. it needs to guarantee of affordable for the medicare consumers and protect the low income. it must have the strongest consumer protection for seniors and aggressive risk adjustment to protect the marketplace. this is what a democratic, member of the senate tells me, sort of a central principles for premium support to move forward. that seems hardly irrational to me. that teeny strikes me as these are ideas we should talk about

with each other, and there's plenty of room for conversation with one another, and we i do have that conversation. so, you know, i think we need to put this in perspective. this is a program that is going bankrupt. we had the actuaries come here, budget me or ways and means committee telling us or fighters will be the system, they will stop seeing medicare beneficiaries, the trust fund is going bankrupt, all those things are known to us now it and it's just so much smarter given that 10,000 are retiring every single day, to get ahead of this problem, to prepare the program so that it can be a 20 that is not whether for today's seniors but tomorrow's seniors. ..

>> would determine the government contribution. if you chose the lowest bid plan, you'd get the money back. if you wanted to go higher up the scale, you could. you could choose a more inefficient plan or one that offered additional benefits for

higher cost. but most people would look at how can i get these benefits at a cost that i can afford. and the government contribution at the second lowest bid would then mean if you're in fee-for-service medicare, you'd have the option if that plan was higher or of moving -- of moving to one that cost you less and getting the same benefits. there would be parts of the country where the fee-for-service plan might be the best plan, and you could, you could stay there or other people in other plans could move there. but it seems like a good bet for offering seniors comprehensive services at the best possible price. >> could i add something just

really quick to congressman ryan? and that is the point that in some rural areas you may not have competition. >> right. >> so you have to take steps to protect rural areas where there may not be any competition, and can we did that by saying that no beneficiary would have to pay more than the current part b premium for a standard plan. so you can take care of those areas where they may not be sufficient competition to really create a competitive model. >> five minutes goes fast. thank you. >> thank you. mr. gur lack is recognized for five minutes. >> thank you, mr. chairman. dr. rivlin, looking at your testimony and specifically quoting you to say i believe a well-crafted, bipartisan bill that introduces a premium support model on preserving traditional medicare can help achieve these goals, and then you go on to say that the domenici-rivlin proposal is very similar to the bipartisan proposal presented by chairman paul ryan and senator ron wyden

in december 2011. so as a result of that testimony, i would take it then you consider the ryan-wyden plan to be a premium support plan, is that correct? >> yes, i do. >> okay. and since the plan was incorporated into the house republican budget and passed a few months ago, therefore, that plan as passed by the house is a premium support plan, is that correct? >> yes. i wouldn't -- i think there are some differences between the plan put in the budget and -- a budget resolution is just a budget resolution. >> right. >> it isn't a draft -- >> correct. >> -- of a medicare law. so it's a bit elliptical. and i would stick with my statement that i support ryan-wyden. >> as i think of the word "voucher," i think of a situation where government would provide a payment to a private citizen, either cash or some sort of check form of payment,

and that citizen would take that and then purchase a product or a service with that money received from the government. is that a typical or rational definition of what a voucher is? >> that's what a voucher means to me, and premium support as we define it is definitely not a voucher. >> okay. >> you don't get a check from the government, you get a choice among plans, and the plan gets a risk-adjusted payment, a payment that reflects your age and health condition. and you don't even know what that is as the individual bidder, as the individual beneficiary. >> okay. >> that's between the government and the plan. >> okay. so the domenici-rivlin proposal was not a voucher program, correct? >> no, it was not a voucher. >> and the ryan and wyden proposal was not -- >> not as i understand those terms, no. >> okay. thank you so much. yield back. >> thank you.

mr. thompson is recognized. >> thank you, mr. chairman, and thanks to all the witnesses for being here. i'm a little heartened, actually, to hear about -- there seems to be a lot of agreement. everybody agrees we need to fix medicare, we need to make it work, so that's the best news i've heard on this topic for a long time. i would submit, mr. chairman, that it might be helpful as we're looking at this if we had a plan many front of us. we have heard a lot of criticism about mr. ryan's plan, we've heard criticism about the ryan-wyden plan, we've heard those who are proponents of that suggesting that maybe it's not what the critics say it is. it would be good if we had a plan we could actually see the details of that plan and be able to get down in the weeds and look at it. until that happens, we're just going to maybe spinning our wheels. but i do know a couple things for sure. i know that as i travel my

seven-county district that includes both rural areas, senator breaux, as well as urban areas, i hear a lot from the people i represent about medicare and what they think about medicare. and i hear them tell stories juxtaposing the medicare they have today vis-a-vis what their parents or grandparents had. and it's clear, and i hear it all the time, they like what they have now with medicare. they like that. now, i hear criticism of medicare, i hear people say don't cut my benefits, and i also hear people say keep your government hands off my medicare which is one that i always kind of chuckle out of because, i guess, everyone hadn't gotten the memo yet that medicare is, in fact, a government program. but i've never heard anybody say, please, please, go to a voucher system, do away with my defined benefit program.

so -- and i don't think i'm in the minority there. the kaiser family foundation did polling on this, i think it's 70% of the people agree with that. and i think we really need to keep in perspective the fact that providing health care to seniors and to people with disabilities isn't a huge moneymaker. it's not a huge moneymaker. um, and i think that it's important that we note, and i'm glad mr. antos pointed out the fact that he puts great belief and credit in what the trustees say. i want to reiterate what mr. stark said. the trustees just said that the accountable care act lengthens the life of medicare by eight years. and they said that if we, the cbo has said if we put in place

my friend, paul ryan's proposal, they project the total health care spending would grow faster under that proposal. and for the typical 65-year-old, there'd be an increased cost between 50 and 66%. and, mr. aaron, could you comment on the effects to society of health care spending growing that fast and what would it do to the not only health care, but to the greater economy? >> i don't think there's a lot of -- i don't think there's a lot of difference among the four witnesses on the fact that rising health care costs are a problem in this country. they squeeze public budgets, they squeeze private compensation. for that reason systemic health care reform is the key to moving ahead. i think there's a serious risk of trying to screw down on the costs of just one element even a

large and significant element such as medicare while not attending to the rest of the health care system. for that reason i think that the key now, the most important thing to do now is to move ahead with systemic health care reform. the law of the land is the affordable care act. nobody, i think, regards that law as perfect in every way. we're going to learn new things as it is implemented, and we will probably change it down the road. but the first job is to make to the best of our ability, to make that system work. to the extent that we do that, we then should, in my view, be in an open-minded and willing to come back in future years and consider whether changes such as the ones that are being proposed here today should be enacted and implemented. but i think now is not the time to do that.

>> thank you. my time's expired, yield back. >> i thank the gentleman, and i'd just like to emphasize that as our witnesses have pointed out, the trust fund is going bankrupt in 2024. the trustees indicated it was going bankrupt in 2024 last year. that means we have one year less than we did a year ago. so this is something the sooner we begin on a bipartisan manner working on this and not using, hopefully, scare terms like "voucher," i don't know of anyone except a few people on the other side that are using that term. the purpose of this hearing is to talk about premium support which is a bipartisan suggestion

on how we might be able to fix the system and preserve it. so i'd just like to make that point. with that, mr. pryce, dr. pryce is recognized. >> thank you, mr. chairman, and i want to commend the chairman for holding this hearing and want to, also, recognize and commend the chairman of the budget committee, mr. ryan, for his work within our conference in educating people about the need for reform, but also the positive nature of premium support. also want to thank each of the panelists. you all have put really a life's work into many things, but not the least of which is positive suggestions and reforms for our health care system. as a physician, i can tell you that folks are hurting out there. not just, not just patients and not just doctors, there are real challenges in the current system

that we have. by way of clarification and to make certain that folks understand that our proposal is a guaranteed proposal for seniors, it's stated in all of, all of the communication that we have, it's also stated in the legislative language. it's a guarantee. and so seniors need to appreciate that what we're trying to do is save and strengthen and improve medicare in a positive way. there's been some talk about what's medicare going to look like in 25 years, in 75 years, what the finances are going to be. i want to just share with you what the current system looks like out there in the real world. status quo is clearly unacceptable. there are new medicare patients, we talk about 10,000 folks reaching retirement age or getting on medicare every single day. if you're in a community and you are currently a non-medicare patient reaching medicare age tomorrow and you are currently being seen by a physician who

does not see medicare patients, the challenge that you have in finding a doctor to see you as a medicare patient is huge. the difficulty of new medicare patients to find a physician seeing new medicare patients is massive. the physicians out there are going crazy with this current system. doesn't make any sense at all, and it's more is and more onerous, more and more difficult to be able to just care for patients. one out of every three physicians in this country limits the number of patients that they see, one out of every eight physicians in this country sees no medicare patients at all. so we need to find a positive solution which is what we've been trying to put forward on our side of the aisle. ms. rivlin, i want to -- i was encouraged by the tenor of your testimony and commend you for

the work that you've done in the area of premium support. you mentioned that your proposal differs some from the ryan-wyden proposal, and when i got to that area of your testimony which wasn't in your spoke been testimony -- spoken testimony, but was in your written testimony, one of the areas you differ is that you believe that we can move to a premium support system for seniors sooner than is in our proposal. is that correct? >> that is correct. >> and would you expand on that? tell me why you -- our concern was that if we didn't what we call grandfather the grandfathers, that we would not only take political heat, but the challenge of moving this that direction that quickly would be too great. please, help me understand why you think we can move there sooner. >> because we preserve traditional fee-for-service medicare as the default option.

i mean, it does grandfather anybody who's in it, and it's a permanent option. if you reach that age, you're in it unless you opt into something else. and we believe that the changes that would take place in the competitive bidding are substantial challenges, but they could be met by, say, 2018. we'll have some experience in setting up exchanges under the affordable care act by then. and there's no reason not to start sooner and let everybody have a choice. you can view this as an improvement on medicare advantage that makes the competitive bidding, introduces competitive bidding and makes medicare advantage more

accessible and better. and if you do it that way, it's not such a big deal. >> i want to, i want to thank you for that, and we will go back and scrub our numbers. but i want to thank you for what, hopefully, will be the genesis of a newfound, bipartisan opportunity to move forward and save and strengthen and improve medicare by providing for those choices, but guaranteeing that seniors have the option of remaining on the current medicare. thank you, mr. chairman. >> would the gentleman yield? i happen to be a fan of his bill to get rid of this idea that if a physician doesn't take medicare, they're out of the system for two years, and i join with him in trying to see that we get that changed because that doesn't help anybody, and you're to be credited for seeing that and trying to change it. thank you very much. >> thank you, mr. stark. i may fall into the category of mr. ryan, though, if i start saying nice things about you, we may all be in trouble.

thank you very much. >> mr. kind is recognized. >> thank you, mr. chairman. thank you for holding this hear, and i want to thank the witnesses for their testimony today. senator breaux, just for the record, i still have a '68 chevy malibu convertible that i love to draw around, and it's one of those cars you can get under the hood and do your own oil changes, and my guess is the seniors in medicare feel comfortable with medicare right now, they want to see improvements made, they also don't want to see it decimated. and i'm one of those dwindling breeds here, apparently, in congress these days; a moderate, centrist member of congress trying to find different pathways forward, hopefully in a bay partisan fashion, to address the problems of our time, and i can't think of a bigger challenge than the decision functional -- dysfunctional health care system and the impact it's having on our national budget and international finances. there appears to be a lot of agreement on the panel today,

but a lot of the tools that we put in place in the affordable care act need time to move forward. delivery system reform, so we get better integrated, coordinated care, payment reform so it's value-based, not volume-based. in a lot of respects, this hearing and discussion we're having is premature. and i agree, i think the affordable care act needs a chance to move forward to see if this stuff works before you can have a serious conversation about a voucher or a premium support plan and who, ultimately, is going to bear that risk. but i've always been interested in just three things when it comes to health care reform; better quality of care, better bang for the buck and making sure that all americans have access to that type of care in this country. and how we get there is something that we have to continue to talk about. but one of my concerns with the republican budget proposal and their voucher or premium proposal is the risk in who's going to bear it. but a bit of a parochial concern

that i have from the state of wisconsin. we have traditionally, historically, been one of the lowest reimbursement states in the entire nation. and under their proposal, apparently, the rates will get locked in at the lower of either the current fee-for-service reimbursement rate or the second lowest plan in that region which would guarantee in wisconsin that our providers are locked in at the lowest medicare reimbursement rate which they are struggling to live under today. which tells me that they're going to have to continue to cost shift the inadequacy of medicare reimbursements onto the backs of -- >> will the gentleman yield? >> under the backs of private health care plans -- in a second, so i can make my point. this will not only continue the death spiral that our health care providers are experiencing in the state of wisconsin, but the death spiral that businesses in wisconsin are facing with rising health care costs because of the cost shifting that is currently impacting them.

making it harder for them to compete not only at home, but globally. and it does not make sense that we go down this road. not until at least we find whether delivery system reform and payment reforms actually have a chance of working. i've tried in my way to work in a bipartisan fashion on this committee and, mr. aaron, you pointed out it's crucial that these exchanges have a chance to move forward and show whether they're viable, and i've been an author of the shop act, and every year i introduce that proposal. i had an equal number of republicans and democrats on that bill. we put it in the affordable care act, and my republican colleagues ran for the hills. i was one of the authors on reimbursing our health care providers for counseling on directives, and every year we introduce that bill, we had at least fife or six republican members who were on that legislation. that was put into the affordable care act, and that turned into

death panels. so having that bipartisan conversation is difficult to have when you've got principles or issues that we had previously agreed on sudden will hi divide us today -- suddenly divide us today. and i agree with mr. thompson, paul, to have a serious conversation, we need words on paper because we all know and i think everyone on this panel would agree that the devil's in the details on how any type of premium support or voucher plan is, ultimately, structured. and we don't have that. i talked to ron wyden, too, and sometimes i feel like i'm talking to two different people who are embracing the same type of plan. what paul understands what the plan would mean and what ron wyden is sometimes they're talking past each other. so unless or until you put something on paper so we can truly analyze the impact of what this is going to mean, all this is theoretical. >> if gentleman would yield, i'll send you the plan that senator wyden and i co-authored

with our signature, and ill send it over to your office. >> all right. it's important no these delivery system and payment reforms as part of the affordable care act right now have a chance to continue to move forward. and if for some reason supreme court or this body decides to overturn everything, i think that's going to lead to an absolute state of chaos in the health care system that may take a generation to recover from if we go back to square one again. thank you, mr. chairman. >> mr. pascual is recognized. >> thank you, mr. chairman. thank you, the panelists. i've heard and i've said many times health care reform is entitlement reform. folks on the other side don't want to hear that. we haven't touched entitlement reform in the health care bill. i think that is utter nonsense. one-third of the health care bill is devoted to medicare and medicaid. it is very specific about the recommendations, and those are recommendations that we should

be considering if we weren't trying to suffocate this legislation before it breathes fully in the next two years. not only did, we're going to reduce costs for medicare, but it also, health care act, reduced costs for beneficiaries. unless you don't agree with the cbo numbers. the majority's attempt to repeal reform and turn medicare into let's not use a voucher program, let's not use that word, i call it the more out of your own pocket folks program. i think that will hurt beneficiaries. and there's no doubt about it, this is going to mean more money out of pocket. no one has denied that, no one. so according to the cbo office, the republican budget will dramatically cut spending in

medicare for new beneficiaries by more than $2200 per person, per year. that's what the cbo says. and we conveniently use the cbo o when they support our position, and then we tell them that they don't know what they're talking about when it doesn't support our issue. our position. and starting in 2030, by $8,000 by 2050 -- you want to talk about the future, let's talk about the future -- we don't have to scrap the current system. in fact, as we're sitting here today talking about strengthening medicare, the health care reform bill is already hard at work actually testing new payment and delivery systems that will lead innovation not only for medicare, but for the entire health care system. and let's talk about that health care system. you're talking about competition, let's increase competition in terms of medicare. we don't have competition in the health care system.

many states have only two or three companies who write health insurance. why don't we do something about that? if we want to foster competition, let's foster competition. we don't merely mean it. this is pure, it's empty, these are words that we use back and forth. this is one-upmanship, that's all we are after. the basics of health care will be changed by the health care act for the better of americans. it will not be a socialistic system. thank god we graduated from that since more insurance companies will be involved in order for us to gain favor with the people that we're dealing with. this is, you know, we're heading back to 1964. i am convinced that that's the direction we want to go in. when senior poverty was at the greatest since the great depression.

that's where we want to go. why don't we just say that? we're using a lot of pretty words. yeah, you may shake your head, but i am telling you, we are marking time in place while many seniors are stopped at the door because they are under medicare. that's what we should be addressing, that's what we should be saying, enough of this. the health care system is not working. now, the health care system has been totally taken over by the insurance, health insurance companies of this country. you know it and i know it. we don't have competition. in new jersey what do we have, three or four companies that write health insurance? this is competition? what is this competition? the -- maybe next year we'll have three companies. maybe company c will take over company d. how many states do we have only three or four or less companies

writing health insurance, and you want to put our seniors into that situation? that's not competition. that's a joke. you know it and i know it. by the way, mr. aaron, i want to congratulate you on the work that you've done. i know since i've been here, for 16 years, you've been at the forefront of talking about these issues. these are critical issues for all of us. i know that it's not very popular to try to hold down out-of-pocket expenses. that's not a popular position, mr. aaron. but i don't care whether it is or isn't, you've done the right thing. i admire what you're doing. we've got enough here to work with within the legislation to change medicare, but let's not throw away everything was we want -- because we want to get to a few who will profit only. >> thank you, mr. chairman. dr. boustany's recognized. >> thank you, mr. chairman. thank you for holding this

hearing. i think this has been a nice reprieve where we actually get to talk about policy, and i want to thank all the panelists here today for the serious work you've done over many, many years to advance the debate and to advance real solutions to solving health care. senator breaux, let me publicly thank you for your many, many years of service to our state of louisiana and our country and your continued willingness to do this and to serve in a public capacity to advance the debate in health care. mr. aaron, you raised the point about competition and the fact that it has not lowered cost. i would submit that we're really stuck right now between a price-controlled system and vastly imperfect competition. we don't really have the kind of competition that's necessary both in the health care financing arena as well as in the delivery system aspect of

this. and i think if we could get the more perfect competition there, we would see the advantages of lowering costs and enhancing quality. and that's coming from somebody who's had many years practicing in the health care system as a physician. i have some really deep concerns about the tilt toward price controls in this which i think it's pretty indisputable that's what we're operating under right now. and the problem is we already have a serious shortage of physicians and nurses in this country, and if we continue on this path where we've seen, we're facing cuts in sequestration, we've seen cuts year after year to providers, what is this really going to mean for access? because coverage does not equal or equate to access to good, high-quality care. and i know, senator breaux, you and i -- actually, even before i got to congress back in the

'90s -- had serious concerns about trends i was seeing in the medicare program. for instance, i'd do an emergency coronary bypass operation, and then in the aftermath of all that, we couldn't find a primary care physician to take care of the patient's basic health care needs, and i'd have to get on the phone and start begging, begging physicians in my community that i knew well and worked with to take on a new patient. and the whole issue was the cost. the cost of care and the cost to these physician practices is not being met by reimbursement. and so if we can get to a system that brings us back to a real competition, i think it makes a difference. and i want to compliment chairman ryan. i know he walked out, but he's actually taken a lot of the work that dr. rivlin, senator breaux, mr. antos, you've worked on, and mr. aaron, and put it into a body of work along with senator wyden to try to get us to that,

and i don't know of any other alternative. so would anybody comment, is there another alternative out there other than the premium support model that -- >> i think the key to the solving the problems that you've described, and quit eloquently, i believe, regarding the fragmentation of care comes in some of the innovations that are in the affordable care act. in particular two that i would focus on. one is the creation of accountable care organizations which are groups of providers who would be paid to assure the health of people who enroll as much as health maintenance organizations do, and the second would be bundled payments so that in the event of a coronary artery bypass graph surgery case, a payment would be made not just for the act of surgery, but for the follow-up care as well so that you together with a primary care physician and perhaps a nurse practitioner who

would regularly contact the patient to make sure that he or she was taking recommended medications would all work together. that's the key. >> one of the fundamental problems not addressed in the accountable care act, affordable care act is the, in the context of accountable care organizations is we still have federal barriers in place that prohibit physicians to integrate care with hospitals, and that has not been addressed adequately. we need statutory relief in that area if we're going to see those kinds of innovations. >> i agree with you completely, and it's a -- [inaudible] how the law may need to be amended. >> i think this was pointed out, brian talked about the demonstration programs that are available in the accountable care act. i remember when i was in congress, when i wanted to stop something from happening, i used

to offer an amendment to do a study hoping it never got completed. i be i think the things that are in the accountable care act, the demonstration programs are very important. but you can be for both going to a premium support system and a demonstration project in the accountable care act. if the demonstration programs work, it will improve the fee-for-service delivery system, and if you have premium support, they will be greater competitors. that's what we're trying to bring about. i think the demonstration programs are helpful, they're important, but they're not an either/or situation. you can move to a premium sport system and support the demonstration projects and hope that they work very well. >> dr. rivlin, do you want to comment? >> yes. i fully support what senator breaux just said. it's a mistake to think of these as alternatives, at least our plan envisions that the affordable care act continues, that the demonstrations and the

various institutions that were set up to improve the delivery system go ahead, and we hope that works. we're only saying there ought to be another way to get these innovations into use, and that would be competition. >> thank you. mr. antos? >> i agree with that, but it would also be a mistake to believe that these things are going to materialize overnight. as someone said, the devil is in the details, and accountable care organizations are devilish. >> thank you. i yield back, mr. chairman. >> [inaudible] >> i want to thank our witnesses for your testimony today. this has been an extremely interesting discussion, one that highlights the need for congress to act soon in order to place medicare on sound financial footing. premium support proposals like

those we heard about today hold promise to improve how care is delivered, better protect beneficiaries against medicare's cost-sharing requirements and utilize competition to control costs for the program as a whole. as a reminder, any member wishing to submit a question for the record will have 14 days to do so. if any questions are submitted, i ask the witnesses to respond in a timely manner. with that, the subcommittee's adjourned. [inaudible conversations]

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

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handling at c-span.org/shop. president obama flies to fort stewart in georgia today to speak to troops and sign an executive order dealing with for-profit colleges. the white house says some schools looking for money from the g.i. bill have preyed on veterans with brain injuries and encouraged service members to take on costly loans. the executive order would ban for-profit colleges with a history of predatory behavior from military bases. president's remarks from fort stewart live here on c-span2 at 12:35 p.m. eastern. >> you're watching c-span2, with politics and public affairs. weekdays featuring live coverage of the u.s. senate. on weeknights watch key public policy events, and every weekend the latest nonfiction authors and books on booktv. you can see past programs and get our schedules at our web site, and you can join in the conversation on social media sites. >> a government report found

veterans have to wait two months on average for mental health care. the report was issued tuesday, and a day later the senate veterans' affairs committee looked at the issue of veterans' access to mental health care. testifying at the hearing were several va officials and veterans' advocates. >> good morning, this hearing will come to order. i'd like to welcome all of you to today's hearing to evaluate va access to mental health care services. today's hearing builds upon two hearings held last year. at each of the previous hearings, the committee heard from the va how accessible mental health care services were. this was inconsistent with what we heard from veterans and the

va mental health care providers. so last year following the july hearing, i asked the department to survey its own mental health care providers to get a better assessment of the situation. the results, as we all now know, were less than satisfactory. among the findings, we learned that nearly 40% of providers surveyed could not schedule an appointment in their own clinic for a new patient within the 14 days. over 40% could not schedule an established patient within 14 days of their desired appointment, and 70% reported inadequate staffing or space to meet the mental health care needs. the second hearing held in november looked at the discrepancy between what the va was telling us and what the providers were saying. we heard from a va provider and other experts about the critical importance of access to the right type of care delivered timely by qualified mental

health professionals. at last november's hearing, i announced that i would be asking va's office of inspector general to investigate the true availability of mental health care services at va facilities. i want to thank the ig for their tremendous efforts in addressing such an enormous request. the findings of this first phase of the investigation are at once substantial and troubling. we have heard frequently about how long it takes for veterans to get into treatment, and i'm glad the ig has brought those concerns to light. the ig will also discuss an entirely different and more useful way of understanding access to care. this model would give more reliable data and reduce the rampant gaming of the system that we have seen thus far. the ig has also found the existing scheduling system is hopelessly insufficient and needs to be replaced. va has struggled with developing a new scheduling system.

i understand va is working to get a replacement system in place. i would like the department's commitment that they will work to get this done right and get it done soon. the ig findings also show some serious discrepancies in what va has been telling this committee and veterans. va stated that 95% of veterans received mental health evaluation within 14 days. in reality it was only about 50%. vha data reported that after the evaluation was completed, 95% of veterans received a treatment employment within 14 days n. reality it was only 64%. for those in treatment, 12% were scheduled beyond the 14-day follow-up appointment window with providers telling the ig that they were delaying follow-up for months not because of the veterans' needs, because their schedules were too full. va is failing to meet it own

mandates for timeliness and instead is finding ways to make the data look like they are complying. va can and must do much better. important steps have been taken in the right direction by the department. last week va announced the addition of 1600 mental health providers, and late last year va announced an increase in staffing levels at the veterans' crisis line. but as we will see today, the hard work remains in front of us at a time when veterans are dying by suicide at an alarming rate. we know that the sooner a veteran can get a mental health care appointment after they request it, the more likely they are to follow through with care. we can't afford to leave them discouraged when trying to access care, and when in care, we must be getting veterans their next appointment in a clinically-appropriate time. we need to be sure there are enough resources so providers do not have to delay treatment because their schedules are too full.

while i commend va for the decision to hire another 1600 mental health providers, there is still no reliable staffing model to determine where these individuals are needed. without that model va needs to explain how they will know where to place these additional providers. there are other challenges with getting the best providers into the system. i understand that nationally there are shortages of mental health providers, and it's even harder for va because they cannot always pay the highest salaries in the community. there are still a large number of vacancies in va's mental health ranks. i want to hear from the department how they will fill the existing gaps and insure the new positions they have announced do not become 1600 empty offices. ultimately, what really matters is how long it takes for a veteran to start that first treatment session. what really matters is not abandoning that veteran. i recently saw andrea sawyer whose husband lloyd suffers from

ptsd and depression. andrea bravely testified before this committee last july about the tremendous difficulties she and her husband faced in getting him into care. lloyd still faces challenges, but he's now getting the care he needs. that is what matters. we cannot let our veterans down, especially when they have shown the courage to stand up and ask for help. i look forward to hearing from va, how they intend to address the issues the ig has found. now more than ever is the time for action and for va to show effective leadership. let the hearing today serve as an unequivocal call to action. the department must get this right. in closing, i do want to be clear that while we have discussed a number of problems with the system at large, none of this reflects poorly on va's providers. i believe i can speak for all of us in thanking va's many mental health providers for the incredible job that they do do,

but there be no mistake, these individuals are incredibly dedicated to their mission. they choose to work harder than most of their peers, often for less lucrative benefits because they have a deep and unshaking commitment to our veterans. to the all of va's psychiatrists, psychologists, social workers and other providers and to all the administrative staff who support them, thank you so much for the good job and keep up the important work. and with that, i want to turn it over to senator brown who's standing in for senator burr today. >> thank you, madam chair. it's good to be here in place of senator burr, good to be back on the committee serving with you. i want to thank you for holding this very important hearing. somebody i'm still serving, i see and hear of these types of situations regularly. you know, $5.9 billion, that's the increase that va got, and out of that, you know, do you think we could hire some more people to address these very real concerns?

$5.9 billion. and to read some of the things that we've been reading about the suicidal veteran calling for help, gone unanswered. one more person killing themselves, and the veterans' mental health care is delayed put out by "the washington post", actually, yesterday talking about how the system is being gamed by the va and not actually scheduling and following through with scheduling and providing a good opportunity for these soldiers to get the care and coverage that they need. it's mind-boggling. i mean, i understand the delay, i understand that there are problems, i understand that claims goes over a year, but when somebody calls to say i'm thinking of killing myself, well, do you feel that way right now? well, not right in this moment, but i tried to hang myself yesterday, does that count? and then to be blown off, it just makes absolutely no sense to me at all. so i'm glad you're holding this hearing, and, you know, i want

to continue to look into mental health services. your insights in this committee help perform the oversight to insure the veterans get the services that they need, and that's a good thing. as you know, one of the several hearings regarding mental health services provided by the va, this is another one, and last year i remember we did learn about the very serious mental health service that were needed and, quite frankly, lacking. and i want to just say that today's hearing will focus on evaluating the availability of these services and assessing the care that's delivered. and the testimony we hear today will be from va's inspector general as well as iraq veteran and former va mental health officer nick tolentino, and, nick, i want to thank you for your testimony and pointing out where the loopholes are sought and openly share today hide the fact that the facilities are not meeting their performance metrics. and i've got to tell you, it's unacceptable as somebody who still serves and sees and speaks

regularly by people affected by these very serious ailments. and the gaming of the system has to stop, and the ig found that our veterans are not given the opportunity to actually offer a desired date for their next appointment. they were simply told when and where to show up, and no consideration or compassion to address the very real concerns that they have. and scheduling system is not the only problem with delivering mental health care. even though the va has increased the staffing by 48 percent between 2006 and '10, both the ig and nick point out that it's understaffed and lacks a methodology to assess their staffing needs. and it's no surprise that just one week after this hearing va announced they're hiring 1900 additional mental health staffers. that's great. it's a good start but, man, what have we been doing up to this point? we need to do it better. we have people's lives depending on these decisions that we're making. and it's a good step, as i said, but how long will it take to

actually fill these positions, and what happens to that soldier who calls as has been happening with jacob manning and others? and we'll hear today from community groups that are helping, general tom jones followed simplify honesty to help veterans from the current conflicts manage their mental health, and i want to thank you, sir, for that effort, going bo and beyond. and it'll help veterans volunteer to help fellow soldiers to cope with those invisible wounds of war which we all know about. and it's a great example of the community coming forward and addressing needs not currently being met. so thank you for that. and in the end, simply hiring more staff and fixing the va's broken scheduling system will not cure all the issues, but it will certainly take a combination of changes at the facility and va office levels, and the va will use free basic care, staff increases, developing better performance be metrics to fix a severely broken

system, and i concur with you that the individual people that are there are going yeoman's work, but you need more people, more computers? what is it? $5.9 billion should go a long way to addressing those issues, and madam chair, as i referenced i'm heading upstairs, but then i'll be right back down, so i look forward to everybody's testimony. thank you. >> at this time i would like to introduce the first panel. representing the va is mr. bill schoenhard, he is companied today by dr. ann to net zeiss, chief consultant to the office of meant l health services, and dr. mary schohn at the department of veterans affairs. we have dr. david daigh accompanied by dr. michael shepherd, senior physician in the ig's office of health care inspections. also from the office of

inspector general, we have ms. linda halliday, audits and evaluations accompanied by dr. larry reinkemeyer, and next we will hear from nick tolentino, officer in the va, and finally we will hear from the executive direct every of outdoor odyssey, major general thomas jones. mr. schoenhard, we will begin with your testimony. we have a lot of answers we need from you so, please, begin. >> thank you. chairman murray, we appreciate the opportunity today to address the access to quality of mental health care services to our nation's veterans. and we appreciate so much discussion of a topic that is integral to the well being and full living out of a fullfilled life of our nation's veterans. mental health is integral to the

overall well being and physical health of a veteran. it's important if there's underlying depression, problem drinking or substance abuse or other medical, mental ailment that this be diagnosed in order to insure that those who have served our country have the full treatment of something that is so core the their overall well being and to their ability to also implement the physical health aspects of medication management, staying employed and the rest which is so important to the quality of life of a veteran who has served this country. it is the sacred mission of va to insure that this very integral part of our care is well delivered. and i appreciate so much your comments regarding the 20,500 providers who on the ground work so hard every day to serve our nation's veterans in this

important mission. we, in the written statement i have outlined three areas of improvement and concern, but i'd like to make, first, mention that we appreciate so much your leadership, the committee's review and the inspector general's review. this is an important aspect of care, and we appreciate all of the assistance. and we will be working very closely with the inspector general as we go forward with their report as it relates to the first recommendation i would like to address, and that is that we agree with the inspector general that our, our appointment measurement system should be revised to include a combination of measures that better capture the overall efforts throughout a course of treatment for a veteran. while maintaining flexibility to accommodate a veteran's unique

condition and phase of treatment. we must also continue our efforts to strengthen mental health integration into our primary care in order to insure in the primary care settings that we are assessing mental health needs of our nation's veterans and also be able to address the stigma that's often associated with this. it can be discussed in a primary care setting. second point we'd like to make is announced by secretary shinseki last week. we are increasing staff to enhance both the access to and quality of mental health care by hiring 1900 additional staff, more than 1600 of those are mental health clinicians. as i mentioned, in this will augment the current complement of 20,500 mental health employees in our system and is designed to provide additional staff in our facilities, it's

also designed to increase our staffing of our crisis line which is so integral to the identification and treatment of people who are in crisis as ranking member brown spoke of so eloquently. and it's also an important aspect of increase in that we will be adding additional examiners for compensation in pension examinations. that's an important transition from active duty to, um, veteran status for those who are currently on active duty and for those who present with new conditions. we have a solemn responsibility to insure that we increase our staff to insure that we can handle this volume in a timely fashion and that we can do this in a way that doesn't erode our capacity to seven our exist -- to serve our existing patients.

i want to emphasize that this additional staffing will be continued to be evaluating the assessed data and refine the staffing model, and we are currently piloting this in three visions. and this is a work in progress that will be continually improved as part of our comprehensive approach to insuring that our facilities have the resources to insure that we accomplish in this mission. the third point i would like to make is that in deploying evidence-based therapies to insure veterans have access to the most effective meds for -- methods for ptsd and other mental health ailments, we are making more widespread and improving our training for those who are receiving care and delivering care of evidence-based treatments. we're shifting from a more traditional approach to one with newer treatments and would acknowledge that we have not always communicated these

changes as clearly as we might to our nation's veterans, so we're redoubling our efforts to improve communication not only to our providers, but to our veterans to insure that these evidence-based therapies are implemented in a way that can be supported by the veteran and fully educated and trained personnel assuring that that is delivered. in summary, we just thank you again for your encouragement, for your support. this is an important part of care that is fundamental to the well being of our nation's veterans, and we look forward to answering your questions and those of the committee. >> thank you very much. ms. halliday? >> madam chairman, members of the committee, thank you for the opportunity to discuss the results of our recent report on veterans' access to mental health care services in va

facilities. we conducted the review at the request of the committee, the va secretary and the house veterans' affairs committee. today i will discuss our efforts to determine how accurately the va records wait times in mental health services for both new and established patient appointments. dr. daigh, the assistant inspector general for health care inspections, will address whether the wait times data is an accurate depiction of the veterans' abilities to access those services. we are accompanied today by dr. michael shepherd, a senior physician in the office of health care inspections, and mr. larry reinkemeyer, the director of the kansas city office of audit. our review found inconsistent scheduling practices diminish the usability of information needed to fully assess current capacity, resource distribution and productivity across the va's system.

in va's fiscal year 2011 in the performance accountability report, vha reported 95% of first-time patients received a full mental health evaluation within 14 days. however, we concluded that that 14-day reported measure has no real value as an access to care measure because vha measured how long it took to conduct the mental health evaluation, not how long the patient waited to receive that evaluation. we calculated the number of days between the first-time patient's initial contact in mental health and the completion of their evaluation. we projected that vha provided only 49% for approximately 184,000 of these evaluations within 14 days of either the veteran's request or a referral for mental health care. on average, it took vha about 50

days to provide the remaining patients their full evaluation. .. we also projected that vha had approximately 8.8 million or 88% of the follow-up appointments and treatment within 14 days. thus approximately 1.2 million or 12% of the appointments nationwide exceeded 14 days.

in contrast, vha reported 28% receive timely care for treatment. we base our analysis on the dates documented in the medical records. however we have concerns on the integrity of the information because providers to told us they used the desired care based on their scheduled availability. i want to point out that we reported concerns with stifel's data in our audit about patient scheduling procedures in 2005 and outpatient wait time in 2007. we found schedulers for entering incorrect desired date and the current review shows the practices continue. for more patient appointments, the schedulers frequently stated the next available planned months lot as the desired date disappointments for new patients

this is the actual waiting time for appointments. to illustrate, vha showed 81% or approximately 211,000 patients receive their appointments on their desired appointment date. we found the veterans could still awaited two to three months for an appointment, and vha data would show a zero wait time. based on discussions with medical center staff, and i will review the data is implausible to have that many appointments scheduled on the exact days a patient desired. i offer the rest of my time to dr. day to provide you a conclusion. >> mer madam chair, ranking members, i'm honored to testify before you today. i and my stuff in the office of health care inspections on a daily basis deal with care issues in the va, and we know that the employees and the

leadership within va strive to provide the best care and to the subject of the meeting i do believe that va provides very high quality health care to its veterans. in fact, with respect to quality metrics, i believe va leads the nation with respect to both the use of data and the publication of that data on the web site. with respect to access for c.a.r.e. tracks i believe it is quite a different story. i believe as much wrecks are flawed and as the report indicates, the doctor indicated that he will put together a group to try to resolve the issue and get the access to care metrics in line so that they do accurately reflect the business process these that are ongoing at the va. i plan to talk about some of the access to care metrics in the private sector, but i think what i would like to make or two different statements after hearing the opening statement. the first would be i think the va has a number of missions to

read to provide health care the of the mission to do research. they have a mission to train individuals who will work in the united states and elsewhere in the health care industry. they have a mission to be available in times of national disaster. and i think as individuals out there and hospitals decide how they are going to spend their time, those missions are being accepted as being equal saying the primary mission is the delivery of health care and we will address those assets first as provisional schedule their time or allocate their time. i.t. when we have a crisis like we've had that our prioritization of missions, again, state it clearly from top to bottom, would allow individuals across the system to rethink how they're spending their time to read the second issue i think is important is to set a standard of productivity.

i realize that health care can't be number driven. i realize it's a personal interaction between patient and a provider. but at the same time, they're has to be some method to determine that you're getting enough word or productivity from the people that are working for you. so i think that although the va has worked on these issues for a while and the rest of be a clear and measurable and in my view productivity standard that is easily relatable to the work done in the private sector by the provider so that one can decide where the money spent is actually being effectively used. i think the other issues that are brought forward in terms of the kind of access to care standards we could use i think that dr. brac -- we currently

improve the standards they have in place. with that i would end my comments and be happy to answer questions. >> thank you for a much. mr. tolentino. i am honored to appear before you today to share a deep concerns about the administration of the mental health care system. my testimony is based on my experience as a va health care administrative officer as well as service on the network executive committee. membership on several national workers and a background of quality management, that led to an m.b.a. degree. these concerns about the manchester, new hampshire va medical center failure to provide needed care ultimately led to my resignation last september. i want to commend this committee for your vigilant oversight of the v.a. health care. let me also acknowledge the va recent announcement plans to add to the work force and address

problems. but i want to emphasize that additional staffing alone will not remedy the systemic problems in the mental health care. let me be clear, i do not discredit the va or the mental health care staff to work diligently to help veterans. but for all it strives to do, the va's mental health care system is deeply flawed. the system is open to putting america goals ahead of the mental health care needs. it's too successful to the gaming practice is aimed at making the facilities look good and too will focus on overseeing the effectiveness of care it promises to provide. the system problems compromise the word of a dedicated mental health care staff and feel of the veterans. like many va veteran tecum senator the objective of our facility from top management down is to meet our members. meaning to meet our performance measures. the goal was to see as many veterans as possible, but not necessarily to provide them the

treatment they needed. performance measures are well intended. but they are linked to executive pay and bonuses and as a result, credit incentive to finally allow the facility to meet its numbers without actually providing services. for too often, the priority is to meet a measure rather than meet the needs of the veterans. many factors including understaffing make it very difficult to meet the performance requirements. administrators don't feel they can acknowledge that. instead, as soon as the program and of my duty to manuals are programmed the leadership began planning how to meet those measures. that led to brainstorming even with colleagues of mine across the country to find loopholes to gain the requirements that couldn't be met. while life itself multiple examples and michael statements, i'd like to share two of them now. several performance measures mandate that veterans and mental health treatment be seen within a certain time frame. that manchester would demand for

metal health care was great and staffing was very limited the facility director demanded a plan to get veterans seen at any cost. we got the order focused only on the veterans immediate problem. quickly and that you lose medication and don't ask further questions about the needs because coming and i quote, we don't want to know or we will have to triet. another director requires a patient who is actively suicidal or at high risk for suicide should be seen at least once per week for four weeks after an inpatient discharge. this is to ensure the veterans receiving the care needed to reduce the risk of the remission and to increase the success of treatment. instead of providing the individual therapy manchester created a group for them said that was inappropriate and contrary to the directors intent. veterans who refuse to join the group are often resistant to treatment. the idea of the group to be

substituted spread throughout the network and in fact the mental health executive committee actually promoted this idea of the so-called best practice. even though it was not tall good clinical practice it was seen as a good way to meet performance measures. i believe that most facilities have been understaffed rental service because the va lacks the methodology on what to determine mental health stuffing is needed and individual facilities and a misguided attempt to justify the mental health services stated that the priority needs to be quantity rather than quality. she said, and i could come have contact with as many veterans as we can. even if we aren't able to help them. the outcome of the facility continues to enroll a growing number of veterans far more than that mental health commission could handle and as a result they fall through the cracks. tragically there was no effective oversight to detect

the deep system problems we face, for example, every year the medical center completed an office survey to assess the facility compliance with the va mandate to provide a uniform mental health services but each year the network told us we were never to answer the service were not provided. many of our answers were actually changed to say that required services were being provided when the in fact or not. during my years of manchester, other members of the mental health stuff and by repeatedly raised concerns with both facility and network leadership regarding practices we believed were unethical or violated the policy. those concerns largely fell on deaf ears. our staff also repeatedly brought to the concerns to the facilities ethics committee and to our great frustration, however, the ethics committee consistently declined to take up these issues because they felt they were clinical matters. for me, the final straw was the medical center's failure to take meaningful action upon the discovery of the mental health commission was visibly intoxicated while providing care

to our veterans. ultimately, it couldn't continue to work at the facility where veterans wellbeing seemed secondary to making the numbers look good. i very much hope the va will make real changes to address the system problems i described. i believe that there are steps that can be taken beyond ending staff. i humbly offer these suggestions. first, the va should stop the war in leadership for meeting the processing requirements that are not real measures of effective mental health care. second, the va should institute a much more extensive oversight and to health care is actually being provided from and how program funding is deployed to ensure the funds actually go to the programs they are intended to supplement. finally, i would urge this committee to press the va to develop and implement a very long overdue empirically supported the telehealth seventh methodology so it's no longer necessary to guess whether 19 more mental health staff will be enough. in closing, i am honored to have had the opportunity to share

with my experience and assessment problems that i hope you can help with to resolve. i'd be very pleased to answer any questions we have. thank you. >> thank you very much. major general jones. >> [inaudible] can you hear me now? >> low of the mic up to you. thank you. >> retired marine, founder and director of a camp for times llosa i have a lot of experience to deal with those who have mental health issues. i have been visiting walter reed and bethesda ever since the start of a war in afghanistan in 2001 i've met thousands of folks and i've been privileged to be

on the board of the fund that a deal with the families of the wounded. i've also started semper fi odyssey as a growth. while the started as a normal transition course, a captain at bethesda was wounded and visited many times over the next year. while in therapy, he asked me to help him start a 501c3, since i had already done so. we originally started as a normal transition course however after a while, the mental health issues were such that we really got into the whole issue of dealing with mental health. i had my back, i was able to bring a lot of folks in from the outside and psychiatrist dr. bill nash was so moved by the experience that he had been

involved in a number of gatherings of mental health professionals. from that, i was able to because i'm an adjunct at the institute and now this is here in d.c. looking at best practices of mental health. what we had done, we have 30 sessions now on outdoor odyssey. because i had the facilities, what we have done is billed on volunteers strategies with team leaders and almost all the people involved in the voluntary category. what has transpired is the whole issue of trust croatia and bonding is force the military when you're dealing with the veterans. of our sessions, 35 or so of outreach attend each time just have one last week. we've dealt with over a thousand not only veterans, those

discharged from the military. we work in conjunction with those that give a pretty good index of the problems we are having in the military, but also more strikingly with the problems we are heading in the veterans community. and what we found is that many if not most of the people that are undergoing a the clinician's care have not -- even the source of the main stress that's created the problem. i agree with some of the panelists here. i don't think the numbers of additional mental health coroner's will solve the problem. i think they have to have a better understanding of what the demands are of the individual or your. i think it's one thing that we have learned that through our experience with bringing a mental health professionals to these experiences of with these individuals are facing with

them. so i would encourage other folks here and even my panel members if we are so inclined to be involved, because i think the inside information it provides you was absolutely illuminating. what we've learned in the outcomes we can see the same thing and get a normal transition course and we are getting breakthroughs of people actually coming forward and talking about demons and they heretofore never talked about before. we've built a network of trust that is lasting, not just an at work in the sense of a transition course but a network that will follow them after they leave the experience. most importantly, what we have learned is the fact that a large percentage and a growing percentage of folks are having mental health issues. and i would say, it's an opinion, but i think it is a pretty well founded opinion, that the number is going to be growing in the future. and i would think that we need experience for the folks that do

deal with the study of a clinician have a better understanding of what the issues are that they are dealing with thank you very much and i will answer any questions and encourage any staff members of your staff to visit and we have plenty to put you down. thank you very much. >> thank you very much. >> mr. schoenhard, first let me to say that i'm jury happy to hear that the va is finally acknowledging there is a problem. when the department as saying there is near perfect compliance any other indication is the major problem and an incredible failure that no one was looking into this. in fact, when you sit at that table before this committee, we expect you to take seriously the issues that are raised here. it shouldn't take multiple hearings and surveys and letters and ultimately an ig investigation to get you to act.

i also would like to suggest that it's the reality on the ground could be so far off from what the central office thought was happening as it relates to mental health and to take a very hard to get some of the other areas of care for similar disconnect. now, what we have heard from the ing is very, very troubling. for months now, we've been questioning whether the central office had a full understanding of the situation out on the field. and i believe the ig report has very clearly shown you do not. as i want to start by asking you today, after hearing from this committee, from veterans, from providers and from outside experts why you were not proactive about this problem of months ago. >> chairman murray, we've been looking at mental health care for years and supported the contras, we increase our

capacity and high year about 8,000 new providers between 2007 to 2011. we relied primarily on the mental health handbook the would be the source of the way at which we would deliver care to the nation's veterans. it has been the focus of the department to ensure that we are getting evidence based therapies and staffing model that was largely based on the handbook put out in 2009. i think what we have learned in this journey, and we have been wanting to work very closely with our providers is a number of things. as i mentioned in my opening statement, the way in which we measure the performance measures is not a good measure of time. we would love to work with the

ig and any other resources to assist us in ensuring that we provide the veteran center performance measure is going. >> with all due respect, i think back in 2005 the ig said this information was there. so that is a long time with a lot of veterans in between. so my question is how are you going to address the gap that we have seen in with a central office believes and what is happening in the field. >> as dr. daigh described in our response to the ig report, we have a number of things going on. one is first, we have a working group that will report this summer on a new set of performance measures that includes providers on the ground in assisting us with ensuring that we develop measures in conjunction with support from the ing that are veteran center don the veterans individual

condition and one that we can revamp and 04 word. we fully embraced better performance measure stickney to be revised, and we will be doing that with the work of people on the front lines to assist us. we have the benefit of the mental health visits that are assisting us. we are learning as we go on other issues having to do with scheduling, and all of this effort is assisting us in not just having people in the central office develop proposed solutions, but to engage the field in a way that we need to in order to ensure the wheeler veteran center and able to support providers and delivering this care. >> i appreciate that but it's very troubling to me that this didn't happen site for ten years ago, that we are just now -- that this connect is there but we will go back to that because i want to ask mr. tolentino --

and i really appreciate your willingness to come forward today and i believe your testimony will be very helpful to address many of the changes that are needed in a timely fashion. in your testimony you suggested that the va institute more extensive oversight into how mental health care is actually delivered and spent. given how that many of the facilities administrators or it getting around the current system at how do you think the va can most effectively perform that oversight? >> madam chair, to be honest i don't have a very good answer for you because of the fact that it is so prevalent. as soon as something is put out is torn apart to look to see with the work around this. i feel that the reporting that is done is very redundant reporting and it feels like it

goes nowhere. there is no feedback loop to the it's one way telling you what you want to hear we did at the facility and the network but there's no coming back and rechecking are coming back and feedback to say well, you said you spend this money on the services but there is no workload to verify. there's nothing concrete to deal to speak on what you've done. in the short time that i worked there, many times we have vast amounts of financial money in different programs. but very seldom did we ever get requests to verify what we've done with workloads, with any kind of feedback reports or anything like that. so i think opening the lines of communication and developing a feedback loop would be very helpful and very transparent at

that. >> mr. schoenhard, my time is up i want to turn to senator brown but i do want to address a very important issue. the department has announced 1600 new mental health care providers, and i appreciate that step today i think it's really needed, but i am concerned that the va hospitals are going to run into the same hurdles that the va has been and not be able to heitor a health staff and i hope that medical centers are doing everything including using all available hiring incentives to fill those vacancies. and dhaka, but we cannot assure you that is the next question this committee is going to look at. but i want to ask you specifically how are you going to make sure that 1600 new mental health care providers that you now don't become 1600 new vacancies? >> chairman murray, that's a very important question, and we have stood up and our human research group and vha work

group to assist us. one is the recruitment and retention of mental health providers with a focus on psychiatry as for the greatest need and a problem and retaining and recruiting mental health providers. the second task force is a hiring task force that is what can we be doing to expedite and make sure that we are having the process of recruitment as speedy as possible. the group is put together a number of recommendations the we will be implementing. part of what dr. daigh spoke of in terms of the four parturition one of the great assets having been in the private sector for many years before coming to the va is that many mental health care providers including hundreds of cheney's today get part of their training in the va and have the opportunity to

experience this going forward. we need to better link with these trainees and ensure that we have in hand for employers when they finish this. >> that's one issue but then how you arrived at the staffing plan is unclear to me. 1600 mental health care providers the youth allocated the information the we got from the department yesterday on where that was going to go isn't supported buy any concrete factors evidence. in fact yesterday directors told senator begich and i that she learned of the new positions only a couple days ago, didn't know if it was sufficient or how the department even reached those numbers. as a, a lot to ask you how did you arrive at that number 1600, and what makes you confident that it's going to be effectively placed across the country. what is the staffing plan you used to do that? >> i'm sorry i misunderstood the question and i'm going to ask

dr. schoenhard who may want to embellish on this but we may want to model what books of the volume of services and i wonder if dr. schoenhard light speed to this. i would be happy to answer further triet >> thank you. yes, it's part of our response to the committee in november we plan to develop the staffing model. the staffing model -- >> you plan to develop a staffing plan that's not yet in place? >> we did develop the staffing model of the was a part of our action plan in november. we developed the staffing model and we are in the process of implementing it in business one or 22 to understand how to amend it. so we don't want to just simply say here is a number of staff without a plan for how this rules out. this is the right number of staff to really evaluate how

well and how effective this methodology is. our plan however also is not to wait until we get a full evaluation of the plan but basically to staff up so we will be ready to implement the plan throughout the country by the end of the fiscal year. so, we will have -- we are planning the planas self is based on identification of existing staff the facility, the population, the range of services offered and the demand for services. and our plan is to be able to use this to protect the needs so that we will let the standard model in the future that is empirically evaluated and we will know how many staff we need. >> my time is out. i do want to come back to this but i will let senator brown and >> thank you. ms. sector coming announced last week the va will hire 900

additional mental health staff, 1600 mental health providers and than 300 support staff to read in response to a question for the record submitted by cementer bull, a poll of your december facilities revealed they were 1500 open mental health physicians. so i guess my question is are these 1900 positions announced last week by the va in addition to those already identified as senator byrd has opened? >> 1900 additional positions are based on what we believe our the needed complement. >> is it in addition -- >> these are additional positions, in addition to those that we are searching to recruit. as a mix of 3400 positions? >> no sir, these are additional positions on top of what we are currently recruiting.

>> use it 1500 positions and now you're saying 1900 -- >> 1500 vacancies, and dr. schoenhard, you may want to comment on this but -- >> who's in charge? >> for the committee let me just clarify these are not related to the number of vacancies, these are related to the number of positions that are needed in the facilities and so we will be adding 1900 positions, 1600 in clerical provider support. in addition to those we are currently recruiting for paris michel long will it take to fill these positions? >> it depends all love a lot providers that we are searching for. >> give me an idea, is it a week or a month? >> it can take four or five months. estimate how do you determine the number of staff and the type of commissions that are needed,

how do you make that determination? >> we are allocating the fte for its distribution to the facilities. we will be working with the facilities in the business. part of what we haven't described here that is in place is a robust system by which dr. schoenhard is working with the mental health leads and with a new management information system that we have in place we of greater visibility to manage the sue going forward. >> this is four or five months still going forward? >> we are planning by may to identify what we want to do that in conjunction with the leadership. >> thank you. but in the interim you have soldiers that are killing themselves and people that need

the services and i know the unit for mental health services in the book also says that you can actually on a fee basis you can actually referred people who need help. so i'm curious when you've read about these things there's such an overlook and break down what is it only 2% per year of the total patient population of mental health sinnott fer non-va garre why is it 2% hit the handbook says you should and could do it? >> yes, we do that where we can where we have shortages, the community as shortages. >> is seems to me based on what we've heard and in the testimony we've been receiving so why don't you in the interim before you work and upload these 1900 people, why don't you get these people out the door and get them care and coverage right away? >> well, sir, first let me clarify for those that need urgent care, we are in and

phatic that we ensure those at risk are treated and referred to suicide prevention coordinator for immediate treatment. >> jack manning needed to cover urgent care and didn't get it and he killed himself. so what is the definition of critical care and immediate care? to me it means she calls and he gets help right then and there. >> anyone that presents with any at risk factor should be seen and treated right away on a 24 our triage. >> but they're not. >> they should be. some of the they are not. >> we try to ensure that they are. >> but they are not, correct? i know the answer so you can certainly just say they are not. we've had some people slip through the cracks. if that's the case then we need to actually of source and use these resources that we have, these other folks that are out there that want to try to help.

we should be doing that. do you agree or disagree? >> ra -- >> do you agree or disagree? >> i think we should take them in our system because we can best serve their urgent needs by ensuring -- >> with all due respect that isn't happening. that's why we are here. the report said there's a breakdown meeting standards and you're not join of handling the individual needs of the individual soldiers that are killing themselves, so it's clearly not working. so my question is do you think we should be sending out more people are not? yes or no outside of the system. >> we do not have the capacity but for those that are most at risk that need urgent care, we should insure that they receive treatment within the va. >> when you're not, correct? i'm not saying every time, there

are instances there's been a problem. is that a fair statement? >> where we do that, we need to ensure that we have -- >> listen, it's pretty simple. are there instances in which we, the va, collectively everybody here, we've let somebody fall through the cracks; yes or no? >> there are instances where -- >> okay, not perfect, in those instances the should we then be making sure that we don't do that again and if there is a problem that we refer them to the appropriate open agencies that can help right away, is that a fair statement? we are only doing 2%, only 2% of the folks are referred out and it's clear there may be some sectors where there is a problem. not everybody and these are the people that are working their tails off each and every day they are overloaded and overworked. if that's the case let's give them care and coverage.

>> dr. schoenhard alj -- >> i will get to them. if you could comment on the testimony that you've heard and comment on the fact that based on your experiences in manchester did you see -- would you think of the testimony from the secretary, first of all, and number two, am i missing something? is there an appropriate way to refer people out like that and is it being done? if it isn't, why not? >> listening to the testimony so far i would like to comment on the hiring practices. it's hard to recruit and fill these positions. there are barriers on the front line that are not being heard at this level appear such as when the special purpose funds come in there for a number of years, one, too, whatever it may be a lot of facilities, many, not just manchester, those positions were being listed as not to

exceed two years were one year to be able to go along with a special funding so they didn't have to worry about their budget in the future and give them the option to opt out. so if i am a psychiatrist or mental health conditions, why especially in this economy and i going to leave a full-time position to go to work for the va if it's on even guaranteed i'm going to be there in two years or that position is to be there in two years, that's the reality, that is one of many examples. the front lines are encountering in trying to get people in there and a second when you talk about the service, it felt where i was at that the fee service was saying that our system was not adequate so we are not going to send people out if we can't deliver this care the we are so proud of that we offer and then when they were feed out, in the

uniform handbook it says that we, the va is then responsible for ensuring the management of the people in the community and that wasn't even because we didn't have the personnel do that. >> thanks for the insight. i also want to -- [inaudible] i will stay all day. this is an important issue, madam chair. i want to talk about the bonus program. you have people getting salaries and them bonuses on performance. i've liked to talk about that in the next round of questions because i think it's important to note if somebody is getting a salary they do their job and just sitting members to get a bonus, i find that a little bit surprising. so i would like to talk about that and i will refer to the next round. islamic absolutely and we will have as many rounds as necessary.

>> thank you, madame share. i want to thank everybody that's testified today from a world perspective i will tell you one of the reasons the vhf contract in a state of montana is because the private sector doesn't have any more mental health professionals and the va, and i just want to point out because it's mental health professionals whether it's in the private sector or the va, getting these folks is a big problem and i very much appreciate mr. tolentino nobody's going to go to work for a year or two years when the private sector has much more predictability in their jobs and we need to take into consideration when we start allocating dollars for the va to make sure they have the advantage to be able to compete and i very much appreciate that perspective. along the same lines i just want to have senator brown was right in the area of 1500 positions open and an additional 1900, so there is about 3400 positions

and it might not all be psychiatrists. they might not all be clinicians', but how you are going to fill those in an area of the private sector is sucking folks up. do you have an allocation of the 1600 folks and if you do -- could we get a list of those that are going to be allocated? and i know you talked about metrics, number of veterans and that kind of stuff because you give me a list of metrics on why the numbers, are there how many are going to be psychiatrists and nurses, clinicians are any of them going to be psychologists? >> we are leading to the discussion of the facilities. it could be psychologists, it could be -- >> when it comes to contracting out, do you typically only use psychiatrists or can you use psychologists, too?

>> we can contrast with others. >> there are some accessible the of those folks. i want to put into things that mr. tolentino said along with major general johnston and major general jones i want to thank you for what you're doing. i very much appreciate it. mr. tolentino said when he was there he said it was fairly common if someone came in with a problem, don't ask if there was another issue. there's all sorts of correlations that are wrong. i just want to tell you okay if that's done, and i believe he's probably right because then we can pay a problem but to combine them with what major general jones said the folks that he's working with some of the major stress is unknown we've got a problem in our system here because the only way you are going to find out how to get to the real root of the problem when it comes to mental health, and i'm not a mental health professional, you've got to find

out what the stress is, what created the problem. does that kind of -- let me just ask you if you had a va professional and one of the hospitals tell their people don't ask any questions because we don't want to know, i am hoping that doesn't come from other end, why would they do that? >> if that is being done that is totally unacceptable, and we will review the situation. we have a review going on in manchester and we will continue to follow up any time that that occurs because -- >> i'm going to show you a lot to do it in every visit we've got. that's just my opinion because it's totally unacceptable. we are not going to get our arms around this. you have been built this hand

with multiple deployment of the mental health issue is a big issue, and it is an issue that quite honestly we don't get our arms around it there are going to be more and more people slept through the cracks whether we want them to or not that's the way it is. and i just, you know, our use in the private sector is important to read partnerships we develop our important. nobody wants to dismantle the va but when it comes to mental health issues at all hands on deck. lastly, i just i have a bunch of questions here that were written up. the metrics that are used and the access to care metrics are said and it might have been you, those that are being applied, i

don't know if this is the same thing or not the the report means it looked like people were getting the treatment in a timely manner when they were not. >> i think that the problem is that the schedulers were operating consistently by this rule that said you should schedule the appointment according to the state that was desired, and the desired date, what is the desired date is it with the patient or the doctor wants. and the to and from of the scheduling i think the va created a metric for the business rules for which are not supported in the systematic way. so when you look at the data it isn't usable from my point of view. that is in large measure a part of the problem with the access measures across the system. we also hear reports of people

trying to game the system, but i don't have evidence that i can give to you. i certainly can say we don't think that it accurately reflect success in the va. >> one last thing and then this will be the last one. there's a stigma in this country and probably in the world but definitely in america, the united states, a tax to the mental health. i have multiple stories about folks who won't get treatment because they are afraid it will be on the record read the want people to get a job or it might affect the job they do have, perception my family, friends, colleagues. as the va have an active education program to try to reach out to those folks to let them know that this is part of -- as major general jones said it's increasing, it's growing and it's not uncommon and it is

okay. is there some kind of educational outreach going on? >> yes, senator, there is to make the connection initiative that has just been undertaken. it goes back to the primary care integration of mental health where we are able to scream for ptsd, and the other aspect of care that we haven't mentioned today is the federal centers who are also ways in which veterans can approach for health if for whatever reason they have to be reluctant to access the traditional system. >> i agree, and before going i want to thank the chairman for the length. i just want to say thank you for all we do. look, i put my self on the line every day because you have a big job to do. but you've got to make sure that what's going on up here with things that the chairman says

and other people on this committee that it actually gets to the ground, because we are hearing things are not going so well in some areas. we sure that things are going fine and others and mental health is a huge challenge and it's not easy, and please come to make sure that it gets to the ground, and if there's stuff like mr. tolentino said about every dollars, to every money, i wouldn't take a job like that if it was in demand so let's figure out how to fix that instead of how to make it work and also by the way because we have in my state a good job and others let's find out how we can dovetail on things like what major general jones is doing because that can be an incredible, i mean, you know, whether you are fishing or riding a horse or whenever i don't care those can be incredible programs to get people back on their feet. thank you very much, madame chair. >> thank you, madame chairwoman. secretary schoenhard, i was pleased to hear the va announce its plan to hire 1900 mental health workers, and then i was

additionally pleased with the announcement yesterday about a family therapist and a licensed professional mental health counselors. might discourage it is how long it took for them to implement. i have a history with particularly those provisions that in 2006 congress passed information technology act and part of that act was a piece of legislation on introduced to encourage some of the rice and insist that you haulier those professionals within the va, and now five and a half years later it is occurring. so, while i think i will stay on the positive note, i am discouraged by how long it took but i am very pleased at this point in time to see that you move in a direction. and i encourage you to tie your those people that put them to work as rapidly as possible. part of my interest in the topic is coming from a state as rural as kansas, in which our access to mental health professionals

is perhaps even more limited than more urban and suburban streets, and we need to take it vantage of the wide array of professional services are available at every opportunity. and so, i am here to encourage you now that you've made this announcement let's bring it to fruition, and thank you for reaching the conclusion and getting us to this point. i want to direct my question to general jones. thank you very much for your semper fi odyssey efforts. i have a kansan visit me the last month that has organized the program -- i don't know if it is modeled on the same thing you're doing the same kind of focus and effort -- and its somewhat related to the conversation of the questions of senator tester about kind of the stigma or the lack of willingness to at net delete to admit one needs help and lack of knowledge of what programs are

available and how to connect the veteran with what's there. and i just want to give you the opportunity to educate me and others on what it is that you've been able to do to bring that figure and that isn't likely to know of the existence of your program or programs like yours, and second, what can be done to overcome their reluctance of military men and women and veteran's to access what is available such as your program. >> first off i think that the semper fi fonted i've been a board member of provides the ability for these veterans to come. admittedly most of the veterans that come back to the case workers of the semper fi fund have some problems or they wouldn't be there. they've had a difficult time making the transition. so when the life in western pennsylvania for one of the weeklong sessions, they arrive

with a major degree of skepticism and we try to restore them to what was the strength of their experience in the marine corps, the cohesion, team building and basically restoring the trust. i would say -- trust in the system and others. i think my work for the semper fi odyssey because of the mental health professionals that have come in and really are brought into the program and have advertise the program and allowed me to speak to other groups led to a project i'm doing with the institute of the defense analysis sponsored by osd that looks at best practices. i was a marine for a long time. we never talked much about mental health issues until

recently. as a vietnam platoon commander, we never talked about a spirited but now there's programs in the marine corps and i would say the army, too, comprehensive army, marine force program that's operational stress control and readiness, it's a great program. but it's not easy to overcome the stigma and the program rests on the strength of the nco. no major general was going to read into a squad of what to our company and build an immediate trust. it's going to come from the nco. so overcoming that skepticism from overcoming that chasm of trust is difficult but it's happening. especially the units that have deployed four or five times coming down the nco officers are seeing the power of with a squad leader or platoon commander can do to identify problems when they are still in the category of the stress injuries and have a migrated combat stress illness. i think that is the strength of the marine corps program.

a think the problem with my opinion now of the army program is very well built. the application isn't focused on the young nco as the programs. the in co identifying an iraq or afghanistan but there's a problem you to stop the dialogue right there and it's on the record of the process you don't have to wait six months after he turns and he's got this problem he pulls out then when he is by himself, said he tries to restore very successfully restored because of these veterans have come in and fall into the services. this past week we get 35 marines. we have an individual travel away from oregon. his brother was killed in vietnam as a company commander. he himself was a marine corps officer, the ceo of the first business he's given up a week of

his time to really have an orthopedic surgeon coming from wyoming. it doesn't take a phi beta kappa that these people are getting a chasm of trust taking care of pretty quickly. i would say by wednesday of the seven day program these people start realizing they care, then you are on the road to the edification. that is in the demons start coming out and find the guy is company commander he feels guilty irrationally but true he's never started that with a commission. that's why when you find out a guy in his apartment in wisconsin for two and a half years, the only person he talked to is the clinician and he's never divorced the clinician he told a marine accidentally because the sectors are in line with each other. so i think that we have no foolproof system but the power of the core and of the army

clearly has changed and cohesion and trust and if you can restore that then you are on the road to a good program. there is no shortage of people that come and chronicle their experience and they are not damming the condition that all but it is simply not understand the individual to build that bond of trust. it's been a general, thank you for the service to the country and other veterans and thank you all for the interest and well-being of the nation's service men and byman. thank you. >> thank you very much. dr. daigh, let me turn to you. as you know it's hard enough to get veterans and to the system to receive bedle health care. once a veteran does take effect to reach out for help, we need to knock down every potential barrier to care. clearly the report your team produced a huge gap between the

time the va says it takes to get the veterans' health care and the reality of how long it actually takes them to get see at facilities across the country. now the va has concurred with all of your recommendations, but i think it's clear we all have some real concerns because some of these issues have been problems for years. so can you address a question what you think it would take to get the va to get this right this time? >> i think to begin with, the population gets dispersed across the country and the va isn't evenly dispersed across the country, so the veterans that go to fixed facilities and receive their care i'm guessing is trying to address the current plan for 1600 people i haven't seen the details of the plan

comes of the first issue is to realize you have a problem where you have facilities and you don't have facilities. and i think the second problem is that as it has been stated here, there simply are not enough mental health providers to hire off the street in a timely fashion i believe. we looked the other day i think there's something like 1200 psychiatry graduates a year in this country from our medical school. so there is a limited pool and there's a great deal of demand for mental health providers in our discussions with because the downturn economy and other factors in dimond military command had also gone up in their experience of ten or 20% the last couple of years. i think we were asked several years ago to look at access to mental health care in montana, and it was a very