partnership with specialists societies beginning to issue under the program called choosing wisely eight top-5 list with the radiologists say these of the top things that we are letting that we should stop. not the health plan, not the government saying stop, but the leaders of the specialists saying, we should not be doing routine mri some patients with uncomplicated back pain because it is low-value care. ..

first, providers are validating my creasy. hospitals are by another hospitals. medical groups are fighting each other. hospitals by medical groups. and on and on. everyone is trying to put themselves in a position to receive this value-oriented event in two makers of the organizational capacity you have to have. for instance, to prevent post-soviet nations. second, i.t. is necessary and under dr. blumenthal's leadership, we taken great strides to make sure the industry as no more than five or 10 years behind most american industries. the kind of changes we talk

about can't be achieved without a digital medical records were busy quite quickly in that direction. thirdly, i do want to pay a special shout out to the safety net where problems particularly challenged. the public hospitals are probably the only places where value payment is enshrined in law and they will need particular support and help to get over the notion that moving to value-based payment is inevitably bad for them. i played to not only support the goals of cpr, but the 20% is actually achievable. as a catalyst's energy applied a system which went tickets going continues on its own without additional support. cpr is by no means the only thing happening here. patent reform is not the only thing, but in our view of the distal to the energy will be

disclosed the achievable. thank you for all your work. >> thank you, dr. smith. now we can turn it to the audience and see what questions or comments you have. a microphone will be passed around so those listening online and on camera can hear you. if you please identify yourself, too. >> mike miller, health policy treatment medication. by my calculations, medicare has 35% of their release in touch by some kind of value-based reimbursement system. i'm wondering how the 20% figure was derived that. if you think the medical industry is lazy, greedy, some combination of the above. >> want to declare the data we report or just a commercial daughters on trade dollars.

in our case, when we look at the data path has said what he was a ge they health plans that were around 1% to 3% of pay that. 20% of the goal was somewhere between extremely vicious and realistic. you hired your question correctly were talking about the number of beneficiaries touched. that is different from dollar stash. the only way trade paper attached up with the magic for benchmarking purposes on how many patients are an attributed model of some kind. i don't know what the answer is in commercial dollars, but that gives you some insight and two the 20% goal. it looks like wearing a fast track and we make it there before 2020 in which case we are a catalyst we will think ahead about how to raise the bar is the challenge. other questions?

>> i'm brustein won't. i recently a few years ago retired from the government accountability office. i'm sure many people to survive at the recent "time" magazine article that emphatically made the point that one of the reasons we have a low value health system is because the price is providers demand are so high. compared to other countries but also within the united states and other health systems. i wonder if the panelists agree with sadr to what extent they agree and if so what can be done. >> this is elizabeth and i'll just start with a response. that is unlike any other industry that we all touch and interact with, and industry in which there is very little transparent sea in terms of cost and quality data.

historically speaking, it wasn't feasible or possible for consumers to easily access information about the cost of care. i think the times story that she references an illustration of individual risks and challenges associated with this strain apparently. further health land perspective, in 2002 bp can actually publishing the prices of certain services for consumers to access through our online directories and member tools. since then, with 50050 episodes of care priced in total across in interpreting radiologist and the mri health price with the cost at the clay county hospital

versus a freestanding imaging center and the health calculate not only what the cost is so a show that charged the provider may put forth, but we also showed the discounted rate and with the patient may pay out of pocket. they correlate that to quality data. he is industry available data from leapfrog and see msn data from around repositories where we have an opportunity to provide additional information. the challenge is twofold. suzanne mentioned when she reviewed the results a part of the challenge is getting our health care consumers comfortable the technology. as a couple things purchasers can do to drive by. one is to create benefit design that encourages consumers to be selective shoppers and that means putting different price for different benefit levels that different sort of sites of service are different network

options to help drive patients to price shop, to price compare make informed decisions. i think we see the industry moved there, but i will say i think we have a significant opportunity to continue engaging our patient population. importantly, we have a ways to go in making readily available more broadly cost and quality data from the provider. >> you wanted to comment. >> i'm glad she brought data. i don't know an employer who doesn't find it outrageous that people don't know the price of everything when they want in the way they wanted. i applaud the plants trying in their way to get there they have made some progress. until we amazon to fight this thing and a simple to do like anything else at the adaptability, we're a long way.

i think it was a great piece. sunshine is still the best antiseptic and i was a nice beginning to pay sunshine on the topic. >> all just make one additional comment that is also part of the underlying, may be less obvious message. it does underscore the concept of supply and demand. one of the things we are starting to see and i'm sure that aetna sees it as well as we increase the transparency not just a quality, but also a cost, we have an increasing number of employers that are starting to say, i don't necessarily want that hospital and may not work that is charging twice as much for that inpatient stay without a corresponding twice as high level of quality. i think the transparency is an important piece, but there's another import element as well.

>> for anyone is interested, cms -- i'm sorry, cpr will be hosting a national summit on the topic on june 11 in d.c. carter national summit on provider to air the issues and have an open and honest debate about what to do. there's a question online from.here jill selin about the work on developing a domain episode of payment if he could comment on not work as a partnership at brandeis. >> one in the program we are working on is going well and we have announced 48 episodes that will be central to that program. the episode based in program is

moving well. on the other side we are making good progress in developing a career. i can't give you a lot of insight other than to say we are moving forward and i believe will benefit tool. >> thank you. we have time for one or two more questions in the room a close to. question on the front row. >> i., jennifer lavelle with american medical news. one thing i haven't heard yet is the patient voice. you talk a lot about physician accountability. what about the patient accountability and proven quality and lowering costs? i see people who are overweight, patients who are taking medication. i'm just kind of wondering,

where does the role of educating the patient -- a mention patient navigation, but it wonderfully could hear more about that particularly from dr. smith. >> well, first of all, almost all patients are increasingly able to pay financial consequences. even insured patients are increasingly exposed to financial consequences of ill health. it's worth pointing out the skin in the game argument bothers me a little bit because the patients are the one throughout the most skin in the game and they do suffer consequences, physical, mental and financial from bad health decisions. it is important for them to be educated. we also recognize financial consequences have import role in educating them, but i'm not sure how that's related to this discussion directly.

maybe somebody else has an answer. >> i was going to quickly save for my employer is, we do think we are taking it from the give of our employees and their dependents as well as retirees. we have to take their view on this and we've tried to set up programs in a way they benefit. in essence, we are no more, no less than our employees and their health is what brings this value. >> i think it's a great question. when you talk about paid them based on quality, they will face on his mind, the sum is the patients. i don't think were going to be successful unless we marry the two. there is a lot going on. the value-based incentive is on the education, some of the stuff marked up about. it just wasn't today's topic.

is one side and you have to have the other as well. >> thank you for those comments. not only are people's bellies rumbling, but were at the end of time. i'm going to remind everybody there will be recording if you want to pass it on to colleagues posted today at 12:30. if anybody wants to keep up with the work, sign-up for updates. i want to thank the speaker so much. the two foundations and the cpr staff and everyone else who helped bring us to this point today. thank you so much for coming. [applause] [inaudible conversations]

>> veterans health care analyst discuss the issue of suicides among returning combat veterans of the treatment of mental illness. bernie sanders chairs this committee. it's two hours 20 minutes. [inaudible conversations] >> this hearing of the senate veterans committee is beginning and i want to start by thanking all of our wonderful panelists who have years of experience in

the areas that will be delving into today and i want to thank them very much for coming here today and i want to thank the va for being here as well. as i think we all know, it is now 10 years since the united states went to war in iraq, went to afghanistan and what we learned in a variety of ways is the cost of those words has been very, very high. david hyde not just a note tragic loss of life we've experienced, not just in terms of those who come home without arms or legs or eyesight or hearing problems, but also in terms that will be called the invisible wounds of war, which are quite as real as any other kind of wood. those winds include

posttraumatic stress disorder, ptsd, traumatic brain injury, tbi and systems associated with the serious illnesses. further and tragically, the serious problem of suicide. we are losing about 22 veterans every single day as a result of suicide. that's more than a dozen veterans every year. while suicide is a major problem in the united states as a whole for civilian population, it isn't terrible tragedy for the veterans community and dissent that we must address. i'm a preface my remarks today think everybody understands the issues we deal with today are very, very tough issues and if anybody had a magic solution to mental wellness in general, trust me we would've heard about about that a long, long time

ago. were going to do our best to figure where we are in terms of needs of our veterans going forward. everyone is in agreement that ensuring timely access for high quality mental health care is critical not only for veterans but for their loved ones as well. what we hear today from our panel is mental health issues impact model that the soldier or the veteran but the wife, has been, children as well. our goal must be to ensure veterans get the best mental health care possible and make it in a timely non-bureaucratic way. how the health care is delivered is of enormous comp points. i went to commend the va for its work in this area. the department has made import straightforward in providing

mental health to her veterans. in fact in many ways, the va is leading the nation in terms of ptsd research, that clearly with all of the accomplishments, much, much more must be done because we are and training to an area that is impacting tens and tens of thousands of veterans and we must find the best solutions we can. we know that her veterans to the adult care services be done quickly. today all first-time patients referred to requesting mental health care services are required to receive an initial valuation within 24 hours in a comprehensive evaluation within 14 days. in april of last year, the office of inspector general found via jay was not not

beating benchmarks. some wait 50 days for an evaluation. if someone is struggling, hurting and terminally come if someone is drinking too much, doing drugs, weaving 60 days is not acceptable in that is in fact a deeply troubling thing. a year after negative findings it appears the va has made progress in implementing recommendations for the ig report and in many ways people are now as i understand it getting evaluations within 24 hours. that is an issue we will explore this morning with the va. the point is people are hurting. we need to get them in the door, get them into the system and waiting two search is absolutely unacceptable.

one issue that i remain very concerned about, both in the va and also the health education committee is not just a veterans issue. it is an issue for an entire nation is the shortage we have in terms of mental operators. the long wait times i mentioned are caused by staffing shortages. and the secretary should seki has implemented the executive order to hire new commissions and as of march 13, va has hired within 3000 mental health professionals and industry to support including more than 1100 new mental health can shins. this is good progress towards reaching the va school. however, i am concerned, very concerned to va has hired 47 clinicians in the last two.

i think we all understand the challenge here. you want to make sure the people you hire our well-trained and are the quality that her veterans deserve. clearly the va must step up the pace to meet its goal of 1600 new clinicians by the end of june of this year. in order to meet this goal, the va will need to hire almost 500 clinicians in the next two months. frankly i don't see how that's possible only want to talk to the va about how they move forward in this area. the goal is not bringing people into the system, making sure they are good quality. we have to get people in the system is rapidly as we can. it is clear we all want veterans to be seen by properly trained mental health others who can

provide the high quality care veterans deserve. the va has made important steps in this area. clinicians are turning an evidence-based therapies such as cognitive behavior or prolonged exposure. while clinicians or train and therapies, the va must do better job of tracking utilization to ensure clinicians are trained to do is put into part is all across the country. access to timely high-quality care only matter if the care is delivered to veterans in an appropriate way. va must provide care and operating settings to meet the needs of each veteran. medical centers, outreach clinics, vet centers and health services each play important roles in appropriate care delivery. the medical centers treat the

most severe cases such as ptsd. your critical investing needs of patients admitted to the hospital for physical injuries. i am a great supporter and i'm not sure we utilize tennis matches we should. that provides a safe welcoming homelike environment for veterans who receive care both on one counseling as well as group settings. veterans often feel comfortable in the nonbureaucratic environment. additionally, often closer to veterans homes of certain situations, see back for veterans to clinicians at va medical centers and has done an excellent job in terms of total health in general. it's critical va provide options of care. they must ensure not only option to made available for veterans

know about them. the next hearing will have is a reach general. you have the best are in the world et cetera doesn't know about it, does nobody any good at all. while va has made strides in improving the full bench and mental limits to more to ensure better prevention for today's series amendments, veterans of tomorrow. the army and we are all aware of the frightening level of suicides as members of the armed services of approximately one a day and based in large part in the affairs to task for some behavioral health completed a comprehensive review of behavioral health care reports provided multiple recommendations for improving mental health counseling. what we begin to also understand

as a soldier is a soldier from the first day in the military to his last day on earth would use in va. the continuity of care has got to be extremely important. while we often think of the military and vas providers and mental health care for servicemembers and veterans, community organizations like the ones i will testify today play a key role in helping veterans access care they need. these organizations partner to identify veterans in need of care, work to help them prepare and provide direct care to veterans. we will hear from this wonderful organization and i want to thank you call for the work you do in thank you for being with us today. i'll be introducing you in a few minutes when you testify. these organizations do not shy away from the worst consequence is including suicide.

in my home state of vermont, the vermont national guard has intervened to prevent suicides from occurring and that is true with all the recommendations here today. let me just conclude by saying the issue we are dealing with today is a very difficult one. it is an issue of enormous con going. it is an issue that impacts the lives of tens and tens and tens of thousands and in women who put their lives on the line to defend this country whether as ptsd, traumatic brain injury, suicide. these are issues we must tell them to and improve our outcomes. thank you for being here and i like to give them might be senator burr. >> thank you, mr. chairman. thank you for calling the hearing. i welcome our witnesses today

and look forward to the insight you can provide. kim and jake, thank you for sharing your experiences with us. i know some of that will be painful to recount, but we are thankful for the site and it's important we hear first-hand veterans, families and friends about the experience and seeking mental health services so it's absolutely vital to us. mishearing follows three hearings last congress. the barriers faced in facilities after the first hearing, va requested senator murray conducted a poll of mental health care providers which painted a stark picture of these mental health program and ability to provide care veterans need. the committee requested the

inspector general audit the program. the ig found schedulers for not following direct gives a sketch and appointments and providers frequently scheduled patients for follow up appointment based on availability, not the clinical needs of patients. history that a complete break down and in response, today announced the hiring of 1600 mental health providers. on one of the va has admitted to having a problem, i still have questions regarding the initiative. for instance, a staffing analysis to determine the type and how many are needed. there is not enough space and mental health clinics. i can't help but wonder where additional staff will be placed. i believe the problem could be larger than providing mental health services to a current

generation of veterans. va has seen an increase not only for veterans of iraq and afghanistan. va has cemented greaser mother generations as well. that centers on this veterans returning for counseling as vietnam veterans seek services we will find ourselves back here trying to fix the same problem. while va has authority to improve access to mental-health services by by changing outcome measures, hiring staff and fixing broken scheduling processes, va can't fix the problem alone. being is to look outside the box for answers and engage the private sector and charitable organizations for help and trading services without a realistic plan that finds partnerships with providers and charities. the outcomes of a staff analysis

and the internal problems won't see improvement in health services especially with those veterans who need it the most. it's a problem that cannot be solved with one or two changes. nec comprehensive approach to incorporate solutions within and outside the system. what is that all mean? i still think we are hung up that process and not with outcome. we are hung up with how many people to my higher? have we got enough access versus 16 people in the front door and out the back door they are well. if we allow mental health to be treated the disability claims backlog where we focus only on how many people we can higher, i assure you we look at the [inaudible conversations] home and about what they can to

grow. we've got to focus on fixing case. there's got to get the talent we need to try to sit inside or va is to fix these kids make sure they are better in the back and. finally, i want to take a minute to address the terms regarding the quality of care issues in a single use the amc and going issues. i'm more frustrated with how congress was notified. as a prior discussion on this is not the venue for it, but it should be the focus of the committee with the appropriate folks from the va appeared mr. chairman, i want to encourage my colleagues if he can pass opening statements to it today and limit your questions because we want to accommodate the panels before we

go into this. thank you. >> senator tester. >> i've just had to say a few words. coming out of iraq and afghanistan this has been here forever. if we'd had achieved mental illness in a way that was to take her, this issue would be here. i want to say i think the folks working in the va do need to think outside the box and when he take it more crowded rural places like montana and i'm a little proud to beat them anyways. i don't think this issue is going to be solved tomorrow. it's going to take some time. if we work at it together and don't call for resignation to work with and, we can get a lot more done.

>> thank you, senator tester. senator johanns. >> thank you, mr. chairman. i am mindful of his upcoming appeared so i'll pass on an update statement. if i have anything else to do for the record. >> senator isakson. >> let me introduce our wonderful panel. we are very appreciative here with us today. we will hear first from jacob wood, cofounder of team rubicon. next a fellow vermonter and a team leader for this veterans outreach program and then the director of the tragedy assistance program for survivors, kim ruocco. next come the retired lieutenant colonel and a council at the national alliance on mental

health, kenny allred. we'll close the panel with.here barbara van dahlen. it thank you for the work you are doing in the testimony you're about to give us. jacob, let's begin with you. >> please bear with me i reach you a few names. nick cham, jan then, stewart, roscoe berrios, rocha, clay on. to decimate my unit redeployed after a long lady to her in afghanistan could in seven months the last 29, suffered 2000. they need to edwards among those statistics. the names they register mad with in the last four years, two suicide while pursuing peace

with the last name, clay hunt plunked my dear friend and cyberpartner. a dear friend and incredible humanitarian. they help me start an organization called team rubicon which uses skills of combat veterans for service following natural disasters. my cofounder and i launched team rubicon in 2010 and a right to few days after the devastating quake struck, prorated triaged in port-au-prince using principles of warfare to mitigate risk, move quickly come again the trust of an unstable populace and render critical medical aid. after clay suicide we realized that critical truth. as a veterans service organization is the natural disasters as an opportunity to continue the service and regain what they've lost in the military.

many will take the jobs of education or access to health care is okay for some kind of themselves at home but i'm going to argue it's much simpler. returning from a decade-long war suffered from ambiguous leadership, an unclear mission in anticipation disinterested public takes a mental and emotional toll on servicemen and women. picture cowboy from omagh, nebraska. bme sensitive to can't think camp and gives him a rifle. this young man spends 12 months lease has been outside the wire and checks his comrades from attacks. he has purpose. i can think of where he checks his men insuring the would they need. they laugh together and cry and cry together and he is a community. hope unit returns home. he wants her in his uniform.

a few months later he returns home to nebraska, gets a job in reconnects. soon he discovers a seriously. no joke in the case of purpose he felt and can't resist the community has left behind. it will never give him the identity he wants, proudly wearing the uniform of this nation. but to his own devices he questions his work because everyone around him questions. he traced just by lesbos, taken in the code and output devices. the threat is no liquor imminent. we team rubicon with the foundation reason those concepts. purpose, community and identity. helping those affected by disasters, veterans not only

help neighbors, they help themselves. are better in some place goes to war. comment by nick street to children in those refugee camps and squad leaders bring order to ravage communities. when disaster strikes they will once again they set their boots answer the call. they look around and discovering new band of brothers. men and women with a similar because her community. they wear a t-shirt with pride belonging to something bigger than themselves. earlier invention community. today's servicemembers come together from across the country to form taking units. when they leave the military they go back to his internet connection, the brother had the head of the service. the help of a veteran community of also cofounded a technology company called paul's throat also inspired by clay hunt when

a dispute i discovered three marines who lived within 10 miles of the surge in iraq. clay had not been allowed. frustrated at the inability to connect with one another after they leave the service, we set to solve the problem with the most ubiquitous tool, our smartphones. using the gps capability we created an application for military veterans that connects that's been out communicate all around them. it serves as a platform for organizations helping nonprofits reach veterans to provide critical transition services. we hope to connect based on proximity to resources. the app serves as a of foursquare and requires cooperation of the federal state government proven to determine to succumb to some for you underfunded startup. it is my humble opinion at the

root of this issue these three core tenets. purpose, community and identity. team rubicon and is trying to created community through an innovative online tool. thank you for your time. >> thank you very much, mr. wood. andre wng is a team leader for the out reach program. >> chairman sanders coming thank you for your invitation to discuss the outreach program. i've been a better in majors since april 2010 and in that time a team has conducted assessment survey said 4300 veterans to discuss needs the needs of families. the program has evolved and expanded beyond its mandate of helping on the oas and oif veterans.

we also assist members from other conflicts. one of the reasons the program has been so successful is our grassroots way of doing business. we are the ones working with them to find what they really need. the issues range from health care, emotional support, homelessness, employment or financial assistance. one of the most innovative components of our program is the veteran at evisceration medical center and liaison established to help veterans navigate the system. the liaison is located at the white river junction welcome center the entry point to the system for vermont. average specialists will establish a santana to someone who understands how to navigate the system effectively. the liaison works with many

walk-ins, which are typically active-duty veterans to come on their own not realizing how overwhelming the process could be. in addition the liaison attends the va patient committee meeting, which discusses ways to improve relationships and how to best implement changes. 11. calls come to the services and allow us to act in situations in a timely manner. our outreach establishes relationships as well to the

islamist cause to assess the situation and call upon services as needed. have established a strong reporter with the oes oif manager. this relationship has helped my team capture one fallen through the cracks. i received a call from a mother in florida. her son come a veteran is struggling with since its abuse and ptsd. she flew him to vermont from a team picked him up at the airport, brought in to the administration medical center where he was enrolled in an outreach program in half with a disability claim is she. veterans completed the program successfully the night contributing member of the community in colorado.

with this partnership we facilitate care in vermont and the veteran may not be here today. the mother told me my team saved his life. waterboro state that does not have active-duty military solutions, nor an established transportation infrastructure outside of her largest county. for that reason, specialist transfer veteran in the way river junction va for their first couple visits. this time reduces time available to comment other veterans. this time is in reality a short compression. for the servicemembers. faced with helping a soldier in front of them, the specialist tends to more immediate needs. the person-to-person time spent with each service member is an

important component of our program. many veteran could not afford to travel but didn't have the transportation and thereby jeopardize their health. a critical piece of successes followed the servicemembers. specialist account owners for a follow-up plan needed for veterans. to make sure they show up for their appointment with the va or get them link at the community partner such as veterans inc. or financial help for department of labor or currently serve at the bottom line is we establish a relation ship with veteran families. we have the resources, skills and tenacity to make sure veterans get the services they

deserve. our hope is to continue this work until every service member and their family that he thought itself. thank you for the opportunity to discuss the outreach program. i look forward to answering any questions you may have. >> camber rocha was director of the suicide prevention program for survivors. thank you for being with us. >> i am honored to present the testimony. last year we welcomed 931 people who have left the military in transition back to the community. two people per day seeking help in coping and at least 19% of our current caseload. these numbers are higher because

we as they came in not admitting his suicide or different cause cause of death was due. we have a supportive comprehensive care to families with more than three dozen family members with death a suicide as of today. survivors receive multidimensional services including trauma support, emotional support and reduction among survivors. my name is kim ruocco and the surviving widow of marine nature, john ruocco who died by suicide 2005 preparing for his second combat tour for iraq. he died soon after he returned from his first one. i'm direct your suicide professions and survivor care support and a clinical social worker. i'm speaking about challenges facing veteran in getting mental health care.

my testimony presents cases with family members shared information on this issue. they've come to a seeking support. services for veterans can be improved online saved. many common themes emerged while talking to survivors in the death of the recent veteran and one can almost paint a picture about not of a veteran who died by suicide. after being discharged from the veteran struggle in multiple areas of their lives. they usually are not discharge of the treatment plan or appointment. they attend college but have trouble accessing benefits and disability benefits to later denied. they this trouble to find employment and if they do their concentration problems that prevent them from keeping their

job. fiscal injuries complicate the situation further. stress begins adversely affect relationship. the servicemembers become various to their own care because of these issues. people not on the cannot stand in line or crowded waiting rooms or wait two months for an appointment or tolerate turnovers for those who are not seen are frequently changing. it does not have to be that way. suicide is not inevitable. there are many good mental health care is that the bbc treatment work among veterans are taken into the system and really get the kind of planning care they need. to focus on the barrier is getting the treatment.

if the use of the va, but few know b.c. calc, but veterans do not know or believe initially treatment can work. they don't really know what treatment as. they need to be educated how mental health care treatment can work. it is vitally needed for this education. many veterans still a seeking care because the stigma of mental care. when they go there so sick they can barely function and need immediate care not often available. a media campaign to get veterans in earlier and demonstrate what looks like and show them work. it would help get them hurdles and those in the two urgent care

or quickly. he can play a vital role in helping veterans access benefits and support them in between improve connections and nongovernmental agencies to help more fully integrate support programs. these improvements can help save lives. we have the following recommendations on the information gathered. provide more funding for programs to assist veterans. number two, i find care advocates of first contact to support the veteran to veteran described mental health treatment and emphasize treatment can work and highlight the reward of working with veterans serving your country. thank you very much.

>> thank you very much for your testimony. kenny allred is a retired u.s. colonel and military counsel of mental illness. thank you for reading this. >> distinguished members of the committee, the national alliance on mental illness is grateful for the opportunity to share our views and recommendations regarding the va mental health insuring timely access to high-quality care. as my full statement is part of the record, here for the summary. nami addresses veterans mental health care issues and works forward to working closely with the committee. nami is the largest grassroots mental health organization in the nation dedicated to building their lives for millions of americans including warriors, veterans and families affected by mental illness.

i'm proud to lead the nami council. from 1970 to 19 indian army airborne ranger infantry officer committee leader in military intelligence battalion commander of a mixed gender unit. i'm a member of the american legion, military association of america and i've used the health care system for for 23 years. i offer the following key points. has critical scarce resources have full and transparent accountability. we fully support adoption of the recommendations in the fy 2014 independent budget while keeping stakeholders fully informed. nami urges funding for research to keep pace as other areas suspend aid, particularly with respect to reduction, readjustment prevention and treatment of post-dramatic

stress and substance abuse and increase funding and accountability for evidence-based treatment programs. veteran unemployment is higher than civilian unemployment in especially high among our younger veterans. our national guard and reserve, many in remote and rural areas to military service often as their only employer and many are not eligible for benefits and health care. nami supports hiring preferences for all who served. between two believes reducing stigma and suicide prevention is a change in our approach. some acceptable veterans have grown from 18 to 22 a day. in 2012 deaths among soldiers, many who never deployed are higher than combat that. support accountability, collaboration and action to in the statement that tells treatment.

nami believes a purple heart for all combine inducements will encourage and reduce stigma victors must be held accountable unwritten performance evaluation for eliminating stigma and providers and disciplines must provide we encourage veterans to seek treatment. two in the stigma of invisible ones. the nami memorandum offenders handing out saudis should be expanded. action is needed to energize those to improve and encourage mental health and expedite claims processing. technology to consolidate appointment to reduce travel expenseto deliver

counseling and increase community providers to create a hometown stake in veteran recovery and build a sense of ownership for the total cost of military service. veterans within 14 days of their mental health complaint and approve compensation and pension claims for veterans at the diagnose mental illness but did 30 days. expand outreach to underserved populations in pitied women, student veterans, older veterans and other diverse. in summary, barriers to mental health treatment can be eliminated and recoveries possible. we must and epidemic of suicide now the horrific rate of almost one each hour. the long-term costs especially if it does not now.

duties to the committee we look forward to working with you to improve the lives of all veteran and their families living with mental illness. >> kernel allred, thank you for your testimony. dr. barbara van dahlen, thank you for being with us. >> chairman sanders, ranking member burn them or said the committee, thank you for the opportunity to provide testimony. as a clinical psychologist and daughter of a world war ii veteran and owner to appear in proud to offer assistance to those who serve. the department of affairs amidst the print organization and our nation's effort to ensure all who wear the uniform receive mental health care they need. the va has worked hard to keep up with the growing demand over the last 11 years of work.

it is increase the number of centers across the country and added additional centers in efforts to several communities. the va has expanded call centers on which the crisis line. my organization is pleased to have a memorandum of agreement in court nation with the veterans crisis line and finally the va has been a leader in mental health care into primary care settings. ..

>> translated to 8.2 million of mental health care, and if every one of our providers utilize on a weekly basis, we could provide over $36 million of mental health care each year, and given i was able to do this at a cost of $17 an hour. honored to do our part, but eager to do more. while we have been assured sequestering will not affect va programs, the impact across government agencies are certainly affect veterans. we have to think collaboratively, creatively, and collectively how to knit together resources and services that every community has to offer. although progress has been made, we have yet to develop an effective strategy for consistently delivering coordinated care in communities where veterans and their families live and work. to move towards this goal of

timely high quality care, we have to consider several points. one size does not fit all, nor is there a specific progression of care and intervention that is appropriate for every individual and need. for example, some veterans want, need, and will benefit from traditional psychological treatment that can be delivered by the va or by a community provider like those who volunteer with given hours. in contrast, other veterans are not yet willing or able to accept traditional care even though they are suffering. these might respond more favorably to alternative opportunities aapproachs available in the communities and perhaps an alternative approach is all a veteran needs to move forward in life or perhaps another form of care might lead to a willingness to seek other additional treatments from coming home from war. there are other models implemented to fa sit at a time the coordination and collaboration of efforts.

given hours of work in north carolina and virginia regularly brings community organizations together to assess gaps and develop solutions. the community blue print and initiative now with the organization points of light has launched efforts in 42 communities. the focus of this initiative was to identify and coordinate local efforts and provide opportunities in support for the military and veteran community. got your six, a campaign by service nation, brings the entertainment industry together with over two dozen republicked nonprofits like team rubicon, given hour, and others are part of the effort. these organizations work together to further missions of each organization and improve the reintegration of veterans into our communities. the va has participated locally and nationally in efforts associated with the two initiatives i talked about. given hour has seen positive impact that coordination with the va has in the work in fayetteville and other communities, but we can and must

create a more systematic process to knit efforts together if we are to ensure that all who are in need receive the proper care that they deserve. when i first developed the con cement for given hour, it was with the perhaps ideal liz tick notion that i would build a network of mental health professionals prepared to serve and give this resource to the va and dod. although we have successfully built the network, giving this service to the agencies has proven to be very challenging, and given hour is but one of many organizations that has much to offer veterans and their families so how do we get there? the va has tremendous potential to function both as a catalyst and a convener, to engage and encourage national nonprofits and local efforts in the service of the veterans. the va can identify without necessarily endorsing organizations doing important work to support those who serve. it can bring organizations together here in washington and in communities wherever there

are va facilities to explore needs and develop specific strategies that result in actions and outcomes. if there are policies and regulations that prevent the va from functioning in this manner, then it is time to review and adjust policies. we can no longer be hampered by restrictions that prevent us by leveraging all resources and expertise available in our offices and communities. there's no doubt that the greater coordination and collaboration improves well being and saves lives and to doubt that we have the resources needed to attend to those in need. the only doubt is whether we have the will and determination to meet the challenge together. thank you so much. >> thank you very much dr. van dahlen. if there's no objection, senator murray, the former chair, now chair of the budget committee, she has to run in a few minutes issue and i want her to be able to say a few words. >> i just wanted to thank you for having this hearing.

i really appreciate the foe qus orphan providing timely access to health care. it's so important for the veterans, service memberrings, and families, and i wanted to thank the panelists for coming. it takes courage to share personal stories, but your insight is critically important and so clear that va and congress has made important strides towards addressing the invisible wounds of war, but we have a lot more to do. va's recent report on suicides among the nation's veterans is really troubling, and i was sad to note my home state of washington has a high percentage of known veteran suicides so over the coming year, va has work cut out for it. we have to implement the mental health care access act, we need to meet the goal of hiring 1600 new mental health care professionals, and we've got to get the wait times down as we heard, and we need to partner with our community providers, but the army and dod have work

cut out for them as well. they have got to reform the process in diagnose mental conditions accurately, address the issue of the integrated health care records that plague us, and we have to end the unacceptably high rate of military sexual trauma. mr. chairman, i thank you for really focusing on this, and i want to thank everyone who is working on this in giving my support to continue to do that. thank you. >> thank you very much, senator murray. as i think senator test indicated earlier, if we knew the magical answer to illness this country and world would have solved this problem a long time ago. there is no easy answer, but what i'm hearing from all of you, and i appreciate all your testimonies, is that, in a sense, we have to think outside of the box, that we have to understand that something as simple as an unpleasant person at a desk or a wait for two hours or a missed appointment

can be life and death with somebody who is struggling to stay alive, keep themselves together. you know, when you're healthy, oh, god, an hour wait, who cares, but that's the reality for people who are struggling. i think all of you have indicated that peer supported efforts of veterans talking to veterans is enormously important, that occasionally we have to go outside of the box with, i think, one of you said not everyone is alike, and different individuals were responding to different types of approaches. let me just start off -- let me start off with you, dr. van dahlen, in terms of how the va, which, as we all know, is a huge bureaucracy, no ifs, buts, about that, how do we enable them to become more flexible to reach

out to define community support groups and peer groups that are out there. how do we do that? >> thank you. what we find in communities is, and i know this from my work with several of my colleagues at the va, the desire often in the individual is there, to work in a collaborative way, but they are unclear whether they are allowed to, and so one of the things that i would like to suggest is that we literally work on what are the messages at each of the local -- every va whether it's a hospital center, whether it's a vet septemberer, they will know and have access to the community, and so what we should do, and i think it would be pretty easy to do is determine what gets in the way of having regular, as we've dope in the community and others have done, gatherings where the va serves as the convener and catalyst. what stops that from happening so that people begin to talk to each other. they know, then, that if my

organization can't serve that need, caps can do it or nomi can do it. that what needs to happen. >> okay. let me ask this. one of the cultural issues that we are struggling, the military is struggling with, the va, is the culture, the stigma, the word the colonel used. am i a real man if i have an emotional mental problem? we understand that if i lost an arm and leg, i go and get treatment. how do we deal with the culture that says, from a military perspective, there's something not quite manly about you if you have ptsd or tbi. how do we deal with that? mr. wood, you want to respond to that? >> it's very challenging, and it's not a problem we're going to solveover night. as a marine sniper, i was part of the elite unit in the military and certainly one that

carries that stigma in very heavily. we don't often go to see councilling. if you do go to see councilling like clay did injured in iraq before going to afghanistan, you're seen as a weaker link, and that's a stigma we have to fight, absolutely. i, myself, have gone to seek mental health councilling since getting out of the military. i worked with the va and their maketheconnection.net to provide a video testimonial to that. what it does, though, require is regular convenings as dr. van daheln mentioned, and get together. we need to get together in hometowns, marines together with soldiers together with airmen, together with soldiers together in iowa, nebraska, in california where they talk and share with one another their experiences after transitioning out of the military. >> good, okay, thank you.

app drey, if you could, in vermont, we're a very, very rural state, acceptability a lot of national guards people to iraq and afghanistan. tell me about the peer-to-peer effort. is it important that veterans, just as mr. wood said, that veterans who have been through the experience reach out to other veterans, and how do we do that? >> thanks, senator. we have ten folks on the team, all combat veterans. we all had struggles with reintegration issues, all had struggles, you know, transitioning back to the civilian life. i think, in our state, with the national guard, i don't think it's as severe, the stigma, make as it is on active duty base only because, you know, we, you know, i hear at this panel that we talked about community partnerships, and we've really forged over the head in the state of vermont with different initiatives that we've stated,. we have a director of psychological health that works

directly for the national guard on the air and army side, and we -- that stigma, i think, is more so in the military side, but as far as peer-to-peer goes, we, as you know, we go out, we meet the folks, we get -- >> you knock op doors. >> we knock on doors. we have our feet under the kitchen table, and i know the president has an initiative of 800 peer support folks, but i think you heard this, the common nominator is the peer-to-peer. it's very, very important that we can talk. the other thing, too, that is important with the community is we have the military culture. so we -- i can go into ahs with a field telling, hey, this is how you need to maybe approach some of the veterans as an example. thank you. >> thanks very much. senator. >> mr. chairman, thank you. what you guys have provided are great suggestions, directions for us to turn, and i want to thank you for doing that. it's important to the committee. it's as important to the

veterans and administration, and i think they heard everything that you've said. it will stimulate additional questions on my part that i'm not prepared to ask today, so i ask you, mr. chairman, unanimous cop sent, that we're allowed to follow-up with questions with the panels. >> of course, without objection. >> for the sake of time, i'll turn to barbara for a second. you mentioned the community blueprint. can you share in detail how that effort improves outcomes? >> so there are lots of ways. for example, when we first started that work, and that work is a very action oriented plan to bring groups together, identify specific gaps in services, including bringing the va, bringing in fort brag, and that took awhile to get the stake holders to come regularly, but now it's happening. one of the things we recognize and what i highlight about peer-to-peer and availability of

menial health care, one of the things that we identified was that in that community, the behavioral health providers didn't know each other, were not talking to each other, and there was not ease easy access to identify chough -- who were in need and who needed training. we were now in communication so the va knows, the base knows, and whether it's because they know each other or developing specific plans, one. other things we identified in fayetteville is that there are not enough behavioral health care providers there and believed there's not enough to meet the need. now, before we got there, there was a lot of, okay, well, i don't know what to do, try to recruit them, which is not going to happen. what we need to do is look at how do we leverage people in the communities who have mental health knowledge and expertise to give that to peer based efforts like we do with taps and building with team rubicon, how can we train teachers to

understand the science better? how can we reach out to first responders, primary care physicians? if we have these models, and there are many, where the community is bringing together and developing specific programsing that's what we've seen in fayetteville over and over again, or a family over the weekend that contacted us because everybody else said we don't have resources. we were able, because of the network, to find a home for the family that was homeless with three young kids, and then get them long term care, so many examples, and it's all about bringing the right folks together and having regular, ongoing conversations, not a one time and then everybody goes home and continue to do what they've done. >> thank you, mr. chairman. >> thank you, senator burr. senator, tester. >> thank you, mr. chairman, we have great questions, but you guys testimony invoked more so i'm going with my gut. dr. van dahlen, you talked about, and you talked about --

and i docht want to put words in your mouth, and i hope you're right, that there are enough resources out there, and you also said with a previous question that you want to make sure that the va allows those folks to be a part of the mix if they want to be a part of the mix, and i know you probably don't know the whole country from arkansas; is that right? yeah, but the question is that i mean, do you feel that way because i think that's really a good sign? if you think there's resources to use, then we got to talk to the va about how to best help them integrate in the places where they have vet centers where the peer-to-peer stuff goes on and insert somebody who knows the problems from a clinical standpoint. >> i think there's a tremendous number of resources in communities that are not tapped. they are not being coordinated, and without the coordination, they are not fully utilized. looking again at our organization, we have 7,000

people. they are not used, all of them are not being used. would they step up and give more in the communities if asked? absolutely. that's what they are there for. when we work with taps, and we coordinate our efforts, we -- it's a value add. we know how to reach them, ect.. yes, i believe that there's tremendous opportunity that we have not yet tapped. >> that's good news, and we'll probably talk to the doctor about that same thing about ways to get the va involved in this. lieutenant colonel, i have to say i have a tremendous amount of respect for your organization. you do tremendous work in mops, and i want to thank you for that. you mentioned something in testimony i heard before, and the rate of suicide mops noncombat is higher than noncombat veretts. are you guys aware of why that might be? is there a republican for that? >> well, the senator, i can't give you a clinical answer on that, but understanding is that

the veterans face a lot of the same stresses that civilians do, and it sometimes starts with unemployment, the financial issues, the family issues, and the hopelessness. they have programs. if we can be brought together. >> okay, okay. well, like i said, i appreciate your work. this goes to anybody who wants to answer this. there are a lot of investments made by the va. have you been able to have smarter investments we've made through them, and any of you can answer. you nod your head doctor. >> one wonderful program that the va developed is the ssvf, support services for veterans families, but those programs, my understanding, because we've not been able to work with that program because it doesn't cover mental -- mental health is not a piece of that, and so that's a really wonderful program where

there's a lot going on in new york state, for example, where communities are coming together, organizations are fitting together, applying for that funding, receiving funding, but mental health is not a part. it's a great of example of what's working well with many others, but i want to include also mental health care as part of that package because then it would bring a lot of more of those programs into that combined effort, ssvf. >> the bank veterans crisis line has been of incredible help for the veterans in crisis to have app immediate place to call and get help and get hooked up with character in crisis, and offshoots of that, the vets for warriers, a peer-to-peer support call line, they are answered 24/7, and i could see a real value in increasing those kinds of portals where verett raps call, talk to another veteran,

and get families involved in being able to call the numbers too saying this is what i'm seeing, what am i seeing? what do i do with it? what happens when i take him to treatment? there's a real lack of education around what treatment looks like and that you can get better. more portals like that, like vets for warriors, i think, is incredible valuable, and i think it's working well. >> i just thank you all for the testimony. i have like 15 pages of questions. we could do this all afternoon. i appreciate the level of expertise and willingness to help. thank you. thank you, mr. chairman. >> thank you, senator tester. senator johannes. >> thank you, mr. chairman, and let me say to all of you, thanks for being here. tremendous insight gained from just listening to you. let me start with mr. wood. you said something that i have to admit gave me a different

perspective of suicide in what veterans are going through. at the risk of over simplifying your message, i found it very interesting that you were saying, you know, veteran comes home, out of disservice, put the uniform away, the community they have known, lived with, trusted, prayed with, pride with, disappears. now all of the sudden, the life experience is behind them, and the experience for that for anybody would be very, very difficult. tell me a little bit more about that. are you sensing, as you work with veterans that it's a break in that tie that is a first step

or where problems develop that may lead to suicide? >> absolutely. we see it all the time. veterans typically, you know, int active duty right out of high school, grow up in the formative years in the military and experience incredible experiences, both good and bad, during the formative years with close, cohesive unit of men and women, and it creates a resiliency in that veteran, in that service member, while, therein, they cope with extraordinary things. when they come out, they are ripped out of that fabric, now a single thread instead of that tightly woven, you know, fabric and unite they had while in, and part of that is that the elimination of that purpose, that community, that sense of self-that they had that they formed while they were in, so how is it that we can recreate that? i think the first step is helping veterans identify one another in their hometowns so they recreate it through something else. obviously, with team rube --

rubicon, we provide all thee, and with paws up, we try to create an application for the iphones, for the android devices that helps them discover one another so there's a tool that's not the va because the va's got a horrible brand that a lot of veterans don't trust. we need to supplement what the va can provide, which is first class mental health services and health services with something else, and that something else is community, and it has to come from outside the va. >> uh-huh. i want to hear from you on this issue, this thought that once home, that support group isn't there, the fabric that kept things together all the sudden is torn apart. what's your sense of that, is that part of what you're dealing with here? >> it's a huge issue. we see verett raps transitioning

back into communities, having hope about that envision about what that's like, that they will be able to be a job that they're going to have people appreciating their service, is there going to be use for military experience to find a job, and then that doesn't happen. they have difficulty finding job, traumatic brain injuries and con cushions, anxiety attacks, sleeplessness, medication issues getting away from the transition, and there's nobody to talk to about what they have been through. we had an example of a veteran out in wyoming in a very rural area. he went back, started to find a job, and he had severe post-traumatic stress disorder, got a job of $9, but all the chaos within the job, he couldn't deal with the pts and ended up, you know, quitting his job, losing the job, but e http://ed peer support -- he wanted peer port, and he went to the legion to talk to others

to heal moral injuries he had, the post tray mat ceo stress, the survivor guilt, and he committed suicide on that bar stool at the american legion without needs being met. we see a terrible self-destruction path there, and we need to get that integrated into a comawpt with good jobs, good care, and peer support so they find a sense of purpose, a since of meaning in their life, and they create a new identity separate from the military that they are losing. >> you know, i'm out of time, like senator tester, i could go on and op, but the lightbulb for me here is this. if what's -- the peer support, i don't know, the group counseling, those kinds of things seem to me to be a real

pathway forward here in terms of dealing with suicide. i have kind of come into this hearing thinking that this was all about the trauma of war, and i'm sure that's a piece of it, and for some, that might be the dominant piece, but you've given me a different insight that a major piece of this may be that the communities they relied on, lived with, is not there anymore as a support group, and, like i said, that turnedded on the lightbulb for me. >> uh-huh. >> thank you, mr. chairman. >> thank you, senator johans. senator isakson. >> well, i want to thank you for your testimony and requester service, but i want to follow-up on what senator johans said because my light lightbulb went on to. it went off because i understand

when you told the story about the purpose he had is gone, and it's hard to find. i think that is a tremendous observation. you sought councilling at the va; is that correct? >> [inaudible] i did attempt to see councilling with the va. i was underrealmedded with the care received, and i got councilling in the private sector. >> you answered the question before and i i asked if you felt the counselors had an awareness of what the problem was, but you don't think so? >> the veteran i spoke to was a combat individual from vietnam, a tremendous individual, but after doing three sessions nothing but data entry through technology could have taken about five minutes, but instead took probably cumulative five hours of my life, i was too

frustrated to continue and sought private sector care. she had two of the four major recommendations. four was the first contact to help them navigate in the system before the first session; is that right? that was observation number one. observation four she had was cut out paperwork it takes to get from the appointment to the appointment. what i hear from both those, if adopted, would be a help for the veterans administration and to the veteran. >> absolutely, and particularly, number four. google, facebook, and twitter to have three straight sessions of nothing but data industry. we need to find it and implement it sooner rather than later. >> is the app that you developed operational? >> yes, we launched it weeks ago, mr. senator. >> what's been the response so far? >> absolutely tremendous, still

in beta phase with 3,000 users on the platform. through data gathered and observations made, it saved lives, connections happen in real life k and i could fire it up now and find veterans in the dc area using it and connect with them. veterans that i don't know, myself, personally, but they are out there. >> they just need a catalyst? >> they have to find one another. >> my age group is probably not as connected as that age group. >> the new generation don't use the american legion and cfw like they used to, and they have a role moving toward, absolutely, they do, but the post 9/11 generation, we live in technology. it's a part of an extension of our body, and it's for us not to be leveraging technology to make

the connections is foolish with the resources we have available. >> in the interest of time, i'll submit questions for the record, but i thank you for the testimony. it's been an illuminating hearing for us. >> senator isakson, thank you. >> thank you, mr. chairman, and thank you for the hearing today that's important. especially having people on the front line, you guys are out figging the battle, and we appreciate the service, and so many different ways, and affecting, you know, the very positive outcome for so many. you know, this is such an interesting, very difficult problem. we talk about the stress of war, and, yet, you know, some, many were not deployed, and in situations where not as, you know, stressful in the sense of a job. we, but not stressful in combat.

we have a lot of problems in the private sector, in society in general in the same way. we have the reintegration problems like you experienced, mr.wood, which, again, you know, is so common, and you can see, you know, how it happens, and, get, a loft individuals are 50 years old, you know, and, in fact, a pretty significant portion of these, so i guess, really, what i'm wondering about is the root cause. you know, how can we identify and get to the point before they are actually on the phone, you know, with the suicide, you know, call, and i guess what i'm wondering is what factor does fairal difficulties play, the financial problems, and i was used to be a, you know, a ranking member, and then chairman of the economic opportunities and felt like if you could put people to work, you know, get them to support families and things like that, a lot of this, you know, would

diminish, but besides the, you know, the suicide councilling, you wonder about financial council willing, marriage councilling, things like that, again to the root cause. the other thing i'd like for you to comment on, i think in an effort to help people, society today, and just to be doing something is very difficult situation. i think we're over medicating people, and i'd like for you to comment about that. i think that's a real problem, and i think in some individuals, you know, and i think the -- the facts are there that they go the other way and can become suicidal from being over medicated. if you guys would just like to comment on that. mr. wood, you can start if you'd like or really what your thoughts are about some of those things. >> well, i'm not a clinician or doctor, so, please, take my testimony for what it's worth. >> it's worth a lot. >> my experience -- i've never been med kateed for mental

issues myself. the experience i have with it is that it -- most veterans i know, particularly clay hunt, found themselves -- >> did you self-medicate? did you have problems with alcohol and things like that? >> no, i have not. >> okay. >> no. clay hunt was certainly over medicated, and in his experience with the va, jumpedded from medication to medication, dosage to dosage, was med kateed the day he died and had a telling quote at one point we have on video after he was back from hay tie seeing the experience with team rubicon and experiences helping others and receiverring the community and were more therapeutic than any drug the va put him on, and that's something that i believe we can use to get away from over medicating our veterans. >> yeah, if i might, because you brought up something very important that i think an

important thing to -- that i continue to hear is that one size doesn't fit all. that is the issue. that's why we have not found the solution. as a mental health professional working in the field for 20-plus years, and what's critical now is that we figure out how to ensure that in communities, there are different options of care, whether it's financial, absolutely, sometimings that financial councilling, that's what that family needs, and they are off on the right track or marriage or a physician who can step in and say this young man is way over medicated. send him to team rubicon or get therapy out in nature with horses. it's that, and because even though there are many things that we know are helpful, even the very best evidence based treatment is only helpful for a certain percentage. as a mental health professional, that is what i think we, our

community, can offer. our knowledge and expertise to ensure that we identify other efforts, and then make sure those are accessible and link them together. >> no, i agree, i think sometimes the easiest thing to do is write a prescription. that's what we got into a light. >> senator, if i might, you're absolutely correct. older veterans take their lives twice the rate younger veterans are, and it's still to be determined why that is as the chairman said and ranking member, if we had the answers, but there's such a dissimilarity of cultures, and that's why the technology age sometimes is not in touch with the telegraph age, you know, my age [laughter] i go to some of the veteran service organization meetings, and, you know, i'm the youngest one there, and so we have to figure out a way to get the young folks together and old and mental illness, if i say, has a number of programs addressed to what you're talking about. we have over 1100 chapters around the nation in every

state, and i suggest that just from a stand point of our relationship with the va, get on the computer, find your nearest affiliate, call them up, and say bring that organization in with your volunteer training. it's free, and there has to be a push and a pull, and that's the pull part of it, but many people, even though there's a crisis line, will not call it. we have to find them, and pos reps is a way to do it for the young folks, but what about us old people, so, thank you, sir. >> senator burr, did you have a follow-up? >> how long it take you to put together that app, to develop it? >> it was in development for approximately eight or nine months. >> and what are the plans to market awareness of that app? >> we're working with various nonprofit organizations across the country. we're providing organizations like given hour -- give an hour, and there's

channels to push the application down to their followers trying to use a grassroots effort to do it. >> if you recognize anything that this committee can do through government to facilitate awareness of that, would you let us know? >> 100%, i'll shoot it over soops i'm done here. >> thank you. [laughter] >> thank you, senator b urges rr. let me wind this up by saying, again, thanking each of you for the extraordinary efforts made on behalf of the veterans, learning a lot from your testimony, and thank you very much for being here. take care.

>> okay, we'd like to welcome our second panel representing the va is undersecretary for health, thank you very much for being here, accompanied by dr. janet kemp, the director of suicide prevention and community engagement for va's national mental health program, and with sonya baton, and dr. william buzzbee, acting director of the adjusting conferences of the va, and from the department of defense, we have colonel rebecca porter, chief of the behavioral health division of the army's office of the surgeon general. thank you very much for being with us. dr. petzel, let's begin with you. >> good morning, chairman,

ranking member burr, and members of the community, i appreciate the opportunity to discuss the mental health care and services for our nation's veterans, i'm accompanied, as the chairman mentioned, by dr. baton, kemp, and since early 2009,va's been transforming the health care delivery system improving services for veterans, but we know there's much more work, much more work that has to be done. my written testimony has more detailed information, and i submit that for the record. this morning, i will summarize remarks and update you on major accomplishments progressively increasing veterans access by working closely with the federal partners to implement the president's executive order to improve access to menial health, service members, and military families as well as the 2013 national defense authorization act. we know these changes require investment. last year, va announced the goal

to hire 1900 new mental health providers and administrative support, and as of march 12 #th, to 20* 13, va hired 1300 new clinical and administrative staff in support of that goal. we're on track to meet requirements of the executive order by 30 june, 2013. va has many entry points for care including 152 medical centers, 821 outpatient clinics, 300 vet centers, the veterans crisis line, and many more to name just a few. we expanded access to care by leveraging technology, telehealth, phone calls, online tools, mobile apps, and through outreach, primary care, primary care integration of mental health, community partnership, and our academic affiliations. it increased to over 17 million

in 2012, up from 14 million in 2009. the number of veterans receiving specialized mental health treatment rose to 1.3 million in 20 # 12. in part, this is because our primary care clinicians proactively screen for depression, ptsd, problem drinking, and military sexual tray ma to identify they may be in needs of menial health care and to actually get treatment they need. we're also refining how we measure access and outcomes to ensure we accurately reflect the timeliness of the care we provide. there's a work group to set wellness based outcome measures, and five are selected with others to be identified to include satisfaction, did they get the appointment when they wanted it and neededded it? clinical quality effectiveness measures, and clinical process

assessments. in 2012, we conducted site visits to all of the ha health systems meeting with the leadership, the front line staff, veteran, and identified a number of areas for improvement in staffing and scheduling. va is updating the scheduling practices, strengthening performance measures issue and changing our timeliness measures. we will continue to measure performance holding employees and leadership accountable to ensure that the resources are devoted where they are needed for the benefit of verett rap -- veterans. va worked with partners to address access and care delivery gaps. in response, the executive order department of health and human services to establish 15 pilot projects using federally qualified health plans, and they are partnering with dod to advance a public health model to improve access, quality, and

effectiveness of mental health services through an integrated mental health strategy developed jointly by va and dod. we are committed to ensuring the safety of our veterans. even one veteran suicide is one too many. july 25th, 2012, marked the fifth year since the establishment of the veterans' crisis line. va offers this 24/7 assistance, and last year, the line received more than 193,000 calls, resulting in over 6,000 life saving rescues. the crisis line has totaled over its lifetime 750,000 calls. earlier, va released a suicide report. this report includes data on prevalence including those not treated by the va. the report provides us with

valuable information to identify populations that meet targeted interventions like women and vietnam veterans. the report also makes clear that although there is more work to be done, we are making a difference. there is a decrease in suicide reattempts by veterans getting care in the va, calls are less acute, demonstrating that va's early intervention is working. mr. chairman, we appreciate your support in identifying and resolving challenges as we find new ways to care for this nation's veterans, my colleagues, and i are prepared to respond to your questions. >> thank you. >> chairman sanders, ranking member burr, distinguished members of the committee. thank you for the opportunity to appear before you to discuss the army's initiatives to improve soldier readiness and resilience. i want my full statement entered

into the record. the united states army has fought for over 11 years, the longest period of conflict in our nation's history. the unprecedented length and per sis tent nature of conflict tested the capabilities and resilience of our soldiers in the army as an institution and of our supporting families. taking care of our own, mentally, emotionally, and physically is the foundation of the army's culture. the army is keenly aware of the unique structures facing soldiers and families today and comettings to address these issues on several fronts. the army's ready and resilient campaign plan and behavioral health line stress resilience. from preclinical prosecution activity to clinical treatment and surveillance efforts, the ready plan was mandated through a directive issued february 4th, 20 #13 and has army wide programs aimed to embed

resilience into day-to-day operations. we review programs, processes, and policies to ensure effectiveness and reduce redundancy, improve methoddings for commanders to understand high risk behaviors and intervene early and continue improvements to the integrated disability evaluation system. the line is the treatment component of the campaign plan. the line codifies 28 programs to support the health and well being of soldiers and families like behavior health, child services, and the behavior health data portals tam. i want to height light the successes of the programs. the embedded behavior program provides multidisciplinary behavior health teams to provide community health care to soldiers in close proximity to the units and in accord coordination with the unit leaders.

utilization demonstrated significant reductions in behavioral health department, high risk behaviorings, and number of nondeployble soldiers. leaders have a single trusted behavior point of accountant and subject matter experts were questions regarding the health of the soldiers, and embedded members know the unit, known by them, knocking down barriers and stigma. our behavior health program increases access to specialty care in isolated areas to include more than 60 fights in afghanistan. it enables greater continuity of care with serge capacity for enhanced evaluations at soldier readiness processing sites. it is leveraged to recruit providers for hard to fill locations allowingically clinicians to provide care in other areas where it's easier to

high clinical professionals. the army's also implementing new programs to provide care to spouses and children in communities where they live and placing behavior providers in the patient centered medical care clinic. the data portal is an i.t. platform tracking patient outcomes, patient satisfaction, and risk factors by way of a web application enabling improved surveillance and assessment of program and treatment ethics. while the army continues to improve health care to the soldiers and families, we recognize we have to pay special attention to soldiers in transition whether they are relocating to another assignment, returning from deployment, transitioning from active duty to reserves, or preparing to leave the service. the army established a system internally to ensure continuity of care from soldiers moving from installation to installation. we support the dod in transition program with ready access to

nationwide of experienced and independent behave professionals for soldiers spending transition and utilize the military one source as equivalent resource for those transitioning. we work actively with the va to ensure continuity of cay for soldiers transitioning to leave military service. for complex medical services, this includes the integrated disability evaluation system. behavior health care and resilience are important in the readiness of the army and important issues of the veterans. they are capable personnel, evidence based practices, and far reaching program have key pillars in the commitment to an army that's ready and resill yept. thank you, again, for the opportunity to testify before the committee. >> thank you very much. >> let me begin with dr. petzel. i mentioned in opening remarks that as we end temperature years of war in iraq and 11 in

afghanistan or so, the cost of war, i think, is heavier and more tragic than many people realize. i have to start with a simple question. i don't know if you have the answer in front of you. when we're talking about post post-traumatic stress disorder, with we talk about traumatic brain injury, how many human beings are we talking about suffering from these illnesses? >> thank you, mr. chairman. right now, va is taking care of slightly over 500,000 people with post-traumatic stress disorder. >> stop right there. 500,000 returning soldiers? >> correct, not just returning. this is the whole population, mr. chairman. >> not just iraq and information? >> i was about to get to iraq. >> okay. >> we have about 119,000 people from the present conflicts that carry the diagnosis of post-traumatic stress disorder. >> okay. there's an issue, not just the huge number, giving us an

indication of the e norty of the program we try to address here of the that's a lot of people. there's an issue that we did not talk about very much today or in your testimony, and that is tbi, traumatic brain injury. i think we all know, one of the signature illnesses of these wars, iraq and afghanistan, with the incred l amount of explosions that our soldiers were exposed to. talk a little, how many folks are we talking about who you think have the diagnosis of traumatic brain injury? >> we have tested since several years ago, more than five, i believe, everybody that comes back from combat experience, we evaluated them for traumatic brain injury, three levels of traumatic brain injury, severe ptsd, all familiar with that, people who are often cared for in the poly trama centers with many other complications like amputations and blindness.

a relatively number of small people measured in the couple thousand. 395,000 people have been screened. we identify it as 54,000 of those people who screened positive so far for pobl brain injury, and out of that, was quite sophisticated testing identified 35,000 people that have mild to moderate brain injury. >> you're telling us we have some 35,000 people from iraq and afghanistan with mild to moderate traumatic brain injuries? >> yes, most are from iraq and afghanistan. there are some who have. injured in training accidents, ect., but the vast majority from the conflict. >> and that's a tough tbi, tbi is a tough illness to deal with, is it not? >> well, mr. chairman, the biggest issue there is that we don't know what the long term consequences are of mild to

moderate traumatic brain injury, and this is why we have a registry, why we tested these people, identified people with that diagnosis, had them on a registry, and now can follow them over an extended period of time with a good baseline evaluation. it is speculated that depression, anxiety, ptsd and endro crin disorders may be more common in those with tbi going forward. >> okay. we're going to have a second round of questions, but let me conclude my questions with dr. petzel in asking you have engaged in a very ambitious effort to hire mental health clinicians. my understanding is that in order to reach your goal at the end of june; correct?

>> yect. >> you need 195 more mental healthically yitions. >> correct. >> can you get the quality people you want in that period of time? >> we believe so, yes. we are involved in a stand down in blitz it if you will to look at -- the big problem with us in hiring is a hundred days plus been -- has applieded, after we stouterred through the applications, vetting them, credentialing them, and interviewing them takes time. we have plans to compress that substantially. >> okay, i'll take a little extra time to give to the colleagues up here as well because i wanted to get to colonel porter on an issue. look, i think the issue on everyone's mind with regard to the military right now is the tragedy, as we understand it, that last year we lost more soldiers to suicide than to

armed combat, and we're talking, somewhere around 350 or so. can you answer -- let me throw out the first question is, why is this number so incredibly high? why is that occurring? later on, we will talk about what you guys are trying to do to address it, but tell me in your judgment. i think the average americans say, what? we're losing more people to suicide than armed combat. that comes as a shock. why do you think that number is as high as it is? >> thank you, mr. chairman. that is, as you mentioned earlier, a complex issue and complex question. i think a couple things if you want to compare the number loss to suicide to the number lost in combat, part of that is attribute l to the fact that we have a high survivability rate in combat right now, so the number we lose in combat is decreased significantly from

past combat. with regards to suicide in particular, though, sir, i think what we can say is that it's a complex issue, as you noted, that will take more than just behavioral health people to solve, and that why the senior army leadership is looking at bringing in our senior leaders, and all the way down to our squad leaders to try to combat this with respect to improving resilience in the soldiers and family members, and giving our soldiers coping skills for whatever life throws at them whether it's a combat situation or just the daily stressors of being in the army or an american citizen. >> thank you very much. senator burr. >> i'll pick up where senator sanders left off. when the va started the increase of 1600 mental health staff and

administrative staff, were facilities begin any options other than hiring this additional staff like memorandum's understanding with organizations in their community that would enhance and beef up the mental health's ability? >> senator burr, those options have always been there, but the short answer is no. this was aimed at how many people do you need to bring staffing up to the levels you think you need in order to provide the access that we've said. >> was there a matrix created to come up with the number of 1600 menial health providers? >> it was a combination of using the only existing staffing outpatient model for mental health. i think as you know, there's not very good staffing models for mental health, and, in fact, the va is a pioneer in staffing models for mental health. we use that, and we used discussions with the individual

medical cementers about what they view of the needs were. i want to emphasize the fact this is not an end. this is going to be an ongoing evaluation. >> i'm confident that's an accurate statement. >> yeah, yeah, we'll be on in on an going way evaluating whether we have resources available and properly deployed. >> what you say is every facility has the option to partner with community based organization, and not all choose to do it, in the absence of that, we said you got to have more people. we didn't necessarily look to see to what degree there was outreach for community based solutions. >> that was not a part of the original assessment, but i'm taking away from the hearing a reenforced desire to did out and do, as we did with homeless, have a summit in the community, mental health providers. >> i remember a similar stimulation you had last year. >> what was that? >> because i'm not sure that we heard anything from the witnesses this year that we

didn't hear last year about the need for community collaboration between dod and in the case of fayetteville and other military towns between va and the community based providers. what do you do you think of thea system when you hear testimony like from mr. wood's? >> i'm sad he didn't have a better experience, where it was, and correct it. >> do you think he's one out of everybody or is this -- >> i don't think he's a one off. i think that it is a relatively uncommon experience out of the 17 million outpatient visits that we have. ..

>> every person who testified referred to the fact that veterans could get mental health treatment. so i guess i would ask you, your measurement tools flawed and not picking this up or have your measurement tools shown us that we have in address to? >> we took about 95% of the people can get an appointment within 14 days.

when we talk about 17 million appointments, very substantial number of people who work you see not quickly. i cannot deny effective people being seen as quickly as we want and i want to provide whatever they need to get a hold of and get involved in the mental health services and partnering with the community will help that. >> of i.t. or say that. there's a huge difference between reality and goals of the later today where realities of what you stated are the goals and unfortunately, i don't think the crew suggests we hit it. you're back, the user reassessment of providers to measure opinions regarding the mental health program. would you provide to the committee for the record the results of the survey and

individual response is to be open-ended question additional concerns about services at my facility? >> thank you, senator. i believe we been finalizing the report. will have to take for further record with available. >> the attention is to share that. >> we will share the report do. >> i think were able to do that as well. >> thank you, dr. petzel. the executive order that the president could address with a 1600 people also created the military and veterans mental health interagency task hours to the right the president with recommendations to improve services and substance abuse by february of 013. have they provided to the

president and if so, could you provide the committee with a copy of that report? >> task force has provided its report to the president on the first of march. it is my understanding that is going through coordination and concurrences by a number of federal departments and you will have it available as soon as it's released. >> what does that mean? >> i don't know. i'm sure there's numbers of bases terms of what the report said. when it's released you'll be able to have it. >> ito suggested the process of change? >> no commissary. >> senator tester. >> thank you, mr. chairman. is a possibility could look at them as a committee because i hear requests for reports and quite frankly i don't get the

minutes of discussion about these if we've got time. if were going to has to be a four report, we ought to make sure we find out what is in. >> thank you, mr. chairman. i appreciate your leadership here at. does the va have a definition for rural? >> they do and it's not a definition exclusive to the va. it can be defined to race. one is the travel distance to a metropolitan area or the distance it alleviates both of those measurements in defining perot. >> the reason i want to come today since we have 1300 -- 600 or so people hired in the mental health professionals.

dr. rick van dahlen was up earl. i guess you how widespread your program is because those are great where they exist. i'm more concerned where there is no resources. and my question is when you assign a folks, what is the priority? is it based on limited service or no service or had he make that decision? >> recount assignment. we would ask before terrorists and what are the needs of their. they would tell us they need an additional psychiatrist, for psychologists and five psychiatric social workers would be what we would expect them to go after and try and higher.

we don't higher than assignments someplace. >> so you can recommendations ahead of time. if you need someone in montana and i don't even offense the way you work it. but if you need someone in the far northeastern corner 600 miles to the nearest medical va hospital, you hire the person to fill that spot. >> we would try to do that. i have to say, senator had a better alternative would be to use tele- health and provide the service remotely by a psychiatrist in helena. >> point well taken. i'm going to get to you in a second. veteran suicide is an incredible worry. have you done any works with the contract varies versus the veterans who you never can get out and touch in their suicide

rate? >> yes, senator we have. the people under mental health care in the va have a lower and declining suicide than those who are not in contact with the va, not getting care. >> any figures on not? >> i would have to ask dr. kemp. >> as you know, we are just beginning to gather that directly from the states. as a result, we were able to put out the suicide data report this year. as we had states, will be able to firm up those numbers. >> as soon as you get this, i'd like to see them. then it got metrics. >> can i make a couple of their comments about suicide?

there is a discussion about combat experience earlier. and veterans come in a service numbers, there is no relationship necessary between their combat experience and whether they take their lives. >> that was a question from the gentleman from nami. the point is you cannot the people who don't have access to. they were in the benefits of mccutchen encourage them to step out because there's good health care systems i peered if we can't get the men, we can help them. >> that's absolutely right. >> a number minutes than i thought. colonel porter, utah about 350 or maybe the chairman actually,

350 suicides a year in the active military. is that number correct for last year? >> at another we finalize the number. i think it is close. >> is that all the branches of the military? >> does not include -- including the reserve component. >> it's good to know. thank you. we talked about the stigma attached. is the military doing anything about that stigma? we are seeing -- well, we see unacceptable levels quite frankly we don't do a good job as a society. they can be fixed. is the military doing anything

associated with mental health quite >> what the army is doing is they have a stigma reduction campaign intended to educate soldiers and leaders about the benefits of accessing mental health care. but really makes a difference and change is having a health provider is around soldiers and having soldiers have access in their prepaid areas where we take that providers from the hospital and make their place of duty a building authorized for health care use in the brigade area so the brigade leaders know those providers and vice versa. >> is this widespread throughout? >> we are rolling across the

army. we anticipate all operational units supported by the end of fiscal year 16. >> we will hold the va accountable. i think the department of defense has a responsibility to train people of what they're going into so they understand what to expect as they go through military service. i just want to thank everybody for their testimony. >> thank you, senator tester. senator bluesmen. >> thank you, mr. chairman. dr. petzel, do we have a good idea we've heard about the community base and the things that seem to work good you got the classic therapy and witnesses talked about an individual in haiti helping other people in that seem to

help a lot. i heard a young guy that was an amputee, that literally occult pro tapped him on the shoulder and not changed his life. there's all these things. do we have good metrics to know what is working and what doesn't work? >> that's an excellent question. they're a group group of evidence developed recently for posttraumatic stress disorder. there is a relatively new evidence these therapies for depression and anxiety. so there are areas where we do know what to do. there's lots of areas where we don't know what to do. i really want to hearken back to the previous panel mr. wood side

of purpose and community is very important. something they look forward to is important. i would ask top or batten if there's any questions of what is available in treating the multiplicity of mental health disorders. not just ptsd. >> i'm happy to speak to that. we want to make sure all veterans have access to evidence-based psychotherapies and make sure they understand treatment works because that is one of the biggest barriers for people coming in to care to know there is something that will help them. we know not any one thing will play to everybody. we need to have clinicians ready to ask the questions of what's important to the individual veteran when he or she walks to

the door. it may be reducing symptoms, but it may be getting out and getting a job in being able to go to their grandchild's t-ball game and not looking over their shoulder. it's important to find out what is important to the veteran and we as a wide array of services that include peer support, getting into the community and living a healthy lifestyle overall. >> i agree. one of our previous witnesses said a thing thing. one size doesn't siddall. you mentioned a summit and i would encourage you to have a summit along those lines with the community-based stuff. you guys work very hard to try and solve this problem. the trouble is your getting the

we're not addressing the cause of the problem. so you're having to deal with this and many times and least expensive is to write a prescription and you really need to look hard and we can help you but you need to look hard at overprescribing. we see what has happened with the pain management. consuming more opiates and the rest of the world put together. all of this stuff goes together. the other thing you may consider having a summit about is the cannot the cause of thing and that the divorce rate in the military. iers we need to have a marital

problem rather than military when they get out. also the employment picture is so important. deployments. you may not come back with ptsd, which are probably back with family problems if you have seven or eight deployments in the past year. that's a tough thing. >> senator, i think you put your finger on what we're trying to work on. first of all, we need to identify people much earlier in these illnesses in the new transition assistance program mandated for everybody but the va is devoting half a billion dollars will go a long ways

towards helping us see these issues very early, before soldiers are discharged. we can identify people in trouble and make them aware of everything. the other part of what you said identifying the antecedents. the va population arms themselves as the 60 plus population. that's the big group, the majority of people that commit suicide and in that instance, we are talking about depression, chronic pain, sleep disorders, substance misuse in life stressors. most of the job. it's a big change like leaving the military. we chartered a workforce group looking not new approaches to those five things come at doing these things differently so you

can do a better job of identifying people at risk. >> as he said earlier in our previous panel, lots of purpose. feeling like life is over. >> thank you, mr. chairman. >> i believe that senator bloomberg l. will be here in a second. let me ask some questions. it is fair to say the va in dod latour structure, dod health care operations have a good operation for treating the ones that were in terms of prosthetics and how we take care of amputees. papineau institutions do a better job on that. it's a much more complicated

issue within the military mba. if we take a deep breath and look at the magnitude the va has to deal with, tens and tens of thousands of soldiers coming back with ptsd or tbi on top of the problems the veteran five is the number of issues you're dealing with. the testimony, every problem is different and it's got to think outside box and senator bozeman raised that issue. talk about complementary medicine. i don't know if you saw on cnn the other day medication is a real issue. some of the medicated move

towards towards acupuncture as pain relief cut which apparently will be sans cnn at least worked pretty well. to what degree is the va aggressively looking at complementary medicine, acupuncture, massage therapy. what we are dealing with a real-life problems that life is complicated and not necessarily dispensing medicine. it's certainly not pages and pages of forms, which would drive me among many other people quite that. if far veterans spend the afternoon out playing golf, feeling good about each other and talking and come back

feeling better about themselves or they go trout fishing or camping together. it may be more veterans than getting medication. so to what degree are we thinking out of the box to make people felt better about themselves. and by the way, we have to be careful when i make recommend nations. it's not. it's a very easy target. >> i agree totally and that's why it's asking if they had evidence base to what is working. >> is the question i would throw out if you could answer. >> thank you, both. we partner with a tremendous number of organizations around the country an example on the

professional golf association had programs in virtually every city with a medical center where we provide the opportunity for handicapped people particularly to play golf and we sponsor a blinded golf tournament that occurs every year in iowa city. there are many other examples of recreational activities. horseback riding, fishing, kayaking, were individual veterans and service organizations have put together not profit that provide opportunities. whether or not there are enough and using it enough isn't open question. >> want to get back to the issues senator post that raised.

>> let me do with opiates. which is the most dangerous of overmedication. a three-pronged approach is first of all the stepwise process where you begin with the least invasive, these dangerous kind of risky things done up all of our medical centers. we provide acupuncture as the vast majority of our medical centers. progressively more complicated things such as rehabilitation and eventually when you're not able to manage the pain in any other way its opiates and there's protocols about how that prescribing should be done. second step is is we have just begun producing computer program that provides to the medical

center's a listing of patients taking an unusually large number of opioids and prescribers proscribing unusually large number. a person is responsible for tracking that down and seeing what the issues are. the third thing is participating in the state recording of opioids. some of our patients get prescriptions outside the va and we need to bring the data together so we understand the extent of the problem. we will be looked to have access to the statewide data. >> thanks very much. >> thank you, mr. chairman. thank you for having a hearing, which i hope will be the first of a number of steps to dig deeper into the issue of mental health and pursue the line of

questioning that senator sanders has raised an thank you for your service on this issue. the collection of data on the use of pain medication. this issue has bedeviled our society, state authorities. i know from my own experience where we are able to establish an electronic computerized records system that keeps track of who is prescribing and who is taking pain medication like opioids. my first question is what may be helpful to have a single system of record keeping it applies to men and women as military while i'm not a duty and seamlessly with the veterans administration was on track to go forward.

now it has been scrapped. wouldn't it be advisable and desirable to have that kind of system for the purposes of tracking exactly this kind of potentially useful, but also highly dangerous medication? >> senator blew in all, it will enhance greatly capacity to manage patients in general and specific things such as medication issues. the integrated medical record has not been scrapped. that is going forward as we speak and we are expecting by 2014 will have the initial operating capacity for that integrated record. >> i'm glad to hear you say that.

>> the va is absolutely committed to doing that. >> as in dancing it takes to and the announcement a secretary pen on a general should seki was not encouraging. i've since heard conflicting reports and my concern is this interoperability system may not be the same as the seamlessly integrated system that enables real-time tracking of opioids and other highly powerful medications prescribed. >> i'm not an expert in i.t. probably one of the least literate physicians around i.t. but i am told this will be a seamless record. and i share your concern. this is a thing we need to va being constant attention to her

secretary is relentless and pushing forward the integrated record. >> i am delighted to hear that point reaffirmed. i know it's a personal and commitment, which i commend fully unit iici sickly. let me ask you about again to take senator sanders point about take back programs? >> either way, thank you for sponsoring the legislation with the fda. we think the next one idea. anything that can be dangerous medications out of people's hands who don't need them keep them away from teenagers who tend to rifle there. medicine and we are looking at how we can do this.

mailing back is so problem floresville institute as quickly as we can. the receptacle collection depends on a ruling that our police are actual law enforcement officers. we need to establish in fact that they are. i believe the other provision was handing this over at the time of visit to correct tensioners who are looking at whether we can do better not. it's the next one idea that we are going to do everything we can to participate. >> anything we can do or i can do, i would be delighted to undertake. i have seen escape fire the documentary. i thank the chairman mentioned earlier during the preceding semi-hope our people can be exposed to it given the

opportunity because it makes a graphic and dramatic case for the need to be vigilant, particularly by medications are every bit as a fan as the equipment of warfare on the battlefield in terms of their effect on individual people. i hope all of you will continue to do the good work you're doing. but me ask you on a more general level and i doubt whether you have a point on this. he looks like you're about to say something. >> i do want to take up your time. >> that's why you're here. >> is going to turn america that they get about acupuncture and escape fire and transportation were they use acupuncture in substitution for opiates and how

effective that is. i thought that was a very moving and yet. >> at least to the question i was going to ask. in your experience as professionals having dealt with individuals exposed to comment, is very fact cure, a tendency economy experience of these veterans on pain medication. that's part of the question. >> i will ask if anybody else here. the tremendous physical stress they undergo marching with 80-pound packs, et cetera. when you look at the complaints returning veterans have come a muscular skeletal are far and away the leaders. 45% of people returning to this

country after deployment complain about neck, arm, shoulder, back pain, et cetera. that's the only thing i personally can testify to you. i would ask if anyone else -- >> these are the sorts of questions we need to ask if we want to move from seniors to type no says and treatment. we need to understand underlying mechanisms that influence this physical and mental health functioning. when is the examples is when we think about the ideology of ptsd. why do some people develop them some know? one factor about the development of ptsd at may 10th is it's natural for of us if we experience events to not to think about it and how those

memories, those sensations and feelings. that initial level of avoided is natural. that's human nature. when someone uses avoiding certain i mean as primary way of coping with that sort of trauma, they are going to be more likely to develop something like poster manic stress disorder. it's not a far step to say when someone is not willing to experience emotional pain it's also the case they do not want the physical pain. we need to look at underlying fact is there underway to have difficulty sitting with uncomfortable thoughts, feelings, emotions and sensations that tie some of those propensities together. if you're not willing to have emotional pain, and maybe that it's difficult to sit with the the physical pain and you may be more likely to turn towards

things like pain medication rather than psychotherapy and other techniques to cope. >> thank you, mr. chairman. >> thank you further questions. me conclude by thanking all of you. the enormity of the problem the dod and va is facing is unprecedented. i appreciate the hard work the va is doing and addressing this issue. this committee looks over to working to address those problems. thank you for being here. [inaudible conversations]

nancy pelosi discusses the supreme court case of capitol hill reporters. this is 25 minutes. [inaudible conversations] >> good afternoon. i was pretty exciting this morning. it is really a dignified proceeding. the first half of it as you probably know this about standing in the second half about the marriage of the doma

and marriage act. they were responses that were very constructive. it's as big as our constitution country itself and his personal as every marriage in our country between same-sex parties. i had the privilege of being there with kerry amy -- her and her wife amy. karen is a federal employee and has the case that the court about whether her wife, amy can get benefits as a spouse of a federal employee. she was married and not window in california before prop it

took away the opportunity to continue those occasions at weddings in california. on the basis of what i heard the questions of the justices, the response of the participants are very optimistic that doma will be struck down. it doesn't have a rational basis which is one of the criteria that the justification and second way, probably the first full protection of all people in our country. equal protection has been a principal or country was founded on that our constitution was but non-and on the basis for debate is back and forth about equal protection, rational basis on either score.

the arguments, the debate seemed to favor striking down doma, which is very important. the justices made the point that it's probably more than that, that very same 11,000 books or regulation they relate to marriage that do not get equal protection to people married and that's the word they use. it will come and not an hour. just sitting there with amy and caring. it's as big as our constitution. it is as personal as every family and use it there with

them. you've probably seen edie windsor. she's the aggrieved party in the case before the supreme court. i don't know if that's a technical term. they have to pay her back the taxes over $300,000 she had to pay one her spouse died because it was a same-sex marriage. her spouse died in the service did not recognize this was a married couple. but ed windsor is a courageous brave woman in to see here in the court, head held high about her marriage and afraid she's making further people as well as

herself. they are going to be touring the capital, so you may see that happily married couple doing just that. it was pretty thrilling i have to say. >> you represent a district at the epicenter -- [inaudible] out of the rates compare with the 70s for military service? >> all of those are important at the time. whatever the subject had to be, whether it's aids funding, there is always an issue of discrimination because part of our fight was to end discrimination against people with hiv inmates. one of the first issues that came in for over 25 years ago as they hate crimes legislation again to make sure people knew it was very wrong to harm people

on the basis of race, religion, orientation. the other part of that is a long ti perez. we were able to repeal "don't ask, don't tell," but we have work to do there in terms of making sure families in the military get what they need. hopefully will be struck down, but we have work to do. we have is a priority for us here ending discrimination in the work place. i hope all of these people coming out in favor of marriage equality will be there for us in employment equality, to when we try to bring the legislation. but what is for me personally gratifying is in our community, we have a large gay, lesbian,

transgender community whether it's health care providers in every aspect of the community's life. so over the years, one of the questions especially when i became part of the leadership, one of the first questions i wish i was then finally journalists would ask me on a show would be do you support gay marriage and of course i would say i support gay marriage. i don't believe in discrimination of any kind. that would be like we have labeled shoe. now that her audience knows that -- it was a badge of honor for me. for a long time it was something

we knew was inevitable. from our beautiful place in san francisco, city of st. francis, we knew it was inevitable all of this would have been. it is inconceivable that it would end it was our job to use whatever influence we have a t-shirt the distance between the inevitable inconceivable and i think that's what's happening at the court because of many people's courage, especially those directly personally affect did. yesterday i had one of the attendees, senator barkley now, the first openly gay ambassador in their public service spot beside. so it's pretty exciting. but i chose you on health care is offline.

you keep reminding me. [laughter] >> without opening day next friday. we can start all over again. [inaudible] >> let me just say this about that question because when you get the soundtrack comments that were calling it? the audio -- [laughter] soundtrack of the supreme court. you're too young. anyway -- [laughter] what was really interesting to me was to hear clemency spokesperson for doma.

what is still role to play on life. nonetheless. when he was up there, the houses standing on this issue because those the black. my issue, bipartisan legislation advisory group. first of all, it wasn't bipartisan. we showed up one day. republicans voted to go forward and use taxpayer dollars to defend doma. they voted 500 -- blag voted $500,000 a day in a not bipartisan way. get the tape title is that there was bipartisan support for that. but we never met again to go for that money and they set up to

$3 million by now. i don't know if they're speaking with the tax payers dollars being spent without benefit of votes in the blag and none will stay seiners permission to go forward, but not having the blag take action. behavior has been not a model for the future. it's really disappointing and unworthy of a subject before the supreme court of our country that has such an impact on not only marriage equality families, but also our whole country as to who we. i don't know where they are in the subject. have you asked them? again, $3 million speaks very

loudly, especially $3 million without benefit of vote in the so-called bipartisan legislative advisory group. idea mike [inaudible] what took so long? ways to sell coming out on the democratic side? >> i've been there 25 years, so it didn't take me long. this question if i may take it to a different place. this kept coming up in the courts say he why is it now the chief justice a searcher could allover each other to save marriage equality when the bill

passed a large bipartisan vote was therefore it. the question is, was that in this? dereferencing report on the bill in the house that that it was about a reality and a little bit on the mean-spirited side. but she can't paint everybody with that trash. once it goes to the senate to vote the way they though. what wasn't said they are, but part of it, minimart family members have come forward whether somebody's sister, brother, mother, father have come forward to their interest in marriage equality and that's been translated into popular culture whether it movies or

whatever. so we are a different place and it's a generational change as well. you look at statistics and you'll see a generation gap in terms of approval of marriage equality. so i think somebody used the term mayor times can blind, which is one of justice cantonese phrases related to tech says previously. in other words, times can blind whatever the public mood was on the subject at the time, it also created ignorance and that is fading now and more light shed on something like this about this being about discrimination and equal protection about not having a rational basis for the

defense of marriage act. i said to a number of times and i'll say it again. one of the questions that came up in the court today was the justices that did. the originators of doma at the time think it was constitutional . and they claimed that they asked the administration and the justice department and set three times, yes it was constitutional. so why would you asked that question except to find out what the tent was of the republican initiatives at the time. what they didn't say is that i

have in my op-ed today in "usa today" on the web is the republicans knew and they know the right out the doma is not constitutional. in 2005, introduced a bill. doma is the respect for marriage act. it stated that in the case of doma the court did not have the right to judicial review, the right to review on the constitutionality. why would you pass a bill -- by which you pass a bill in congress, in the house the courts do not have the right to rule on the constitutionality of the bill if you thought it could withstand the test?

because you don't tank it can withstand that test and that's why they engage in court stripping. stripping out the court the right of judicial review. some of that time said diamandis and, a case that established judicial review was wrongly decided. so that's who are doing here. they know that was not constitutional and not that i would've responded have been on the other side of the railway mayor. [inaudible] >> in other words, when you pass a bill in the house as we did,

we made i am quite constitutionally. you have the responsibility to honor the constitution. in fact to do just that is the hope that president obama upholding. congress passes a bill. it's questionable in terms of constitutionality. there's no question about your oath to the constitution of the united states. the behavior of the republicans in the house of representatives on this set checked has been so irresponsible. first of all, why would you pass a bill that encourages unshared increases discrimination. the air could just as in favor of more justice, not for discrimination. why would she do such a thing in the first place? and then when its question in terms of the constitutionality

to spend outside the regular order of how that money should be spent to defend increasing discrimination in our society is just plain wrong and given the choice we would all say we are honoring the constitution, not anything that's passed the house and is not pass the constitutionality yet. i've got to go to work now. [inaudible] [inaudible]

>> i don't think we have lost momentum. i think we could stay here more days so we could get our work done more expeditiously if that's the word you use. i've been to a number of states insist congress has gone in in many parts of different states in the public is so far ahead of the congress on this subject. i believe whatever passes in the congress now will not be the end of the day for this issue. senator reid i respect enormously. the public sentiment is very

strong on this subject and we want to come out with the boldest common denominator you can get. i think when senator find stein puts her bill forward in the public knows what is that day, we'll see what the beaux-arts. say it doesn't prevail. it argues all the more strongly for having the toughest, most effect does background checks instead of diluting the background checks because we might not have -- we might not succeed but the assault weapon ban to make that even more effect days. i think that argues in favor. hearken back 20 years. i was one of the whips on the assault weapons ban and. we didn't win the first time,

but then we eventually did. members knew if they voted for that in her district, it would be the end of their career in congress. but they came back and they said if it saves lives, it worked my losing my race to do that. this is a very big deal for the public. it's a legislative body that we have to go forward as boldly as we possibly can. i would not say the assault weapon ban is in their os is going to happen down the road. i think it means more should have been up the road as we go forward. the interest people out of jobs is what we are here to do. we have a moral imperative to restore confidence in our economy, in the safety of our communities passing gun violence

prevention acts in who we are his people. we are a nation of immigrants passion and immigration bill and do not expeditiously. the longer some of these things go, some block of urgency might have been on how strong it should be. we have to make the intensity increase. of course i come from california. 90% of the people support background checks. overwhelming numbers of republicans support background checks. hunters support background checks. it's just the congress has to catch up with safety and that takes me back to the constitution and everything our constitution guarantees.

it won't be until june. what we know what their decision is. but i feel confident having heard the debate in the quite thoughtful questions of the justices that i'm not going to give you a number. [inaudible] >> repeat, three out of four. >> last week there were reports of agreements that would include a choppy and family preferences preferences -- [inaudible] >> it's not a question of that. it's a question of how do people come in because family unification secure our borders