the presiding officer: under the previous order, the senate stands adjourned until 10:00 a.m. on tuesday, april 30, 2013. adjourn:

and i would ask you to take a look at the safe legislation that has been introduced in this area to tell us whether or not it has to meet your concerns and how we can really mitigate against what has happened there. food safety, the cdc is investigating an outbreak of salmonella in 18 states. that is associated with imported cucumbers. it takes up to three years to train the food safety inspector and they aren't going to meet the target for the inspections this year with only 1200 plans and inspections. 2016 the fda is supposed to inspect 19,000 foreign facilities.

we need more inspectors. if it does when do they need to be hired, what does this budget due to meet the requirement, and then what i would like, again i would like you to answer those questions that i would like you to submit for the record also directly to my office a detailed breakdown of the inspection personnel noting the number of personnel for domestic inspections and the member for international inspections. thank you. >> just a quick question, i mean answer to your question and then we will get back in more detail. i want to underscore that last week we did meet our fisma target and exceeded it i believe for the for an inspection that the numbers as you know in the legislation ramp up very quickly, and i do think that we need as we think about the real world that we live in and what is going to be required, we need to think about not just the role of inspections but other

important activities as our overall programs reflected the new authority in the food safety modernization act in this information sharing strengthening a regulatory capacity in other countries during training and technical assistance, the foreign supply and verification program and third-party audit is going to be very important as well to our overall program that will address food safety, and scores the new rules, the produce safety and that even if controls will apply whether you are a domestic or foreign manufacturer or grow worse and i think there are a number of things beyond inspections alone that will help to strengthen the security of the supply chain and food imports. >> i would only add, commissioner, that if in fact there is going to be a

transpacific partnership agreement that the influx of imported seafood from vietnam and thailand and malaysia will be extraordinary. as my colleague mr. fortenberry pointed out, eda person to receive food comes imported, and we know, we know now the rate of contamination alert. that will make your job harder. we need to know on this committee what is required to ensure the public health of this country domestically, internationally and how overwhelmed your agency may be if this committee doesn't do something about the resources that this applies to you. thank you very much. >> thank you. this wraps up our last hearing by budget 14. i want to thank you the staff on both sides of their ordeal for this work on the hearing process, and again, thank you

for being here. we look forward to working with you on the budget. thank you. >> thank you. >> [inaudible conversations]

the hearing is wrapping up. the house right now is voting on the bill was passed last night by the senate to help mitigate delays at airports. the bill is expected to also passed through the house this morning. it would allow the federal aviation administration to allocate up to $253 million already in the faa budget to keep employees and air traffic controllers on the job through the end of the fiscal year on september 30 it. the lawmakers today also wrapping up work on the bill would permit the federal government to continue selling its reserves on the private market to help avoid a helium

shortage. live coverage of the house right now on c-span. earlier this morning, the obama administration officials briefed house members on the situation in syria. the white house announced thursday that intelligence officials have concluded that syria's government has twice used chemical weapons on its own people. following the classified briefing in the intelligence committee ranking member representative kroger's burger briefed reporters on the latest. [inaudible conversations] >> can you speak in a microphone? >> how are you all? questions or are you just --

>> [inaudible] >> first thing this is to bring all of our members together to get information in the classified setting. we feel that there has been some chemical weapons that have been used. there were some still investigating who did it and where it's coming from. right now it was just an evaluation state. one of the most important issues is that we do bring together the other countries. we need to work as a team like we did in libya and we got the arab league involved. it is the same situation here. i would say that i think it's very important for us to continue to talk to russia, because i think russia could really make a difference in helping to resolve this serious trouble situation where people are being killed every day. >> how many incidents as? >> i felt only one question? [laughter] >> how many incidences have you understand? >> i can't get into that answer. >> the secretary kerry said only two. >> he got it then.

[inaudible] >> i think that at this point we have to keep evaluating wher we are. it's a very serious situation. but it's just not about our country being involved. it's getting all the countries involved and attempting to resolve the issue. it is a serious issue. you have issues involving immigration. you have turkey and jordan involved and this is a serious situation where you have a lot of people in these camps, and without food, there is violence that goes on so there are a lot of issues involved. >> do you think that -- what are the challenges with syria in terms of if we were to engage with them what kind of engagements -- >> i will say we as the united states want to go into another war. i think it's a serious situation with people being killed and what happens by the way after assad leaves and that is what we

have to look at in the countries that surround syria. we have issues like turkey and jordan and so, it is still moving issue that we are working with other countries. but as i said before, i think hopefully that russia understands how serious this is, not only with assad still in power but what happens when he eventually leave, which he will. >> what about a no-fly zone? >> there are options on the table here. every option is on the table as far as syria is concerned and one of the most important issues, close to 100,000 people have been killed. and it doesn't seem to stop. and it seems that the balance of power goes back and forth. it seems the opposition is stronger and then the next thing you know it goes back to assad come to the government. and, you know, we are very much concerned about people from other countries. it we are concerned about al qaeda influence coming and we are very concerned about things

when he does leave and his government falls where are those chemicals going to be when they get into the hands of the bad guys especially the different groups, the terrorist groups including hezbollah. >> when he falls let a ground force to favor of the country? >> i can't get in that strategy today i would think with this time all the issues that we have, we can do everything we can to avoid putting this on the ground. we have a unique resources that no other country has and then we can work with the other countries as a team to try to do what we need to do as it relates especially to the issue of chemical weapons. but i will say that when this issue on the chemical weapons came up maybe a month ago, i think russia did step up and i think that they had some influence over assad and his government. >> i can get briefed and evaluated and look at it, but i think that at this time we feel

the weapons were used in a very small way. >> did get a conversation with of the country on the latest developments -- >> what country, with assad? >> with americans. in light of the latest involvement do you think that is -- >> give me that question again. >> the speaker is urging a conversation with the country on the latest developments; do you think it's time for that to happen now? >> i think it's always good to communicate. right now we are not sure where our country is going with our country's involvement, but the involvement of the other countries we are working with to resolve this issue. again i keep on saying i'm going to review it again, russia is a key player. their game as far as resolving the issue and moving on with a post-assad government. okay? >> thank you for stopping. >> [inaudible]

>> training in russia? >> the major issue that i want to focus on and we are focusing on, find out what happens in russia. was he radicalized, did he get trained on how to build a bomb? it's not always easy to say you are going to face defeat could build a bomb, and to say that you haven't tested bombs, remember anwar al-awlaki who analyzed the under the radar underwear bomber and times square bomber we were lucky those didn't go off and they were sophisticated and he and his team were pretty sophisticated and here you have a team with these two brothers had a successful bomb that went off. maybe they were lucky. i just don't know. i think that is the area that we really need to focus on is in fact was he radicalized when he

met other people and those are just things that we need to pull together. >> or they helpful enough? >> i can't discuss that right now. >> i know we are communicating. that is all i can say. >> would anyone seek asylum to go back to their own country? >> why would russia let him come in and go back out to begin with, that's the issue. >> did you have any concern about the mother? >> she is a person of interest that we are looking at to see if she helped radicalize her son or had contact with other people in other terrorist groups. we don't want to put ourselves in the position that we have another threat out there that we have to look at any terrorist groups and chechnya and that their strategy might be to look at the united states as an area that they were successful. so we really have to focus on what happened within russia to get as much intelligence as we can about terrorists in that region. the russians were always concerned about the chechnya rebels coming and now here we

have this situation on our home turf. >> what is your understanding of the kickoff that the russians gave to the u.s. officials back -- >> i can't discuss that yet because we are focused on investigating. the mother did say -- what did she say? the blood was paint that we put there or something? okay. i've got to go. earlier today president obama spoke at the planned parenthood about women's health care and ways to make it more accessible and affordable. this is 20 minutes. ♪ >> thank you! [cheering]

thank you very much. thank you so much. thank you, everybody thank you. thank you. thank you. [cheering] all right, everybody. have a seat. you are making me blush. [laughter] [inaudible] >> i love you, too. thank you. thank you for the warm introduction and for the outstanding leadership that you have shown over the years. you do a great job. [applause] i want to thank all of you for the remarkable work that you are doing day in and day out in providing quality health care to women all across america. you are somebody that when men, young women, old women, so many

important services and we are truly grateful for you. i'm sorry that i couldn't be the party yesterday. i understand that it was a little while. [laughter] that's what i heard. but as all of you know, obviously we have gone through a pretty tough week and a half, and i was down in texas letting the people of texas know that we all love them and care about them in their time of grieving. [applause] but obviously this is a special national conference because it has been nearly a hundred years since the first health clinic of what later would become planned parenthood opened its doors to the women in brooklyn. and for nearly a century now, one core principle has guided everything that all of you do.

that the women should be allowed to make their own decisions about their own health. it's a simple principle. [applause] so, what i see in this audience, extraordinary doctors and nurses and advocates and staff who work tirelessly to keep the doors at the health centers all across the country going, i am reminded of those early efforts and all of the strides that we have made in subsequent decades. and i also think about the millions of mothers and daughters and wives and sisters and friends and neighbors who walk through those doors every year. somewhere there is a woman that just received a new lease on life because of a screening that you provided that helps catch her cancer in time. somewhere there is a woman who is reading easier today because of the support counseling that

she got at her local planned parenthood health clinic. somewhere there is a young woman starting a career who, because of you, is able to decide for herself when she wants to start a family. [applause] one in five women in this country is turned to planned parenthood for healthcare. one in five. [cheering] and for many, planned parenthood is their primary source of health care. not just for contraceptive care for lifesaving prevent care like cancer screenings and health counseling. so, when politicians try to turn planned parenthood and a punching bag, they are not just talking about you, they are talking about the millions of women that you serve. and when they talk about cutting off your funding, let's be clear, they are talking about telling many of those women you are on your own. they are talking about shutting those when in doubt -- women

held at a time they might need it the most. shutting off communities that need more health care options for women, not less. [applause] so the fact is after decades of progress, there are still those that want to turn back the clock. the policy is more suited to the 1950's than to the 21st century. and they've been involved in orchestrated and historic efforts to roll back basic rights when it comes to women's health. 42 states have introduced walls that would ban the word limit access to a woman's right to choose. bill wollman would make it harder to the contraceptive care that they need and would cut off access to cancer screenings and educational programs that help prevent teen pregnancy to get enough to cover the just passed

a law about lines -- baliles your right starting six weeks even if a woman is raped. a woman may not even know that she is pregnant at six weeks. in mississippi a nation was put forward that couldn't not only out on your right to choose that could have all sorts of other far-reaching consequences like cutting off utility treatments, making certain forms of contraception a crime. that is absurd. it's wrong. it is an assault on women's rights and that is why the people of mississippi were given a chance to vote on that initiative, they turned it down. and mississippi is a conservative state. [applause]

mississippi is a conservative state but they want to make it clear there is nothing conservative about the government in adjusting itself into the decisions best made between a woman and her doctor. folks are trying to do this all across the country. when you read about some of these you want to take debate to check the calendar and make sure you are still living in 2013. 40 years after the supreme court affirmed the women's constitutional right to privacy and putting the right to choose, we shouldn't have to remind people that when it comes to a woman's health, no politician should get to decide what is best for you. no one should get to decide what kind of care you get. the only person who should get to make decisions about your health is you. that is why we fought so hard to make health care reform a reality. [applause]

that principle is at the heart of the affordable care act because most insurance plans are now covering the cost of contraceptive care so that a working mom doesn't have to put off the care that she needs to show that she can pay her bills on time. because the affordable care at 47 million women have no access to preventive care like mammograms and cancer screenings with no co-payment, no deductible, no out-of-pocket cost. so they'll have to put off a nanogram just because money is tight. because of the affordable care act come in young people under the age of 26 can now stay on their parents' health care plan and insurance companies soon will no longer be able to deny you coverage based on pre-existing conditions like breast cancer or charging more just because you are a woman. those days are ending. [applause] those days are ending. [applause]

i know how hard you have worked to help us pass health care reform. you and your supporters got out there and organized and need your voice is heard coming you made all the difference. but here's the thing. if americans don't know how to access the new benefits and protections that they are going to recede as we implement this law, then health care reform won't make much of a difference in their lives. so, i am here to also ask for your help because we need to get the word out. we need you to tell your patients come in your friends, neighbors, family members what the health care law means for them. make sure they know that if they don't have health insurance, they will be able to sign up for quality affordable health insurance starting this fall in an online marketplace where the private insurers will compete for their business.

make sure that they know their plans are out there right now that cover the cost of contraception and prevent care free of charge. we've got to spread the word, particularly among women, young women who are the ones who are the most likely to benefit from these laws. we need all the women who come through your doors telling their children from their husbands and the folks in their neighborhoods about the health care options. we need college students who come to your doors talking about the protections and the benefits that are kicking in. you are all in a unique position to deliver that message because the women use serve no you and trust you and the reason for that is that you haven't let them down before. i know it is not always easy and

as she described planned parenthood as the only organization she has been where there are opponents who in her words literally get up every day trying to figure out how to keep us from doing our work. now, if she had worked in the administration -- [laughter] she would be more familiar with this phenomenon. [applause] but when it comes to the patient, you never let them down. no matter what. and that is because you never forget who this is all about. this is about a woman from chicago named courtney who has a disease that can leave when an infertile. in college she turned to planned parenthood for access for affordable contraceptive care to keep her healthy.

you didn't just tell her of plan for a family. you made sure she could start one. today she has two beautiful kids to be and that is what planned parenthood is about. [applause] it's about a woman in washington state named joyce who for years could only afford care of her clinic. she never missed her annual exam. during one of them if your doctors cash and aggressive form of cervical cancer to save her life, today she has been cancer free for 25 years. [applause] so everyday in every state and every center that is planned parenthood operated coming you have empowered some families you have strengthened. that's why no matter how great the challenging house fears the opposition, there is one thing the past few years have shown and that's planned parenthood is not going anywhere.

it's not going anywhere today. it's not going anywhere tomorrow. [applause] as long as we have to fight to make sure that women have access to quality affordable health care, and as long as we have to fight to protect a woman's right to make her own choices about her own health, i want you to know that you also have a president is going to be right there with you fighting every step of the way. thank you, planned parenthood, god bless you. thank you. [applause] president obama earlier this morning speaking at planned

parenthood. he's the first sitting president to speak to the organization. yesterday senator john mccain speaking on the issue of immigration said his goal is to pass a bill through the senate by may or early june. joined by new york senator chuck schumer the men spoke with reporters for about 45 minutes following a meeting with president obama. both senators are part of a bipartisan group known as the gang of eight that unveiled a plan of pathway to citizenship 4,011,000,000 unauthorized immigrants and tightened security along the nation's southwest border. i will make a couple of lines on the immigration bill. i guess being the number one reason that we are here i want to salute john mccain, who's done just an amazing job of leadership that wouldn't have happened without him. he stepped right at the plant early on.

one other point not related to immigration, but harry reid has this idea of having a joint caucus where john would tell what happens to him during the vietnam war but it's never been talked about before. ..

it was an amazing thing to me. gives you a lot of faith in our bill and there are many words to describe it, but one word i think is balanced. every time i'm asked a tough question on the bill there is such balance in it is not that hard to answer, so it is a very fine product i think that and i'm optimistic it will pass. i won't get into the details. i'm sure you will ask about it. the one other point i would make, there is lot of talk about how did boston affect our bill? some of the facts come out in the last day show our bill would have strengthened security because we require the machine reading of any person who leaves the country or comes back into the country as. as you know, tsarnaev when he flew aeroflot his name was misspelled. he was on a customs watch list. that's why janet napolitano mentioned there was a ping when he left the country. that was a customs ping.

even though he was on the tide list, wider anti-terrorism list, that did not show up because the flot was misspelled under ae. under our bill the name would have been machine read by a passport or something else. they would have known exactly who he was. they would know one on the tide list was both leaving and entering the country and it might have made a difference. our bill actually strengthens security and events in boston if anything should impour tune us to leave the status quo and go to a proposal like ours. obviously we're very interested in any other new facts and suggestions that would improve the by. but those who say in my judgment let's wait on the bill because we have to see everything that happened in boston and see all of that, it is an excuse. the only people who are saying that are people against the bill long before boston occurred. john? >> well, i would just like to thank chuck schumer for

the leadership he has displayed in getting together different views, even within the group and different prioritis. and by the way, chuck and i also worked on this attempt to avert a 51-vote, vote in the senate because of the dissatisfaction that, some of which is understandable on the part of harry reid and we have worked on other issues together and i appreciate the opportunity to be associated with him since the american people are very interested in seeing some result from the congress of the united states. i'm sure you saw a poll the other day about favorability of different aspects of our lives and, members of congress ranked just below a colonoscopy. we would like to get above a colonoscopy and i would just

like to elaborate just a second on what chuck said about the, that the tragedy in boston should somehow impede the progress of this bill. we're having hearings. we will have a markup in the judiciary committee. we will then move to the floor where there will be weeks of, i hope not too many weeks of debate, amendments and we will have ample opportunity, if there are lessons to be learned about the boston tragedy, to incorporate in the legislation. this is not the final product. on the issue of the final product, we have agreed that if we feel that the bill can be improved by various amendments, we will support those amendments, or feel free to support or oppose. but if it is an amendment that is designed to kill the bill, as happened in 2007, we will probably vote together to prevent the bill from going down because this

is a, these are fragile compromises that have been made. let me just, again, and i'll stop with this. we think that america will be much more secure with the passage of this bill. we will have a more secure border. we will use technology such as evader radar which was developed in iraq that will help us identify people as they come across. we will have e-verify which will then send a message sooner or later, south of the border, around the world, that even if you get to the united states of america, you will not have a job when you get here because of the stiff employer sanctions and e-verify. i would also point out that exit entry will help us our national security as well. at the press conference that we had the other day, i would like to conclude with this, somebody, one of the reporters asked, well, what

makes you optimistic now whereas in 2007 you failed? and i pointed to the group of people behind us. we are, a coalition has been assembled. we didn't assemble it necessarily. they have assembled from labor to business, the chamber of commerce to evangelical, to the catholic church. when you look at the broad spectrum of support that was, has been expressed for passage of this legislation it is a coalition we did not have in 2007 and i believe that those people are extremely active. 70% of the american people support a path to citizenship ship as long as there, people are here illegally, pay back taxes, pay a fine. learn english and get in line behind everybody else who came to this country legally and that is an

important factor in american approval or disapproval. that is what this legislation is all about. thanks for having us. >> thanks to both of you for coming. let me ask one or two myself. we'll go to david kelly, kneel grant, aaron and alex to start. you were talking about how this isn't the final bill. that the bill would have made the boston situation better. let me ask you whether you discovered anything so far that tells you need to make further improvements in the bill? senator graham, your friend, has, senator mccain talked about a amendment requiring immigrants deemed potentially high-risk to undergo more comprehensive checks. are you seeing anything in boston you want to add stuff to a bill you already feel too good? >> i think it is way too early. we don't know all the lessons. we're finding out new information on a daily basis but i am sure, that by the time this bill reaches the floor, we will be able to reach conclusions and we

will include provisions like that, if we feel they are necessary. working with the administration, by the way, and in some of the smart people at the fbi and other agencies, that so, we are completely open to amendments that would, in any way prevent what happened in boston. i hope nobody has any illusion about that. >> agreed. >> let me ask you one off of immigration and that is about sequester and flight delays. as you know there is dispute how to best handle the airline delays being caused by the sequester. "the wall street journal" reports this morning that some democrats want legislation that would deal just with the air travel portion of the sequester. majority leader reid is having sequester itself be repealed. can you both speak to what you think needs to be done if anything about the air travel delays? >> well, yes. i mean look, my, the best solution is to undo sequester and replace it with more rational types of

cuts. and that would be, you know, leader reid has anment which got a lot of support on our side, none on the other side, to use oco. having said that, i noted that last night jay carney, the president's spokesperson, said that he would be open to a solution just for faa. as we know the transportation department has probably the worst squeeze on sequestration because so many of their employees are not affected because they're funded in good part by trust funds. in other words, the highway trust fund is not subject to sequester. so all the fha and fta employees are not subject there. so it squeezes the air traffic controllers. i know that senator rockefeller along with senator thune was meeting yesterday with the faa to try to come up with a solution and i would certainly be open to it. >> senator mccain. >> we've had hearings in the

senate armed services committee and we heard from everybody but the navy because the kind of hearings that we have, everyone of our uniformed service chiefs have said they can't defend the nation if we continue with this sequester. now, i am, i'm terribly uncomfortable with the delays of faa i think it is a terrible thing. i've been subject to it myself. but when we're looking at virtual threat to our national security, we've got our priorities upside down. and so, i am hell-bent, if we're going to take care of airline passengers, why don't we take care, why don't we take care of our national security? the world is a more dangerous place than i have seen ever in many respects and everyone of our uniformed service chiefs say they aren't going to be able to defend the nation within a year. we've got our priorities upside down.

so, i'll go along with whatever the faa thing is. but it is criminal, and scandalous, that we are ignoring the effect of sequestration on our national security. now we can believe, if you don't believe the uniformed service chiefs, that's fine. i happen to. and they, presenting graphic illustrations of the problems that they are facing. so, yeah, i'm glad to see you will the focus on whether we have to wait in line longer or, there is flight delays, but i wish to god the congress of the united states would focus on the threats to our nation's security, and by the way, keeping good and qualified and talented young men and women in the military who are all considering now getting out because they have seen no future, at least a predictable future, which at least we owe them. >> i would just add one other point. i mean the cuts, john is right in this sense, faa is

causing problems. i don't think it is just traveler inconvenience. it causes economic loss. but, we have lots of other cuts. john mentions military. i hate to see nih being cut, cancer research and things like that which are so vital. we both, i certainly agree that it would be a lot better to figure out a way to undo the whole sequester as opposed doing it piecemeal. having said that i certainly would be open to an faa solution because the transportation department is under an undue amount of immediate squeeze. >> aaron. >> you talked about, republicans going recognition they need -- [inaudible] i heard that from republicans in terms of the general election but there is still a lot of fear i'm hearing about primary challenges from the right if they support comprehensive immigration reform. how do you convince them to that risk is worth taking? >> first of all i believe if

we pass this legislation, it won't gain us a single hispanic vote but what it will do, it will put us on a playing field where we can compete. right now we can not compete. and the numbers i'm sure, in the last couple of elections authenticate that statement. all i can do is, try to show my friend in particularly the state like mind and state of texas and others where the demographics should be convincing. by, six or eight years from now, we will have a, if not a majority, a near to a majority hispanic population in my state. and so, it is a demographic certainty that if we are,

condemn ourselves to 15, 20, 25% of the hispanic vote we will not win elections but i have no illusions about whether this passage of this legislation will gain hispanic voters. it won't. it will put us on a playing field where we can make the argument, as i do with chuck every day, for smaller government, lower taxes, less regulation, a pro-life, pro-defense, et cetera. that is the argument that i think we can make to gain hispanic support. >> i would just make one other comment related. i was sitting with wrub rube with two conservative leaders and one of them said, oh, schumer you're just doing this so you can get more democratic votes because these 11 million people will be allowed to vote. the first one will be allowed to vote in 13.5 years. if you republicans haven't solved the problem with the hispanic community in 13.5 years, you're finished. >> i called paul ryan

yesterday to thank him for his outspoken support of immigration reform. >> tom? >> senator mccain, could you tell us what paul ryan told you and what is his hopes are? >> i believe in it. he said my comments, he said i think my comments are important. he agrees with what i just said. i said, thank you for the vote. he said thanks for calling and still --, wants to run for president. no, he didn't say that. [laughter] >> could both, the other day -- >> -- ticket. [laughter] >> the other day one of your colleagues lindsey graham says the goal is to get 70 votes in the senate and try to build support. >> we need that and i think it a he is doable. >> senator schumer? >> senator schumer. >> that is the way you see it? >> yes, absolutely.

if we were to pass this bill with say over 50 democratic votes which i do think is possible. it has widespread support on the democratic side and only eight or nine republican votes, it would pass. we would get the 60 but it would bode poorly for the house. so what we're looking for, and i think the four of us democrats in the room are mindful of this, getting a large republican vote. and we did some very interesting things. senators hatch, and rubio, feinstein, and bennett were part of the ag section. there was a point where basically most of ag agreed with our proposal but southeast ag didn't. we knew there were a lot of republican senators from the southeast who might vote for our bill but if their growers were very much against the bill it might push them over. we spent actually a few days working out accommodation. their agriculture is little different with rice and cotton and all that. and we worked out an accommodation and southern,

southeast ag is on board. so we're looking not to get 61 votes obviously. that is the minimum. we're looking to get, you know, a good, i would like to get, this is wishful, maybe this is hopeful, but would be wonderful if we get a majority on both sides. >> david grant. >> follow up on that, i think it is very doable. >> [inaudible]. >> yes, sir. >> just as you discussed, getting the 60 plus, 70 votes important for what happens in the house, how many conversations or could you sort of describe, if you have spoken to your colleagues in the house about how they're working on their bill and when we might be able to see that, chairman gowdy and chairman goodlatte you're talking to later today? another thing for senator schumer, you discussed trying to curry some republican support for this. you talk about the diversity visa and what happened to that. is something, a bit of chief supporter of for a long time. talk about, you know, happens to the diversity

visa in the negotiating process? >> we've had conversations with some our colleagues in the house and we will continue to but i think the time to do that is probably after we finish on the floor of the senate with, with a completed package. so we can go over specific points with them. we've had several conversations with them and we'll continue. lindsey graham and i went over, republican policy committee. not too long ago and had conversations with them and, we've encouraged their negotiations, which in many ways are particularly given the makeup of that group, somewhat encouraging. >> on diversity visas i was the author of it back in the '90s, so i care about it. we had strong opposition from both our republican colleagues on our group, on our "gang of eight" as well as we heard that house republicans it was a

nonstarter. what diversity visas were, they were designed to bring in immigrants from countries that can't get them through family connections of the 86% of the legal immigrants who come into the country are family, 84 or 86 are family related. only 16% are job related. diversity was effort to bring in people from europe and africa, ancestry of the majority of americans but who really couldn't get in because it was their fifth cousins who were available, who were, who could come. and it was successful for a while. but now it is actually shifted. the majority of people who come in are from central or i don't know the majority but pleurally from central asia. no longer from your on or africa. given the opposition from our colleagues we decided we couldn't continue to diversity visa. the cbc, congressional black

caucus cares a lot about this. i've been working on them. this is point system that lindsey graham pushed for very hard in the future which does make future legal immigration more job oriented, a little more job oriented. and that is a consensus among most of us. there is plenty of room for family there too. actually, the number of africans because they have so decreased under diversity visa will increase. that is not to mention the number of caribbean members will become r ppies and citizens under the -- rpis under the bill so we think it will be a fair and balanced bill in that regard. >> from from, you said they will increase? why would they increase? >> because in the point system in countries you know represented get some points. >> [inaudible]. -- coming here. -- >> post-university. >> so roughly, but, perhaps

50% of the annual output, 1.8 million graduates. what reassurance can you give to parents and students and midlevel professionals the wave of professional level immigrants will not drive down wages, increase competition for jobs and make it hard to pay back debt? we're not talking about -- [inaudible] talking about full width of university education and statistics journalismism, environmentalists. >> journalists we need a whole new group to come in and straighten things out. but the rest --. >> [inaudible]. >> talking primarily stem. okay? primarily stem. that is over half the graduates, post-graduates in the united states of america today are not from the united states of america. those people ought to be given an opportunity to remain in the united states. there are job requirements for those people and there is no doubt that they are not being filled. if the united states of

america is going to remain the number one nation in the world, we had better be able to keep the best talent in the world. and those people are people who are attending the best universities in the world which happen to be ours. >> i understand which you brought up got a couple of things in there. first, unemployment level for college graduates across the board in america is about 4 1/2, 5%. so obviously not like high school graduates, it is certainly in double digits. second, because of senator durbin's work, they have to be paid a very significant wage. it is a level 2 wage. and so that is going to be a deterrent to anyone who wants to bring in somebody, non-stem, college graduate for these other professions. finally they have to post the job. if a qualified american is available they have to hire him or her within the smsa. we have a lot of safeguards for nonstem people who are

college graduates. >> jerry. >> you say in the house that the path to citizenship is just an absolute nonstarter there and that, that being the case i'm wondering if you think that will be a big problem there? and if you see any other pathway to getting this bill done absent a path to citizenship? >> there is no way of getting this job done without giving people a path to sit shen ship. -- citizenship. a lot of our friends in the hispanic community when they look what is required along that path to citizenship they're not very happy. we're talking about 13 years. talking about a $500 fee. at first, and another one after five years. and all of the hoops that are required here, including border security, there is going to be pushback from that side as well. so all i can say is that, that if it's, legal status

is not something that someone should have to remain in unless they want to, to say you can have a legal status but you can't ever have a path to become a citizen in this country, i just don't think, offends our fundamental principles of fairness in our society. so i understand, i don't understand, but, i know that opposition is there. i don't think it's valid and i don't think it's held even by a majority of republicans, certainly not in the senate. >> it's a nonstarter and for a few reasons. first the substantive reason. in the european countries where they have done this and people don't feel they have a chance to become part of society, there is huge discontent. we've seen that in the results of economic unrest in terms of even terrorism and things like that. the american dream is you can become an american. you have to follow certain rules. you have to work hard. you have to pay your taxes. you have to obey the law.

we even say for the first time you have to learn english. but, you should be able to achieve that american dream, you know, symbolized by the beautiful lady in the harbor of the city in which i live. so it is fundamentally important, not for any political reason but for a substantive reason. and most politically, i would say two things. first most americans support it. a majority of republicans support it. >> as long as -- >> there's a path. you earn it. >> right. >> as long as you earn it. second, would say this. second for the hispanic community it is a nonstarter. i would say for most democrats it is a nonstarter. the one thing four of us insisted there has to be a path to citizenship. john and other three said it has to be a qualified, earned path it citizenship. they insisted that people go to the back of the line, not gain any benefit from crossing the border and we have achieved that but,

any -- >> effective control of the border. >> and effective control of the border but any attempt to say in the house that you will not have a path to citizenship will be a nonstarter. i say that unequivocally, it will not pass the senate. i don't think it would get a democratic vote. >> next to michael warren. michael. >> what happens to legal immigrants who are on the path to citizenship somewhere along the way if i am minutetation of the bill a and border security and check marks are not met? >> it doesn't start. >> what happens to illegal immigrants -- >> they remain in illegal status until we comply with all of the requirements that they have to comply with personally and requirements for a secure border. look, in 1986 i voted for simpson mazoli under our beloved ronald reagan. three million people were in this country illegally and give them all amnesty and never face the problem

again. now we have 11 million people who are here illegally. i'm not going to stand for a third wave. and so that means th we not only have to have a secure border but 40% of the people who are here illegally overstayed their visas. so we have to track that down. the most important aspect of this bill to be honest with you, is, that the, if an employer knowingly hires a person who is here illegally, they will be penalized for doing so and we will have their ability to authenticate that through tamper-proof documents. that's what dries up the magnet, if we, look, the one thing that bothers me to be honest with you, this is a demand for drugs and drugs will continue to come across our southern border as long as there's a demand for it. and to me is a problem that we haven't even addressed but it is separate from illegal immigration. but, look, we can not have a

third wave. we owe it to the american people and the only way you do that, is combination of the e-verify, exit-entry, secure border and penalties for employers who hire people that don't have the proper documentation. >> just make a couple of points. i agree with john. i always said the american people will support common sense balanced solutions to legal immigration and 11 million who are here, if and only if they're concerned there won't be a third wave, future wave of illegal immigration. and our bill is stronger than anything, it is much, much stronger than anything that has been envisioned. as for the border metrics they are very real. john took us to the border, myself and michael bennet. it was a revelation to me. we passed a bill, the two of us in 2010? several years back that put $600 million into the border. and people said, you know, i got some of my constituents

say we don't need anything on the border. that 600 million, effectively raised across the whole 2,000 southern border, from 68 to 82%. effective whoever attempts to cross either catch or turn back 82%. now we're spending extra, another 4.5 first and another two if that doesn't work, that doesn't achieve 90%. it will work. one thing we insisted on that these metrics not be spaghetti. they be achievable, concrete, metrics. but i will tell you something. listen to this. on their border in arizona they only have two planes, two drones and they can only fly them eight hours a day because they don't have the personnel. here's what i learned. it is a vast border. nothing like new york. and, for better and for worse. and in any case, but, you don't have it catch them right at the border. you have these drones. they can follow people

across the border and they catch everything. they see everything that crosses. they can follow them for 20, 25, 30, 50 miles inland and catch them in there. one got in the news, the one lady we saw trying to cross the border, they didn't apprehend her as climbing over a fence. this is in nogales where they have a fence. we know exactly where she will go and they will catch her in 20 minutes and they did. so these metrics, i believe are going to really be more effective than people think. we are going to secure the borderer and they're achievable. they're not there so, let's say a president cops who is anti-immigration. they can't use the system, can't game the system to say we're not creating a path to citizenship. >> could i mention one other thing? >> yeah. >> technology. in about a month it will be 120 degrees down on the arizona-sonora border. very tough on people. sitting in a vehicle in that heat and in the desert is

very debilitating. . . control of the border which might've been impossible 10, 15 years ago. >> [inaudible] >> we will know in five years, okay? if after five years, remember this is a 10 year pass, and

after five years that we have not met those requirements then we will convene a convention and they will spend additional monies. if we do it right i am totally confident -- confident. we also in this bill as i mentioned before, 40% of the people never came across our border. they just came on a visa and overstayed, and we are addressing outside of it, aspect of it spent we are about 15 minutes away from the end. a lot of people on question. not all will give him. i apologize. >> make them short. specs of the don't rise up. outlooks, and neither, k., brian. delay in the stride top -- the lady in the stride top. i don't know your name. jordan.

alex. >> so u. cmb o commerce has endorser legislation but other members of the committee are unhappy with the cap for visas for construction workers british everybody is unhappy but they have signed a. everybody is unhappy but they have signed up. >> [inaudible] >> you'll have to show me a major group that is in opposition. of course, they're unhappy. and on the other side they're very unhappy as well. that's what you call a compromise. >> next question. [laughter] >> would you accept or have 50% increase in the number of visas or -- >> number. look, this is a carefully negotiated package. the bottom line is we did talk to your, i talked to dom donahue a great deal. case in brooklyn, too.

-- he is from brooklyn, too. >> [inaudible] >> that's right. that's what jeff flake says. the lady across the border heard my new york accent i thought she was already in new york last night. >> -- [laughter] basically said we're going to be quite generous on high income on college graduates, spam, and all that. because those jobs there's a consensus that there is -- there's a definite shortage. they have rit 100 miles to the west. rpi 100 miles to the east. two of the largest most successful engineering schools in the country and they couldn't get the engineers. so generous on the high-end, but we are much tougher on the

low-skilled and with the exception of agriculture because we know americans don't do that. and yes, it's a pretty tough bill on the low when. it provides for needs that people have but it is kind of tough. and to their credit the business can do it alone. even to construct, smaller construction industries, the smaller folks, the homebuilders and stuff, they have said, well, want to change but we are not going against the bill. because nobody really, as john said, nobody wants to go against the bill. but i think that we, the bottom line is that if the carefully balanced situation and i think everyone go along with the. >> one of the reasons why they went along with it is the status quo is totally unacceptable in america today. it's unacceptable to nine have 11 going people, human beings, god's children come in our society without any of the rights of protections of citizenship or at least legal

status. go ahead. >> [inaudible] >> i'm not going to be nailed on anything specific. i don't envision as changing the balance in the w. these issues. -- w. these are issues. >> [inaudible] >> could you speak up a little? >> [inaudible] >> my view is we decided we can't do individual bills because the problem is people saying what about me. they try that angle has congress. probably hitech is more broad support than anything else but they put in the house bill and he got nowhere in the senate. because, for instance, the hispanic community said what about us? the agriculture canada sd wh

about us. and what we found is, ironically, and maybe a little counterintuitive that the best way to pass immigration legislation is actually a comprehensive bill. that can achieve more balance. everybody can get much but not all of what they want. and so i think the idea of doing separate bills is just not going to work. it's not worked in the past. it's not going to work in the future. >> to his credit, and advocacy for the dreamers, always wanted to bring up the d.r.e.a.m. act. we say fine, and now let's secure the border. let's have an amendment on that and let's -- so we will always never succeed. it has got to be a comprehensive approach. >> changing the subject, the marketplace fairness act before the senate this week, and i spoke yesterday -- [inaudible] is the states would require to

abandoned their current internet laws. for example, new uk has what's called -- [inaudible] and economic presence law. amazon is also concerned as some states would retain the current laws, not opting to a national system. what do you do to solve the potential problem with some states retaining the state laws? >> when he came to committee, i was reluctant to support the bill because it didn't allow for the different systems within the states, particularly our own state of new york. and i negotiated with new york state, senators durbin and enzi, and they have made changes in the bill so that states that have been different system but still collect the sales tax as we do in new york will be allowed. now newark state supports the bill. but new york will not have to change its system. overstock will just have to

adopt a different state systems. the bill will allow new york state system and other states to continue as is. >> i want to ask, i wonder if both of you could comment about the gun legislation from last week. and if the obama administration did all they could to get that passed or if it's a situation where the president or the administration can't change votes in the senate? >> i've been involved in gun legislation since 1994. i fought for the brady bill and i was a house sponsor of diane feinstein's assault weapons ban when it was in the center. it's a very hard issue. i think it is totally unfair to blame the president. the president worked really hard on this issue. he put political capital on the line. he made it one of the centerpieces of his state of the union address. and he went all around the

country to try to rally support. my view, the way to change the votes on gun issues is, aside from her lying on the colleges of people to do what they think is right, which obviously plays a much larger role than many of you get senators and congressmen credit for. but is to change, is to change the underlying table. and what has to happen is, how were you able to pass these bills in 1984? the broad middle rows up and said we want rational laws on guns. like? because crime is ripping apart america. the police everybody else said we have to do something. and so that passed, 1994 election occurred rightly or wrongly, those two bills were in part blamed are democrats losing control of the house and the senate. and for 20 years not much

happened. and these mass shootings have caused the broad middle to rise up again. and i think we are at a turning point. this is my own view. i don't know what john thinks. i think we're at a turning point. i think the average person, we've always known that the pro-gun folks have the propensity but the pro-gun control people of the numbers. i think the numbers are getting a little more intense. and for instance, when i went around my state last weekend, for the first time in very conservative areas i not only heard from the pro-nra people, you're taking away my rights, but also i heard from people who said, keep at it. where i never heard in those areas before. and i think that's going to happen. this is my own little prediction. i think will bring this bill back before the end of the year and i think you may find some change. we may change the bill a little bit but i think you may find some changes out there in the public. loss of senators -- because of the intensity are not so sure

anymore. >> well, i would just like as i did on the floor, applaud senator manchin and senator toomey who had the courage to come forward with a bill that i thought was very common sense. it wasn't exactly as i had wanted. i think we need to define the internet aspect of gun sales a little better, but i do agree with chuck that i think the issue is going to come back. but we also have to address the fact that we are not putting criminals, prosecuting criminals who failed gun checks. and we are also not addressing the issue of crazy people who are doing terrible things, whether it be tucson, arizona, aurora, colorado, or newtown, connecticut. that is probably the toughest part of this issue. where do individual rights and and the obligation to protect

the population began? and we really need to have that national discussion, i think in more depth. >> [inaudible] is there anything they could have done? >> i don't know what, what the administration could have done. i don't know what more, whenever one of these things fails we point the finger of blame, but i don't come i don't accept -- both pat toomey and senator manchin come from states with sizable second amendment defenders, i'll call them. >> last question. >> this is sort of a segue back to immigration. kincould ask both of you senato, at this point what do you think is the most useful role that president obama could play in

this immigration debate? >> i think the role that he is playing now. and that is that he has encouraged the group of us that came up with this legislation. he has expressed his public support of it, and and at the same time he's not tried to dictate the terms of it. and i think that his role has been very appropriate. and if we get it through the senate and i think he will again weigh-in to try to convince our colleagues in the house to move forward with it. so i think his role has been exactly appropriate. i agree -- >> i agree with that exactly. i asked the president on several occasions to give our group, gang of eight, space.

because we were coming up with a bipartisan compromise, and, obviously, the presence of views on some things are somethings i probably would agree with personally but we couldn't get a bipartisan compromise on, and he was terrific. on me, i was -- i would describe his role as just about perfect. >> i wouldn't go that far last night. night. >> that's why waited for you to answer first. but he said certain not immutable pretty strong deadlines about acting. and gave us the space to come up with our proposal. and that's what we will meet again. i think that this has come from really a bipartisan group in the senate. it's not everything the president wants, he understood that and he is playing the role exactly right. >> thank you. >> could i conclude with one further comment? i do sense a slight change in

the environment in the senate. i think there is a willingness to maybe address some important issues in a fashion that was not the case in the last four years. we averted and 51 votes in filibuster. we are moving forward with a gun legislation. there is every opportunity. i think i emphasize opportunity, for a grand bargain. and so i do, for the first time in some time, harbor some optimism about a chance for bipartisan approach to some of the really compelling issues we're facing. >> i agree with john. is a difference. both sides want to meet -- we hope, i hope, i think john does, too, that are immigration bill sort of sets the model for doing this, coming to bipartisan

agreement on other major issues. there's a desire among the majority of people in both parties, not everybody, but a majority people in both parties to actually do that. so i think this session is going to be a lot more productive than the last few, on a whole bunch of issues. >> which is not a high bar. [laughter] >> [inaudible] spent i think reflection, part of it is a reflection of extreme dissatisfaction that the american people have expressed and our polling data. you know, we all seek approval, that's part of the reason why we do the things we do. and to serve the people effectively. when the majority of americans think we are not doing that, sooner or later that does happen, and integrity approval ratings of congress are really at all time lows. that's not -- in fact i predict if it continues along this path you were going to see a third

party in the united states. the overwhelming increase in voter registration is independent registration, and those people are voting independence plus they don't find a home in either party. sooner or later that dynamic is going to affect the political landscape. >> thank you again. >> thank you. >> [inaudible conversations] >> this weekend we spoke with congressman adam smith, the top democrat on the house armed service committee. he discussed how the united states should respond to intelligence reports.

>> what do we do about it? the president did say it was a red line but my big thing here is that would be cautious about how we respond. i do not want to commit u.s. troops and u.s. forces to syria. i don't think it would be a wise use of our resources. i also think that being able to secure the chemical weapons that are in syria come extraordinarily difficult is possible at all. so we're going to have to have very serious conversations with partners in the region. international partners about how we proceed. because what has not been said by the administration at any point beyond the red line is what that means. what will they do? what is the best response? personally, i urge caution. we do not need another war. >> you can see this entire interview with congressman adam smith the top democrat on the house armed services committee sunday on c-span. newsmakers is at 10 a.m. and

6 p.m. eastern. >> i went in. i walked into the little kiosk. i said i'm bob ney here to report in the guard came up as a walk down. hhe said i do one of your campaign managers in ohio. said okay. got down and there. the guard said here, you have some hate mail. it was in california i remember and massachusetts to get some hate mail waiting on you. they give even a. you go through this most interesting part of the stripped-down, and then i got into the intake, walked into prison, down into the courtyard. the warden, i will useful in which i do in the book by the warden told amanda was posted take me around, get away from them. he can find his own way. and it's either not knowing where to go, where i'm staying, will close to get. these new be close they call them. like pajama pants. and another precious had where is your escort that is supposed

to take you read? i do know, some little guy in a suit yelled somehow let bush. he took me in the back way of laundering. i walked in an and a man a city there and he said, are you the congressman? i said used to be. he said it you're a republican, aren't you? and i said, well, republicans put me in here, you know? i had to pull up some humor. i was the mayor of east cleveland. welcome, i will give you some close. >> more with bob ney sunday at eight on c-span's q&a. >> a house subcommittee today looked at the medical confidentiality restrictions required by law to know as hipaa. several witnesses testified that some parents are unable to get information as on their children's dental health needs. pennsylvania and tim murphy chaired the hearing.

[inaudible conversations] >> good morning. we are here today to the oversight investigation subcommittee of energy and commerce for hearing entitled that hipaa help or hinder care and public safety? as there is a classified briefing, we're going to wait opening statement in order to get right to the witness testimony. we will allow members to submit their opening testimony for the record. a hearing last month addressed issues raised at the newtown tragic some of the witnesses said help hipaa had hindered their ability. we will hear from a number of folks, government representatives, professionals, parents, experts, family members to it's an important issue. i ask all members of the reason we're here is members of congress themselves are experts and an illegal many of these issues we appreciate your attention to this. we are here to ask questions and learn the facts about hipaa from

those who are knowledgeable of them and -- disruptions will not be tolerated and people will be discharged if new. we also are asking members to stick closely to the time limit as we go through. >> will the chairman yield? >> just spent the chairmen and i've agreed to put all of the opening statements in the record and i think that's appropriate given the classified briefing which was just as scheduled yesterday. out of respect to the witnesses, many of whom have come around the country, the chairman and ai decided we really wanted to hear from the witnesses. i will say, mr. chairman, though that this is really an important topic. the transport issue particularly as they relate to gun violence. and so i welcome but it's also important if we're being asked to get the u.s. military or otherwise involved in syria in this classified briefing is what

the sector and state. so on behalf of everybody i want to apologize to the witnesses. some of us may be coming in and out. but we will read a testament and we'll make sure we know what's going on. so thank you very much. >> i also want to let members know i communicated with majority leader eric cantor last evening and he is working on a special briefing for any members who remained. >> you are aware that the committee is -- i say this to the witnesses, and when doing so we have the practice of taking testimony under oath. you have any objection to testifying under oath? thanks. the chair then advises you that under the rules of the house you are entitled to be advised by counsel. do you wish to be advised by counsel during the test was today? in that case we please rise and raise your right hand? i will swear you in. [witnesses were sworn in] >> let the record show the

witness have answered in the affirmative. you're not under oath and subject to the penalties set forth in title 18, section 1001 of the united states code. you may each not give a five minute opening statement but let me introduce the witnesses for today's hearing. the first that we have mr. leon rodriguez, the director of the office of civil rights at the department of health and human services. he oversees the administrativevs division. we also have professor mark rothstein, joined up with him at university of louisville, brandeis school of law and the school of medicine. he holds of law and medicine and is the son of director at the institute for bioethics, health policy and law at the university of louisville school of medicine. you may begin. make sure your microphone is on. >> may i begin? good morning, mr. chairman, ranking member degette and members of the subcommittee. it is an honor for me to be here

today in my capacity as director of the office for civil rights at the u.s. department of health and human services. and i thank you for calling a hearing on this very important topic. as hhs is enforcement agency for civil rights and health privacy rights, ocr handles enforcement policy develop an education for compliance of laws in those areas. our office was an important role in ensuring that an individual sensitive health information remains private and secure and that individuals are able to exercise important rights with respect to the health information. one of the underpinnings of hipaa is an often health care depends for many patients on their trust that their health information remains confidential. hipaa also ensures that health information can flow from important industry purposes such as patient treatment, obtain payment for health services and protecting the country's public health and safety.

i have often said that hipaa is meant to be about another blockage and it is above all to maximize the welfare and interests of the patients. as such i look forward to discussing the existing flexibilities within hipaa. kindle recognizes the vital role that family members play in supporting patients with significant illness, both physical and mental. i have a defamatory stories that were placed in the record and are heartbroken by them. and so, therefore, take seriously this committee desire to get to the right answer on these issues. to directly address the concerns that underlie existing i will discuss the path that the mac officer for providers disclosing information reserve during treatment to protect the health and safety of other patients. for example, hipaa permits personal healtpersonal health io be used or disclosed without an individual's authorization for health treatment and payment and for the business operations of

covered entities. hipaa also permits other uses and disclosures for certain public health activities for law enforcement purposes and to avert serious and imminent threats to health or safety. i would like to talk about disclosures to family members and friends of patients. this is an important area. ordinarily if a patient is not the object the information being either shared in front of family members or friends, or with seven members or friends, hipaa provides a clear avenue for disclosure in those cases. additionally, if a patient is incapacitated, and when i say incapacitated, we mean for that word to be given its full ordinary meaning. health care may still communicate with family and friends of the patient, if the provider determines, based on their professional judgment, in doing so is in the best interest of the individual. and this is i think an important point to underscore. hipaa is meant to revolve around

the professional judgment of the provider as to what is in the best interests of the patient. it is not meant to supplant that judgment. ansa for example, enters can discuss the patient's medical condition in front of the patient's sister who accompanies them to appointment. if the patient is unconscious or otherwise incapacitated, the dr. kent can make that judgment to share information with family members. similarly to the mac recognizes that professional codes, state laws, professional standards of care recognize a duty and authority to warn a situation where patient may pose a danger to themselves or others, or may have disclosed information indicating a threat by another to either themselves or a third person. in those cases where there is a serious and imminent risk of harm to health and safety, hipaa has a clearly recognized disclosure in those cases.

and what is an imminent risk to health or safety, it's not something the stereo of an individual going out to commit a violent crime but it covers a number of possible scenarios that health care provider, particularly and mental health care provider may encounter. we take our obligations to educate providers and educators search the. and it's for this reason that we and the administration took the initiative in january after the tragic events in newtown to issue a letter to the nation's health care providers, clarifying these important points. finally, i want to talk for just a moment about the nature in which we utilize our enforcement authority. we focused our merrily on long-standing broad-based security threats. we have never taken enforcement action because a provider has decided the best interest of the patient to disclose information to a third party.

thank you, mr. chairman. thank you, ranking member. thank you much of the committee spent esther ralston coming a recognized for five minutes. >> mr. chairman, -- >> is it on? pulled it real close. >> can you tell at the microphone is on? >> these are government mike next to drink the sequestered there down 20%. [laughter] spent as is my voice. mr. chairman and those of the subcommittee, my name is mark rothstein i'm on the faculty of the universe a little but am testifying today in my individual capacity. and again let me apologize for my laryngitis. it's seasonal i'm afraid. my testimony this morning i want to make the following three points. first, the hipaa privacy rule is essential to patient care and public health and safety. second, exceptions the privacy rule permit disclosure of health information for important public

purposes, and third, additional measures could enhance the effectiveness of the privacy rule. first, ever since the hippocratic oath, medical goes have established positions to maintain the confidentiality of patient health information without assurances of confidentiality, patients will be reluctant to devote sensitive information about the physical and mental health, their behavior and lifestyle that could be vital to the individual treatment. the privacy rule codifies it is crucial requirement of confidentiality which is necessary for ethical and effective individual health care. health privacy laws also are essential to the protection of public health and safety. to illustrate, this afternoon i will be returning home to louisville. at lunch, i do not want my cook or server to be someone who was reluctant to get treatment for hepatitis a because of privacy concerns. i do not want as my taxi driver

some with chronic tuberculosis who is afraid to get ongoing treatment. i do not want my flight safety placed at risk by an air traffic controller with a mental health problem or a pilot with a substance abuse who was deterred from obtaining behavioral health care. confidentiality protections, therefore, serve to advance both the patients and the public interest. although we were all deeply saddened by the recent horrific loss of life caused by some violent mental the unstable individuals and we should appreciate the potential consequences if new excessive mental health reporting requirements were enacted. each year in the united states there are over 38,000 suicides and over 700,000 emergency room visits caused a self-inflicted harms. an estimated 26.2% of the people in the u.s. have a diagnosed mental disorder in any given year. any steps to lessen confidentiality protections or

mandate the unnecessary disclosure of mental health information could lead to vast numbers of individuals to forgo mental health treatment and potential result in significantly more suicides, self-inflicted harms, and untreated mental illness. second, the privacy rule specifically permits a covered entity to disclose 12 types of health information of importance to the public him and, therefore, the privacy rule does not hinder public safety. among these 12 categories are disclosures for public health activities, about victims of abuse, neglect, or domestic violence, for law enforcement, and to avert a serious threat to health or safety. at 12 public purpose exceptions are permissive. the privacy rule does not require a disclosure. the disclosure obligations arise from other sources such as state public health reporting law. the effect of the public purpose exceptions is to permit otherwise required disclosures without violating the privacy

rules. third, for the last 10 years, inadequate health professional and patient outreach and education programs have led to a lack of understanding of the privacy rule by many of affected individuals and covered entities. a common problem is that some uses and disclosures permitted by the privacy rule are not allowed by some covered entities, perhaps out of ignorance or an overabundance of caution. the 2013 promulgation of the on the this amendment to the privacy rule make an appropriate time for hhs to start a new program of public health care provider education and outreach. in conclusion, the privacy rule i believe is essential to individual health care and public health and safety. additional efforts to increase understanding of the privacy rule by the public and covered entities, as well as revising some of the public purpose exceptions, will enhance the

effectiveness of the privacy rule. i thank you for the opportunity to testify this morning spent i think both the gentlemen -- i think both the german. during the subcommittee march 5 forum we had onto their mental illness, hipaa as a statistical obstacle to getting his am helping you. he explained one of his sons doctors judged him to be quote of extreme high risk for suicide are the bad outcome, unquote. more than once. and yet failed to show -- share this information. matthew tragically took his own life only much later while living with his paintings only after matthews debt that they were able to attain their son's medical records. is this an example were hipaa work as intended? mr. rothstein. >> know, but if hipaa were followed to the lead that would've permitted the disclosure of speed would you agree with that? does have amec provide a license letter from revealing health

information to a young adult living with parents, yes or no? >> mr. rodriguez? >> under certain circumstances it might. in most circumstances there would be half for disclosure. >> does it allow physicians to provide information up to age 26 as a fish by the affordable care act? so if you're still dependent or can you tell me where the cutoff is? >> the cutoff in terms of the patients ordinary ability to object to the provide disclosure is the age of majority, whatever it happens to be any particular state's pixel in pennsylvania is 14, before tino could decide whether the information is disclosed? >> i would assume normally it would be a king. >> are either give me with the term -- with the term, what that term means? >> i am aware of that because if

this hearing. certainly going back to the discussion of serious incapacity and the discussion of serious and imminent risk of harm, certainly situations where that condition either renders the patient to be in a condition of incapacity, or where the consequences of that condition be unaddressed are aces risk of imminent harm to health or safety. again it doesn't mean going out and come in a gun crime. a commune of right and different things that could action harmful to the patient. then yes. in those cases the patient could disclose without dissent. >> i agree. >> it sounds like from what it read from her testimony what you said is that we may find that a lot of providers are misinterpreting or over interpreting the laws on hipaa,

to prevent them from disclosing to patients. is that what you are are suggesting is happening is? >> chairman, we have observed in a variety of our areas enforcement that there is anxiety about our rules and all him the wrong place but if you look at where we've taken enforcement action, it's been focused on institutions that have had long-standing failures to protect the security of all of their patients information. hipaa was designed to respect the providers judgment as to their patients best interest but i think that is often unfortunate misunderstood and that's one of the recently by the clarification and. >> this gets to the crux of the matter of why we're here today and will her testimony from some professionals, experts and parents. what if the provider decides not to show the memo, the information, whatever for those reasons? what if the patient doesn't sign a release? the patient himself does not even recognize they have a

problem. and the parents even go to court tuesday we would like to these records reviewed in some cases the hospital staff can release the records unless the judge says. and yet a condition they still exist that that patient is at risk for suicide or onto themselves are not following the treatment. what then? >> one thing to also keep in mind in answering this question is, hipaa is not the only relevant body of law. so we're also talking about professioprofessio nal ethical standards, both the american psychiatric association, the american psychological association impose clear duties of confidentiality and create exceptions as we do. and, in fact, our rules are built around both those ethical duties and state law duties. such as for example, california board of regents case. clearly in the kind of scenarios where you describe where a

provider is where, for example, the risk of suicide, a very clear situation where w we're talking a serious risk of imminent harm. hipaa does not stand as a barrier, even in the absence of a patient consent to disclosure to anybody who can help the patient, that's a critical element. that% and lessened or removed the threat. if that's the parent then that is what the disclosure well,. >> thank you, mr. chairman. i think we can all agree that the mac provides many important protections for people's medical privacy, and we have a history of bipartisan agreement that people need to be able to keep their sensitive health information private. and so i think we would agree with her witnesses on the importance of hipaa him but also we need to recognize that in many of these mass shootings that we've seen and in many mental illness situations where someone is a risk to themselves and to their families, there are clear to some problems with how

providers and institutions are interpreting hipaa obligations. because it seems that if someone is a danger to themselves or to others, that would be up to the providers decision to advise the parents or other responsible adult. is that correct, mr. rodriguez? >> yes, it -- >> and mr. ross tinker is that current? >> yes spent i'm not going to blindly defend hipaa but i think we should be very, very careful when because of the changes to that statute. we heard in march about providers interpretations of hipaa and how they can be barriers to treating not just financially but also the physically ill. i myself a as a parent, either diabetic child, and even before she was 18 sometimes we had a hard time getting providers to give us information. that's not because of hipaa it's

because the providers misinterpreted have amec. so when we heard these tragic stories today, and that hoping i'll get back from that, i think we need to retake that sicily but we need to look at ways to educate providers. in the aftermath of the murder of 32 people at virginia tech, we learned that hipaa interpretation prevented mental health professionals from a probably sharing information. misinterpretations of hipaa and other private laws were also identified by the gao and by president obama's gun violence task force as an obstacle to reporting individuals who should be barred from gun ownership, to the background check system. so mr. rodriguez, i think you would say hhs has tried to be responsive to these concerns that interpretations of hipaa and other privacy rules have created obstacles, is that correct? >> that's correct state and i just had a letter out on

january 15 of this year to health providers around the country. trying to delineate exactly what hipaa says, correct. >> yes, we did spend tell us why you sent this letter? >> we thought that because of all the concerns about the interaction between situations where a provider is worth information indicating danger to the patient or others come and some of the events we've been hearing about in recent years, that it was important to remind providers of both the duty, the permissions under hipaa, but also to remind them, the ethical stand and the applicable state laws that clear to give him a pathway to report in these kind of situations. >> and hhs recently issued advance notice of proposed rulemaking to solicit public

comment on hipaa, and it receded there is to the reporting of individuals connected to mental health, is that correct? >> that is correct. >> can you expand prevent why this advancement of rulemaking is necessary and what information you're trying to collect? >> sure. in most states reporting as to disqualify an information comes from the judicial system which is not covered under hipaa. we are aware at least generically about some examples. new york and the recent was one very clear example of states were reporting occurred from veterans that were covered by hipaa and reporting with ordinarily have been prohibited by hipaa. we want to understand where and to what extent have amec is a measure in those cases, and take any appropriate steps to remove those barriers. >> just one last question. the affordable care act come in extended insurance to dependence up to the age of 26, correct? >> that is correct. >> but it didn't say that individuals up to the age of 26.

maybe that's a good question for you, mr. rothstein you didn't say individual up to an age of 26 were still considered legally dependent of their parents. because they're getting health insurance, is that correct? >> yes. >> and, in fact, the provision of affordable care act didn't even talk about, didn't even talk about hipaa, didn't? >> correct. >> mr. chairman, i would ask unanimous consent to put his january 15, 2013, letter from the director to providers into the record. >> without objection. >> thank you very much. >> i now recognize doctor gingrey from georgia for five hundred. >> mr. chairman, thank you, and thank you very much for calling this very important hearing. i've been sitting here thinking as a physician and member of the subcommittee that it's kind of

ironic, isn't it, that this law passed in 1996, my, is almost like, sounds like the hippocratic oath, in the first place do no harm can it really in a way has nothing to do with the hippocratic oath which is hundreds if not thousands of years old. but in a way it does touch upon that in the first was, do no harm in regard to how you treat a patient but also this information sharing. because if it's not done correctly, great harm, there is potential for great harm. not only to the patient but to the general public. so i just think, i find that sort of ironic. mr. rodriguez, when was the last time that the office of civil rights under hhs updated the health care providers guide to the hipaa privacy rule posted to

the ocr website? and how about the patients guide, sinking? >> congressman, doctor, we are op routine basis as different issues. as you know, we issued a major role that profoundly affects consumers and providers in january of this year. so we've been busy posting updates relevant to that rule spent that was the gender 20 federal? >> that's correct. similarly when we identify the concerns about gun violence after the new 10 shooting, we took immediate and decisive steps to put this reminder about the manner in which hipaa interacts with the duties to thy were. we're updating our nation. >> with these guys and to common questions about hipaa, correct? >> correct. >> do you receive input from either the general public or the health care providers about the effectiveness of these updates?

>> we do. we speak returning to both consumer groups and provider groups. my door is always open. in fact, i took the initiative is going to connect with several other family members here today because i want to hear from them. i want to know is considered make sure that we're getting -- >> i'm could come right back to you but mr. rothstein, are you summer with these guys? do you have any sense and how effective they are? >> well, i'm not sure how effective they are but i can comment generally about the outreach and education program and with all due respect to ocr and hhs, i think we have a major problem in this area. if you read the regulations, there are ample places where these kinds of issues, problem of notifying parents, the problem of notifying individuals who are at risk is spelled out. but hipaa is a very

misunderstood regulation. it's misunderstood by the public. it's misunderstood by health care providers, and speed let me interrupt you and say that i fully agree with you. as a private physician for a long time before coming here 10 years ago, i knew that. and i think, in fact i wonder if some physicians don't hide behind hipaa just move on to the next patient and not want to be bothered with an article or a cousin in regard to questions about their loved one. i hope that doesn't -- it something we need to think about. mr. kobak to the director of the office of civil rights, mr. rodriguez. how to ocr measure now, i think when i was talking to choose the second sounded like it was more anecdotal from the perspective. but how does ocr measure whether the clarifications that you

reference, january 25 of this year, how do you measure whether the work, how they are working? for example, have the number of privacy rule complaints filed under the various complaint categories been trending downwards with every further clarification, hopefully this most recent one from ocr, does ocr keep track? do you think this would be a helpful metric to track come in checking the performance, your performance of your outraged and education ethics concerning the privacy rules? >> so, in answering the first part of your question, the truth is our caseload has remained steady and, in fact, has grown slightly. over the years since we commenced enforcement. we received something in the order of i think approximately 80,000 complaints since we first began receiving. the amount is fairly steady over the years. part of what's going on here is

you reference 1996 but our rules didn't become final until 2003 and 2005. so there's been a learning curve over the years both for consumers and providers to understand what hipaa requires and what it authorizes. and we often emphasize the hipaa is flexible and scalable. meaning that it is meant to be designed for a very wide variety of health care scenarios. i agree, generally, that our caseload is certainly an indicator, i don't think it's the only indicator, of how well folks are understanding the requirements. i certainly agree with the proposition. i think there have been -- i'm not able to speak for them specifically right now in terms of where patient concerns are, where provider consumes him but we certainly do hear a lot of anecdotal information. >> mr. chairman, thank you for allowing the witnesses to answer the i yield back. thank you both.

>> i now recognize mr. braley for five minutes spent thank you, mr. chairman, for holding this very important issue which deals with the ongoing struggle of public safety. these are not easy issues to deal with. what i think part of the challenge we face an part of the concerns that family members who happened to be impacted by our inability to solve this problem is that these particular provisions you've been talking about, mr. rodriguez, are commonly known as a duty to warn provision. and yet to most of those who understand duty to warn, a duty as a mandatory obligation, not a permissive requirement. and even though i understand completely your explanation of how this permissive disclosure is then subject to state laws dealing with mandatory disclosure, i think many health care professionals, particularly mental health care professionals, look at the hipaa liquid, see that it is permissive and that's the end of the story for them. i would like to hear from both

of you, how are we educating the public, and more specifically mental health care providers, about this bridge between supposedly mandatory duty to warn, provisions that are asked the permissive, and state law requirements that might be mandatory? >> so, one of the issues that i think the drafters of our role in this area were attempting to tackle. because we are talking but i think talking about duties and authority to warrant. in other words, when we talk about, we're talking about an actual duty to warn or to protect -- >> but based on state law, not based upon the land which is hipaa. >> correct. hipaa is meant to get out of the way of those authorities and clear a wide enough blame for the duties and authorities to be utilizing implanted for professional judgment to really be the hallmark of when

disclosure occurs. >> one of the first four and we had on this subject, one of our witnesses with key early who wrote this book about his son's journey to the mental health system and criminal justice system. and he noted appropriately in your that in 1963, president kennedy signed a national mental health law to authorize congress to spend up to $3 billion in the coming decades to construct a national network of community mental-health centers, evan notes on the next page that congress never got around to funding or financing the mental health status. so the process of deinstitutionalization moving from state mental health institutions are community-based mental health care, that was supposed to happen here instead became a process where more and more people wound up in the criminal justice system, and we now have law enforcement officers who often provide front-line mental health care but i think for some of the

families for some of the victims have experienced firsthand the loss of a loved one because of our inability to bridge this gap, especially when a patient is accom t treatment facility by law enforcement officials have a duty to protect the public safety, and they are not provided information about the release of the patient even though there may be a prior history of threats. how do we get to the point where we are protecting the patient's privacy, and at the same time making sure that we aren't blocking the disclosure of information that can protect the public? >> i certainly think we need to continue our educational efforts. that's what that initiative, which incidentally was widely covered in professional media picks i think the reminder we sent in january was something that was really embraced by the mental health profession come is to remind them that lee's hipaa, i can't account for all the professional code and state laws that also apply here, but at least hipaa in those kind of

situations where danger is imposed does not stand as an obstacle to providers acting in the interest of the patient and the public safety. i think it's also worth noting, you know, that is a countervailing concern that patients who fear that their information will not be confidential or to get treated, and that is, i think that's why congressman, when you talk about that difficult balance, that is the balance that both our regulation and health care providers i believe were trying to strike. >> mr. rothstein, one of the other concerns is that if we have a child in a divorce proceeding or a custody proceeding, the number one role of the court system is decide what's in the best interests of the children that is their principal focus. and yet women have told patients who are getting mental health treatment and may or may not be able to make decisions about their own treatment needs,

oftentimes the legal criteria are not what's in the best interest of the patient, but protecting the patient's wishes from a legal standpoint. and that often the advocates focus on that rather than getting the best treatment option that would benefit them in society. what are the obstacles we need to face to deal with that problem? >> a very difficult question to immediate task would be whether the individual is competent, and if the individual is competent, health care providers tend to overlook all the other tests. if the individual is competent and a threat to self or others in that overrules the competency issue if the individual is incompetent, unable to make reasonable decision about his or her mental health, then the confidentiality protection would not apply. >> thank you. >> the gentleman's time has expired. now recognize the gentleman from north carolina for five minutes. >> thank you, mr. chairman. and thank you for, again,

holding this very, very important mental health hearing. especially in love the forum that we have -- in lieu of the forum with the family members. that was a very very important emotional and revealing discussion that we had. which brings me to some of the questions that i have, because i practice in health care. i'm a nurse. my husband is a general surgeon, and juno, hipaa can sometimes get in the way. and as health care professionals, i would say that you would typically err on the side of protecting the patient confidentiality and your self. as a health care professional. mr. rodriguez, i would like to ask you, since the implementation in 2003,

according to my information, hhs has received over 79,920 hipaa complaints. what is the procedure when a complaint comes in? >> sure. the first thing we do is assess whether, in fact, it is a diplomatic complaint at all or whether the complaint is about some other issues outside of our jurisdiction but if we determine that we do have jurisdiction, we then conduct an inquiry, conduct an investigation into the allegations. if we determine that there were violations of relevant hipaa requirements, we then work with the entity, ordinarily, i'm going to talk about exception in terms of our monitor enforcement program. ..

>> can you tell me again since implementation of hippa have there been significant lawsuits filed, is that something you have information about with the alleged violations? when i say lawsuits i mean health care professionals. >> hippa doesn't provide for a cause of action. though there may be a few lawsuits alleging invasion of

privacy or some other -- they refer to the hippa violations but it doesn't provide for it. >> and there again i get back to the ssue of health care providers who would air on the side of, you know, less information is probably better, again always looking out for the patient, and unfortunately always having to cover your own self, and that is one of my areas of concern with hippa because i do believe it is kind of a gray area and it is lost up to too much interpretation. so, mr. rodriguez, my final question i have a little over a minute, do you have a sense of how often hospitals and staff actually go over the regulations and make sure that they are up-to-date? is that done on an annual basis? >> it is variable. we actually did an audit program

last year which is another program required, this was a pilot. and we found a wide range. we found some institutions that take those obligations seriously, do them on an annual basis and ensure that new employees are trained but there are also many providers where that is not the case. the compliance is all over. there are so many things falling on this information. i think this is definitely one of those areas. thank you. i yield back the remainder of my time. >> thank you mr. chairman. let me begin by thanking both of you for your testimony today. thank you very much. it's obvious that you are well prepared. i will address this question to mr. rodriguez. mr. rodriguez, following the

newtown tragedy president of what took action providing to clarify in writing to the law enforcement authorities of threats of violence. first of all, is that true? >> that is true. i signed the letter but it was at the presidential election. >> that was going to lead me to my next question. was it a letter or executive order? >> the letter was really a reminder of the existing duties under the law. and also, of the administration's emphasis that these authorities and duties to bourn should be fully exercised to protect public safety. >> has that action had any impact? >> it has an impact in that there's been renewed discussion on these issues, there was extensive industry coverage of the letter and so therefore we believe there are the folks that needed to reach which are those as particularly the mental health providers.

there were posted on the website and disseminated by a press release and through the various that serves in the hhs to it >> can you describe additional ways of health information technology for economic and clinical health act, which we passed in the recovery act how we and has improved privacy and security requirements for patient records? >> sure. i appreciate that question. first of all, it is done so by bringing business associates within the ambit of the private and security rules. those are the contractors that serve and in fact often come into possession with large quantities of protected health information. we now directly regulate them as we directed health care providers before that. it increases the penalties for violation which we have used extensively for security violations and it establishes

the requirements of the health information. it needs to be reported to our office and the the effect of patience and in the cases of a larger breach also to the relevant media that will be seen by the effect of the patients. >> my question follows can you describe the training of medical professionals receive to ensure they had here to hipaa? >> to my knowledge i want to consider this a comprehensive answer. certainly training on hipaa is offered at many conferences. in fact, we actually have prepared a series of videos that have been posted coming and several more that will be posted on netscape, including some, by the way, relevant to the topic we are discussing here, that discuss various aspects for the privacy and security rules. we are particularly concerned about smaller providers who don't necessarily have the resources of larger institutions. so we are looking for opportunities to reach them.

i also understand there is a medical school curriculum to touch on these as well. >> it is my understanding that health care providers covered by hipaa must notify patients of the privacy of their health information is breached. what methods are used to notify those individuals? >> they can be notified -- they should ordinarily be notified in writing. and again, we also in certain cases provide for notification through the media. >> all right. finally, doctor, even with hipaa projections, we've heard that privacy concerns can cause individuals to actually avoid treatment. i'm not sure i knew that. could increasing information sharing through hipaa cause your individuals to seek treatment? >> excuse me. this certainly is a concern. especially individuals who have sensitive information that they are worried will be disclosed, yes. >> all right. mr. chairman, i yield back.

>> i thank you the gentleman. on the invesaton comme he's asked for an opportunity to join us and so without objection we will allow five minutes to ask questions. >> thank you, mr. chairman murphy. gentlemen, i'm a practicing physician and will see patients this tuesday morning. i have the sense that you are incredibly bright and well versed in this wall and it's totally divorced from the reality of an er physician seeing 20 patient in a shift and at 3 a.m. there is a person that comes in with these issues. i have to tell you -- and i also tell you physicians fear the federal government. the understand that if the federal government comes after them and grabs them in their long legal arms, the physician ultimately wins, but is destroyed in the process. now, i listen to what you say, how this would be to allow certain forms of communication. but i will also say when i read that the maximum penalty is 1.5 million, when the physician

is having their in service that is what they remember. and when they understand that it is permissible not to give information by you may get in trouble if you do, i can tell you they will see the patient at 3 a.m. doesn't have your expertise. but what they do have are examples of physicians who have been grabbed by law and not letting loose until every one of their personal resources has been exhausted. now that is just a comment for now with incredible frustration with the sense that the federal government is denying the entity that the american people have no reason to fear and it has a great reason to fear some people act cautiously. that said, i apologize. let me ask a couple things. we say that they may communicate with the family if there is imminent danger. but what if the patient is noncomplying and come can the family say to the mother of the adult children who lives with her your son hasn't taken his

medicine and therefore we need to do something about that can the physician do that? >> we go back to the idea of serious press. we are not talking about imminent danger in the sense of somebody going out and and what that scenario but it is much broader than that and so if the patient's health would be seriously adversely affected and the providers communication of that information to the parent would provide a way of eliminating or reducing the threat, then hipaa provides a clear authority. >> a patient is bipolar -- i'm a little rusty on my site, this may no longer be used -- but if the arm on lithium and shows the patient is not taking the drug we have a documented fact can the doctor say to the mother he isn't taking lithium. >> you might have heard the beginning of the testimony we

talk in cases of incapacity to it >> i'm sorry, of what? >> evin capacity. >> i'm not saying that they are incapacitated. when the level falls, they don't become immediately incapacitated. they are on the verge but they can still seem same. >> i think the pathway is -- if the result of that would be a serious consequence for the individual's health and hipaa provides a path for those communications. >> there seems to be a little bit of wiggle room. the guy can get back on the nose and bring it back up to snuff. i'm not sure the position would find a safer in that kind of answer. >> well i think the greater safe harbor, congressman, would be this: we have received 80,000 cases since we began enforcing. only 12 of them have resulted in monetary penalties. >> i accept that. but what you are talking about is a fellow seeing patients

three and a shift at 3:00 in the morning who doesn't have your expertise. that is the reality. and i can tell you that what you hear in that in service is that if you violate hipaa, they are going to turn you every which way but loose. i can tell you that would be in service is, because i've been there. >> i would love to see widows and services are because they are not with our history. >> it says the patient health care provider is not permitted to share personal information with the family or friends of van adel to toss the provider not to do so. what if that patient is incompetent? what if they actually at this point in time are not lucid and they think there's black helicopters circulating and their mom is the pilot of one of them? >> and that's why i mentioned -- that is certainly in cases of incapacity and certainly in capacity can input is situation where a patient is far from lucid. then in those cases there is

also a basis. >> sometimes the lack of lucidity is in the eye of the beholder. i will tell you there is a wall street journal article about william brice or bruce, i forget which, he was released and went out and killed his mother with a hatchet. so clearly he was not considered -- he was considered speed yet to be released. i apologize i have to forgo. i'm sorry. >> the chair can ask that everybody be permitted one minute of additional questions and we will go on to the next panel. we have votes coming up soon so we will do one minute. mr. rodriguez as you are aware, states have said confusion over hipaa has prohibited them from sharing 1.5 million records with the national instant background check system of persons who have been in voluntary committed to mental health treatment were deemed mentally incompetent by a court of law and they are therefore prohibited from owning a firearm. our committee sent a letter to the hhs on february 13th asking

about interfering in this list. i know that the hhs has announced it would be soliciting feedback on the reform. why do you believe the states are not applauding those records? >> i certainly have heard of hipaa as one of several different reasons. so why do not understand it to be the only reason. i know certainly in the case of new york state, the reporting was coming out -- or the reporting would have had to have come out of what was a hipaa covered entity and therefore recovering what would have been prohibited. we are now looking to eliminate that kind of barrier. beyond new york i don't know if there are others. >> can you get a written response to this committee on the issue clarifying that? thank you. mr. braley, one minute. >> we were talking earlier about some of the challenges faced with the incredible burdens placed on law enforcement

officials, our penal systems to provide frontline mental health care. this has been a dramatic shift in what happened since congress passed legislation trying to promote community-based health so we now have a long learning experience and people who care about the rights of the mentally ill, like i do, people who care about protecting public safety, like i do want to know what we have learned from these experiences as we move forward and try to create a balanced system that is protecting the public and the rights of patients to get the best possible treatment. when obviously, we've been feeling them. what can we do about that? >> that is a difficult question. on the one hand, we need to increase the funding in the community mental health service. that's for sure. what we can address in this hearing today is the importance of getting out the message of

what hipaa does and does not require. one of the problems overall is that it was intended to be a floor above which medical ethics and state law would take place. but in many areas including mental health areas it is the floor and there is nothing else above it. >> you can offer a written response we would appreciate that. doctor, you are recognized for one minute. >> mr. share i don't know if i can do this and under a minute that quickly. on january 25th for 2013, the hhs published a final rule that makes, quote, significant modifications to the marketing by third-party to the patient for purposes of identifying potential beneficial health opportunities for patients. for instance, many drug companies use third-party to help identify patients in need of care for purposes of inclusion and in clinical

trials. some of the patients including those from my own district have chronic illnesses for which the treatment option exists. with the service still be allowed if such a company come third party company, did not first to the patient consent? thank you. i yield back. >> i'm a little concerned and you mentioned this 26% of people that have a diagnosed mental order, disorder in one year but if you talk about serious mental illness is a smaller percentage. and those are the folks there are incompetent. i speak from personal experience of family members and friends who've been in the situation. don't you think it is a little disingenuous to say here is a group that truly are out of it as opposed to the 26% of the situation will repressions of such like this would be honest

to focus on that group as a for their sake of their family's sake as a unique group? >> the point i was trying to make is if the legislation were enacted that made all mental health records more disclosed. >> so you accept them under the circumstances opposed to the broad 26%. >> that's correct but i'm worried about the discouragement of the 26%. >> someone that has bipolar oftentimes does not have that input and i think we have to be kind of honest about that they have a break and they have no insight whatsoever. >> as someone that has worked with such patient and is close to people seceded -- i yield back. speech repeated estimate thank you so much for being with us today and we appreciate your availability in the future to respond to questions.

as they are stepping up we ask the folks to get ready for the second panel. as we continue on with our previous hearing none -- after newtown and this one on hipaa, the committee is exploring a wide range that deals with mental illness and the treatment etc because of our concerns. i love to make it very clear, all members are aware of this but certainly the members of the audience and people that may be watching. at no time does this committee at any time communicate that those with mental illness or those that are responsible for violence. we recognize that the victims are actually 11 times more likely to be victims of violent crime than monde mentally ill and in the vast majority of people with mental illness are not violent and it's important that we understand that. can the next panel take their seats? as you sit down i will be introducing you. on a second panel we have

dr. richard, a professor of pediatrics and psychiatry at the university of utah school of medicine and the chair of the department of psychiatry and behavioral health and the children's medical center in utah the full disclosure i want to say when i was on the staff of the children's house he was one of my students. she direct the families and health care product that focuses on developing partnerships it and after professionals and family caregivers especially during the transition health care settings mr. wolf is this father of a son who suffered from mental addiction and then we have mr. kelly who is a father of a son with mental illness. mr. brady, we would like to recognize your guest today. >> thank you mr. chairman i'm thrilled to have one of my constituents testify today from parkersburg iowa she has a story to tell about this gentleman that was featured in sports illustrated after he was gunned down by a former student he was

the nfl national high school coach of the year with four of his former players. >> finally we have ms. mcgraw, the director of the health privacy project of the center for democracy and technology. as you are all aware, the committees holding investigative hearings and when doing so has a practice of taking testimony under oath to any of you have any objections to testify under oath? the chair then advises under the rules of the house and in the committee you are entitled to be advised by counsel. do you decided to be advised by counsel during your testimony today? all answered negatively. in that case would you please rise and raise your right hand and i will swear you in. do you swear the testimony you're about to give is the truth, the whole truth and nothing but the truth? the chair recognizes all of the participants answered in the affirmative. you are now under oath and subject to the penalty set forth in section 801 of the united states code and - five minute

summary of your written testimony. without objection we recognize mr. martini. please pull the microphone close. thank you. >> [inaudible] is it on now? okay. thank you. good morning, chairman murphy and members of the subcommittee. i want to say and also an immediate past board member of the american academy of psychology who paid for my trouble today. thank you for inviting me to come and speak with you today about hipaa in clinical practice and the participating in the discussion. throughout my testimony i will be reviewing patient summaries based on my clinical experience with that do not and would easily identifiable information. decisions about the release of psychiatric information are certainly more straightforward when a patient is a minor and not in and said he did. parents and primary care giver is involved in the process are available not only to support the patient also to guide them into psychiatric care. they're not devotee recognize the nature or extent of the leader of emotional problems and this is one reason but child

psychiatrists as well as of the pediatric mental health professionals are trained to involve families and diagnose the treatment. they also know this improves the outcome. all pediatrics specialities struggle with the transition from adolescence into young adulthood. from the period to almost complete autonomy many are not prepared for the responsibly particularly those patients that experience chronic mental illnesses, mental delays and psychiatric disorders. families have provided a framework for their care and in many aspects of their life to read one of my patients had a mild form of autism, developmental delay and anxiety disorder was determined to move out of the home once he was employed. the parents knew, however, he couldn't manage his money, that he was emotionally reactive when faced and new experiences and really couldn't track his medications. nevertheless he didn't want his parents involved in routine care. it forced the parent to go to court, state that their son was not able to care for himself and

must be dependent. unfortunately the ruling in their favor was countered to the goals and psychiatric treatment and it derailed his progress in therapy. psychiatrists spend a lot of time negotiating between parents and their children. we don't want to discourage anyone from accessing care specifically those who will not seek treatment if they believe they will involve their parents. however the application of hipaa regulation should be a negotiation. the patient in his 20s offer from kidney disease. he was in and out of the hospital and the company of his mother. he came into treatment because he was angry and depressed over the circumstances of the disease and subsequent organ transplant. i wanted to involve the mother in therapy and support but he refused because he was concerned about how disappointed she would be given everything they've gone through together to be he was in treatment for about a year and was on anti-depressant medication the drop out of treatment because was too

difficult. two years later, i ran into his position who told me he discontinued his kidney medications and went into renal failure and died. psychiatrist should be able to respect the individual ready of the adolescent or the young adult of the legal protection of hipaa and use the friends and family when necessary to support treatment to be i recognize allowing markham in a kitchen and less privacy for the adult patient or at risk for serious mental illness is a significant change in the intent of law but for to become must we wait for that patient to be at the harm to themselves or others before seeking help from their parents or family to the rules of confidentiality affects the situation still are common among adolescents and young adults like going to college. parents are told even though they are going to be paying the bill they will not have access to medical or psychiatric information without the student's permission to read one such patient with a history of heart disease and ongoing depression wanted to go away to college. her parents wanted her to stay close to home.

she prevailed but within three months she began to deteriorate psychiatrically and mentally. they knew she was ill but they couldn't conct her parents. if the patient had as rious disorder with immediate consequences of the family may not find out about it until they received a bill from 30 days after the event. if there is a bias in the situation, should be towards parental involvement. mental health professionals strive to do what is in the interest of the patient while preserving his or her right to privacy under the protection of law. the basis for the family communication regardless of the bushes at risk of harm to several others. i suggest that the standard be reexamined with a goal of involving families. thank you mr. troup. >> chairman murphy, members of the chemical thank you for inviting me today.

i am at the other end of the age spectrum to buy worker family caregivers of older adults with multiple chronic illnesses, and i think the importance of my experience for your deliberation is that the misinterpretation of hipaa that we heard about from mr. rodriguez and mr. rothstein are far more pervasive than the questions of mental illness. there are americans taking care of their chronically ill older parents or other relatives and i can't tell you how many times i hear from family caregivers that have a parent in the hospital and the family member is expected to do multiple nominations to the conditions, monitor machines and do all of

the care coordination in the community and when you ask about what do i need to know to do this and they say i can't tell you because of hipaa. is that wrong and why does it happen? the features that were already mentioned, there is a training that emphasizes the scary aspect of hipaa. it's often done in a way that if you say anything you are going to be in big trouble. and if the training doesn't say that, then the in formal communication among the health care providers particularly the middle level stuff which isn't necessarily physicians, but nurses, social workers, others were terrified kerrigan to get sued or lose their job. meanwhile laptop's lay all over the place and they aren't paying attention to the actual security of this information. the second reason, and i think

this is very pervasive also elude to its becoming very convenient excuse to avoid difficult conversations with families. it takes time. sometimes it is uncomfortable. it has really nothing to do it privacy of the patient information. why do i have to talk to the slaughter why can't i just tell the patient? if the patient is totally able to understand and 85-year-old mormon with congestive heart failure, moderate dimension, medications and so forth. so i think what we really need is far more education on a balanced level. i think it's instructive that if the next step in care website buy is for family caregivers, the most downloaded is the one to hipaa so people are confused

and they are looking for information. i think that hospitals, recovered entities were never the hour need to be encouraged to provide understandable information to their patients commit to the families, to everyone the deal with. you get a piece of paper. mostly it's about what we can do with your information, it's not about protecting the patient interest at all my question is whose interests are being protected is at the staff members and not getting into trouble? i appreciate that also not being

in trouble. and those are valid. but they should never override the good clinical care and the importance of good communication that older people, younger people, everyone needs to get the best possible clinical care. so it is a very pervasive problem. it's always beyond what you are specifically asking about, but i think it is a kind of water flow once it starts it keeps going and we continue to hope for more clarification. thank you. >> mr. wolf you are recognized. >> mr. murphy and members of the oversight committee, my name is gregg, ceo of the litigation support and official court reporter for the industry in pennsylvania. i'm very thankful for the invitation extended to me so that i may testify and address the needs to change the hipaa wall regarding miners and legally emancipated adults that either have a mental disorder,

disability or drug or alcohol addiction. this will have a positive impact on our society. my son, justin, had caring, compassionate and intelligent young man whose life came to an end december 19th, 2012 from a heroin overdose at a young age of 21. justin was at the university of a sophomore year respectively carried a 3.2 gpa. justin had been seeing a therapist since he was 15 and a half due to anxiety, and a phd. he was placed on adel when he was 17. unlike a physical illness, mental illness as a larger maturation mental one discovers the effect and the result which to treat. in 2012 justin told his mother that he was addicted to oxycontin. she took into the primary care physician without my knowledge over justin's request to be at that time he applies to the doctor of his addiction but when his mother wasn't present he stated he had been using heroin for a few months prior to read

just announced cannot be apprised and didn't want his mother to be informed of his heroin usage. without disclosure of the dr. expressed concerns of justin's mother, told her to take immediately to a crisis center for treatment, however upon the office he convinced his mother threw his drug manipulative behavior to taken instead to a doctor he knew of, which she did to the trusten wouldn't allow his mother into the treatment room, there he admitted to using heroin for the previous year and he was provided some oxen. two months later against his wishes i was informed of his purpose of addiction and implored him to entering rehabilitation treatment. justin was working two jobs with little time to attend treatment. additionally he convinced his mother and i it was helping him with his recovery. another month passed and justin was residing in his college apartment and hit rock bottom. we finally to ken -- we finally get an ultimatum and he entered the of patient treatment for five weeks that summer. once and we have contacted the

intake director to require about his progress to the bayh was informed he couldn't disclose any information under the hipaa regulations. i was frustrated as i couldn't be apprised of my son's condition. during justin's five week rehabilitation i sent him to see an experienced psychologist that ensued until his ultimate demise and is past its december. i explained to the psychiatrist the history of abuse in which he tried to counsel justin and provide an occasion for anxiety and a cd and depression. i learned however leader upon his cousin he hadn't disclosed his heroin addiction to the psychiatrist. he said he tried once. upon his passing his depression and occ medication were found untouched in his apartment. he continued to take his anxiety medication. justin returned to school last fall where he appeared to be doing well pt he even joined a wonderful fraternity where you pledge and was supported by the brotherhood. however, just and obviously was terribly and secretly and it did to sherwen in addition to mental disorders pete he died of an accidental overdose, hiram

overdose just a few weeks later. the doctors no one in our family was aware he was using heroin, he lethal insidious drug. everyone was in shock and disbelief that we found out nevertheless it was too late. i've confronted mr. vince and nine out of ten are not aware snorting heroin is an option which is how he used the drug not by injection. most are also shocked to learn here and is only five to $10 a bag. was alarming to learn that it's actually cheaper to buy a bag of heroin on the street and to purchase per cassette and oxycontin. it even came from the suburban neighborhoods like my son traveled to dangerous place like camden new jersey and philadelphia and pennsylvania to buy drugs to the justin sold some of his personal belongings and items stolen from his mother on several occasions. and he sold his medical to become a vacation that i learned by reading his text messages. i request an exception to be added to hipaa a loving parents of minors with a mental disorder or addiction to maintain legal residency in a parent's home living under the auspices of their parents' care and who are

under their parents' health insurance coverage as specified by president obama until the age of 26, access to that miners's medical records for the following reason colin coke prevention of arms to individual and society, any addiction or mental disorder can be life-threatening to modeling oneself but the society as a whole as indicative of the newtown massacre, columbine, the aurora shooting came just a few. justin would never intentionally hurt himself, but unintentionally his life cut short destroy the lives including his younger brother, austin, who is a type one diabetics and the individuals to assume he told his medicine. after just in passing, he told us of his reckless disregard my driving as well as when he conducted some of his activities. thank god he never hurt anyone on the road. i have pictures of justice department from the last months the demonstrate how he resided including cigarette burns and his bed from nodding off which could have set the apartment complex ablaze resulting in injury or death to himself and others. number two, his stepfather had taken an assault rifle target shooting on occasion for sport.

had we known about his heroin addiction he wouldn't have harmed him. justin often ask my permission to become licensed to buy a gun which i've against despite not knowing his addiction. however i am thankful for not allowing it especially now that i know he was using a mind bending drug -- >> mr. wolf, we are out of time. can you give a final summary and we will come back. is there a final summary you can give to the statement? >> i have some very important points to make and will only take three or four more minutes. >> i will give you an additional minute, go ahead. >> his manipulation as a result of his heroin addiction and i learned that rewires the brains of the only way to experience pleasure is by giving more of the drug. one becomes numb to all surroundings, emotions and in that the resulting in the government should be geared to drug related deaths have risen steadily over 11 years according to a study for the disease control in 2010 drug overdoses killed 38,000 people making drugs and more common close of death in car accidents, guns or alcohol. by comparison 8500 homicides were the result of firearms. according to the 2011 article in

psychology to become accidental drug overdose is the second most cause of death of young people exceeding attributable to firearms from homicide and hiv/aids. according to the u.s. department of health and human services, with an amateur prefrontal cortex, which doesn't develop until 2425-years-old even if teams understand something is dangerous and go ahead and engage in risky behavior. with young adults not having a frontal cortex fully developed, those with mental disorders and addictions exacerbate the irrational behavior. in many circumstances, parents know what is best for their children especially if given the appropriate medical information with which to exercise judgment and guidance to get in effort to help other parents in similar situations i've launched an all-out campaign to the media, president obama call lawmakers in new jersey, pennsylvania, delaware and leaders as yourself to call attention to this issue and to allow before adding additional language to hipaa that may help protect the troubled young adults and their communities from harm. paris aren't able to offer effectively in a vacuum without knowledge by health care providers about the drug enters or mentally disabled legal the children do not have the wherewithal to reasonably think

rationally for themselves. the absence of rationale may result in life written decisions or as a my son's case premature death. hipaa has exceptions for public and safety building. item number five under the disclosures whereby protected all the information can be disclosed without an individual's consent including serious threats to health or safety. covered entities may disclose, protected all the information that they believe is necessary to prevent or lessen serious and imminent threats to a person or the public when such disclosure is made to someone they believe can lessen the threat including the target of the threat. so it should stand to reason language addressing the safety hazard is prudent and necessary. in closing, i am hereby requesting the following language be added to the hipaa exception to avoid ambiguity. parents and legal caretakers of a minor and or an indicated adult with documented drug abuse and or mental health histories will continue to cover the minor and or the anticipated doubled with health coverage and/or continue to support the individual financially will have access to the individual's health care records until the age of 26 to prevent him, her, or the society from harm.

although family and friends or himself couldn't faze him it is my hope would change justin's situation and save millions of young lives in the future. addiction and mental disabilities recasting of the society and check all ethnicities and socioeconomic backgrounds. when you look at the famous and intelligent people whose lives were tragically taken due to mental disturbances and drug abuse, this country has lost a wealth of talent and success, which would have been an asset to the growth and strength of the nation. thank you very much. >> thank you. mr. kelly, you are recognized for five minutes. mr. kelly. >> can you hear me now? thank you, mr. chairman. i am the father of a paranoid schizophrenic son was diagnosed at age 14, which means half of his life he's had this illness. i am afraid i have some rather harsh news and some points to make that are a far lyon and i think mr. cassidy for his comments because it gets to the point. my wife and i upon learning of this diagnosis of embarked on

educating ourselves in every axisf ental health treatment including getting the system, familiarizing ourselves with all of the things that are in our way and then we took it upon ourselves to go out and educate others. we have done that by teaching class is, by serving on boards, we've done that by speaking engagements, we've done it by raising money and also by bringing people into our home and comforting them and holding them to cope. what i'm going to tell you is that we are actually ashamed of ourselves as to what we did not know before our son became mentally ill. and i would dare say that if the members of the committee were to spend a couple of days in the psychosis, this would fly. he would change things tomorrow. and so what needs to happen is the need to be recognized there is a gaping hole and i want to clarify something there's a difference with lack of insight and a psychotic episode. they are two entirely different things. it can last for long periods of time and lack of insight you refuse treatment and you don't

want anyone to help you of any kind most importantly for family members. parents, sisters, grandparents. so what happens is you are setting the stage for tragedy. there is a whole that we are trying to teach, we are trying to address the needs of the severely mentally ill the same way we are the mainstream mentally ill population and it doesn't work. it is illogical. my son has been a u.s. marshal looking for his gun. they thought he was a secret agent. he thinks to this day he served in the iraqi war. he's been naked in the snow and lived under a bridge. he thinks my wife is a stripper and a prostitute and i'm a sexual predator. for an entire year he didn't believe that we were his parents. now you tell me that this individual can possibly make responsible decisions about his care. but when he gets into the hospital, and that is if because sometimes we don't have the recent history from prior hospitalizations to give the new hospital -- by the way, he has been in 14 years he's been in

eight hospitals and four counties in one city dozens of times. so you have a broken chain of treatment. so, imagine the medical system where physicians and treatment providers can't rely on prior history to treat this person. it's beyond comprehension. the other thing that happens is it stifles accountability. and when i tell you that people hide behind hipaa, a 14 year educated man that has been in every such rich impossible and it is only by the grace of god and i don't think there's a plan for my wife and i to somehow make a difference that we are sitting here and that my son hasn't killed himself. he is more likely to kill themselves than he is to live the rest of his life with his illness. and so what we find is once he gets in the hospital treatment can be delayed or not done at all and i want to say this example our sunnis get from the mental health facility the was locked. hipaa was thrown out the window. the hospitals calling us, the police were calling us, the train to pry into his bank records. every policy was enacted to do

this manhunt for my son. they found him four days later. they dragged him into a state hospital with shackles. you can see my statement later. once he was in there he verbally at saudi because of the judge, he was put on suicide watch come to this completely out of it and when the time came for his hearing to see whether he should receive treatment, we were precluded from purchase a pity because of hipaa and that panel looked me in the eye afterward and said we can't do it, our hands are tied to read today's later, the patient, a member was killed in his winning. we don't even want to know what happened. this is what did happen. he was one year in that facility. the abuse and things that happened to him in the hospital and they never, ever let us in. when he was 18 they couldn't live without us. when he was 18-wheeler the enemy and we might have been strangers on the street. we have doctors that have shared with us behind the scenes some things they knew they were going to be in trouble with and they told us we are going to lose our job.

we were members of the community and people know us. so they took chances that when we got outside of the committee there were no chances being taken and we were left out. the other thing that happens is imagine somebody that is mentally ill being discharged back into the society. even under the best plans with families being involved it's a very difficult process. but take a look at someone who is not part of a discharge plan that includes the support network. our son has been released and we haven't found him for weeks wondering if he's dead. hipaa empowers homelessness. my son has been gone. no money, no clothing that is adequate, nothing. gone. we looked on in shelters, gone. we say why didn't you tell us? hipaa says we can't. they preclude us. this notion they have to tell us if it is a threat, will they aren't supposed to let him out if he is a threat. they won't let us do it. so, we search for him from the shelters can't tell if they are

there but and then the next thing that happens is this person that has been released, you don't want this person released like this, and no support, isolated in fear, frustrated, angry, and we are his first target. so people are being released every day with discharge plans and the have no way to transition back into life and you don't want that. you don't want someone that has psychosis as a symptom that pops up and by the way this idea of anticipating and predicting when eminent danger is coming, i just fought in the state of maryland for four months to try to get that across. not one person on the planet can predict the tipping point of someone with a severe mental illness. they can do it. when you try to do is rely on who? rely on the people closest to that person. the family, but they can do it to be we can't give a history text hospital or doctor. what is worse is each year that goes by we have less ability to help so the idea that we are

going to provide information to the hospital is scary. succumb in closing i would like to say that hipaa has a lot of a gaping holes in it. but there is a way to beat hipaa, we seek to find it, which is good. our son and other people's songs deserve the right to be collaborative and inform their state and their child is safe. thank you. >> mr. thomas, you are recognized for five minutes. >> first of all i would like to think the congressman for asking us to come. i would like to think the chairman murphy and the representative following this hearing today on this important subject. my name is jam thomas and the story of yet it was a nightmare that could have been prevented. my wife hasn't been the same since the tragedy occurred and changed the lives of my family and my community. on at june 24, 2009 what started out as a normal beautiful spring morning in the up being the beautiful to beat the beginning

of the nightmare before 8 a.m. a24-year-old former student walked into our high school room and in front of 22 young high school students indeed his gun at close range into my husband. ed didn't survive his injuries and he died on the way to the hospital. if he was only 58-years-old. so many were impacted forever plaid our family lost his son, husband, father, grandfather and brother whom we all loved very much. the students in the waiting room that day along with our extended community lost a mentor to a friend, a teacher and coach. they lost their sense of confidence and security. and the horror of that day will be with them forever. innocent youngsters including our grandson realized that the world has a dark side. the work of a horrible but a truthful lesson that day. bad things happen to good people for no explainable reason to read even when they think they

are safe to read our grandsons were robbed of the deep love of their grandfather and all the experiences they could have had with them. we miss him every day. it could have been prevented. only four days before he was murdered the same young man rammed his car into the garage of an acquaintance and tried to break his way into the home with a baseball bat. when police arrived they were on a high-speed chase. when the ever handed him he was taken to area hospitals for psychological evaluation. less than 24 hours before i husband died, she decided he didn't want to stay at a hospital so not following the device of the doctor. they were not notified even though they had requested a hospital let them know that he was going to be dismissed. the hospitals justification for

not notifying the law enforcement prior to his release even his parents didn't know until they were called later that evening. no one knew that he had been released, but his privacy had been protected. during the investigation into the murder it was revealed that he had animosity towards ed. we didn't know that. when they asked i would have said to the cause and his killer to him and into his grave. what a horror to think i may have to live with that and once again, mark's privacy had been protected. adults with severe mental illnesses are not always to make good traces for themselves concerning their treatment or their actions they make sure they receive required treatment. they may need outsiders to keep them and others out of harm's

way. but deutsch hipaa, even his parents were unable to get requested information or help make decisions for his treatment. so, i would ask you is the privacy of one individual more sacred than of life for more important than the welfare of our general public? is it more important than allowing our law enforcement to know when a potentially dangerous offender is being released back into the very community they risk their lives every day to protect. he was an inspiration to so many in our community and most importantly, he was a loving son, father, grandfather. i urge the congress to update this so we can prevent further tragedies like this one. you are recognized for five minutes. >> thank you very much. we appreciate the opportunity and want to thank the chairman and the committee for focusing on these issues.

the privacy on an organization called the center for democracy and technology which is a non-profit public interest. we like to think of privacy as an incredibly important role making sure that people who are suffering from stigmatizing conditions like mental illness will actually get into treatment. many people express one out of six and surveys consistently that even if they didn't have some guarantees of confidentiality that they would not seek treatment. and that is the reason we have privacy laws. they are not aimed at trying to create obstacles for people necessarily but to create the kind of treatment environment that people with stigmatizing conditions will want to be. having said that, they are not absolute read they have exceptions and the previous panel talked about them. some of the members of this panel have talked about them as well but allows for the

notification of persons and even to the serious imminent threat and a notification of family members' accepting cases where there's been an of rejection by a patient that has the right to object so even if it would be in emancipated minor or some states that allow the miners to come and the treatment on their own and should be able to control the privacy rates in that case. if that objection hasn't occurred and you aren't dealing with someone that is incapacitated, hipaa does provide for the ability for providers to share information with family members, close friends or people that the people designate. i think it is abundantly clear from the testimony that we have heard today that hipaa is badly mangled in terms of how people interpret it. using it frequently as a shield not to disclose information or because they fear liability which frankly is not anywhere in

hipaa. what is frustrating when i hear these and for all of you, too, hipaa doesn't say you can't disclose the and so for people to blame this on a hipaa is just incredibly frustrating because in fact it does allow the disclosure in those cases and where the disconnect is happening is just incredibly frustrating. i'm a privacy advocate but i believe in the reason for these exceptions we tried to take a very balanced approach on these issues and understand the reason why the exceptions exist. yet for whatever reason, the myth that you can't disclose the family matters, and again the disclosure is not bound by the potential for a serious and imminent threat. it is the case of the individual objects that would be the case where you couldn't disclose today i would say more often

than not, again, the experience of the folks at the table not withstanding, people actually want their family involved. all i saw people say to me my mother to malae elderly mother and caring for, i would like to be able to have her doctor talk about her treatment, get the office is telling me hipaa will not allow it to happen. that is so untrue. i'm incredibly sympathetic to the frustration of people who are told that hipaa requires something that it doesn't. and i am trying to figure out what we can do better in terms of educating folks about what hipaa does and doesn't do because it sounds to me like to many people are hiding behind it and in circumstances where there are exceptions that allow for that information to be shared. some of the testimony of the director rodriguez in the first panel, frankly there was a lot

more. i had a greater understanding of the family members than i did before the hearing so that suggests to me this guidance which is good but the letter gives serious and imminent threat. this is guidance about what can be shared with family members because oftentimes they want that information to be shared with one or more of their family members or close friend that is helping to care for them and yet it doesn't happen. and it could be more clear quite frankly and we could find ways of disseminating this. i know where it is on the web site. but there's probably lots of folks who can't find it are not aware that it exists, and particularly when faced with a person and a health care facility telling them, which is probably something that the unfortunately believe that hipaa will allow that information to the fact when in fact it does. i have to answer any questions and i appreciate the opportunity to use >> i want to also say that our

hearts go out to the families of mr. wolf, mr. kelley and simpson. it's a tragedy today for five minutes, i just want to make it clear you stated you have some opinions and your testimony. you are not a licensed providers, and i correct? and you are not a practicing therapist in this field? it's important for the record because on page ten of your written testimony, you said the doctors don't want to share information and, quote, it is a convenient excuse not to talk to families or listen to what they know about a patient and you went on to say that it's easier to avoid difficult conversations on prognosis and treatment options. dr. martini is that true that they don't want to know this information. >> i think the majority of the physicians are interested in sharing that information. and they very much want to involve the families and care.

we know that particularly for psychiatric patients the prognosis is improved. one of the ways i look at it is i see a patient at the most the families are dealing with these individuals on an ongoing basis, and i think any recommendation i made as a clinician is much more likely to be successful if i'm able to get the support of the family. >> kelley in a word or two because it on several of time, in your standpoint because you also talked to providers about these cases, do you think in this case the providers did not want to talk or they did because they felt they couldn't because of their interpretation of the law? mr. wolf? >> yes, my family physician told me later that he did want to disclose it but he felt that he was under the obligation of hipaa rules not to disclose it. >> in 14 years i've never encountered a situation where a provider didn't want to disclose it in fact they went out on a limb and.

>> i can only speak for what the law enforcement told me and they had difficulty getting the information. >> it said law was adequate and the providers are not really aware of the law and they are on justifiably worried about lawsuits and even hospital administrators that pressure the staff not to disclose information. do you think that is true that it is adequate the wavell law is worded and in terms of the we did the information gets out to providers? >> i don't think it is accurate as far as getting out to the providers because both in my son's case with the rehab situation as well as my family care physician, both of them after were confronted both told me that they definitely would have said something to inform me however, again with signing the

hipaa disclosure, they were not able to. i feel they did have an obli the new it was a life-threatening situation with the use of heroin, but they were obliged to follow the hipaa regulations. .. it's just plain and simple. >> ms. thomas? >> i can speak on behalf of the fact i'm a volunteer the in seat four community, and the threat of lawsuit, it prevents us even from feeling like we're able to tell direct family members conditions of patients that we transport. so either it's misunderstanding

that that's what is emphasized in our training. >> ms. degraw, you said 70%, about 39 said they withhold information from health care providers due to worries about how medical information may be discussed. my understanding is that study was unsure health issues not mental health. mike wright? >> that's right. and the time i hav had to prepae for this testimony i look for more specific statistics on persons being held back from seeking treatment for mental health and i didn't have enough time to find something directly. i did find something on the national alliance on mental element website that talked about how about two-thirds of people with mental illness do not seek treatment for a number of reasons, lack of knowledge, fear of disclosure -- >> i appreciate that and if you find other studies -- >> i would be happy to keep looking. >> we have folks here also saying doctors didn't disclose

information and people were overinterpreting the welcome not disclosing at reducing perhaps patients are also overinterpreting. it would be disclosed. uk something very important to you said it is badly mangled. what can be done to clarify law? do we need legislative language? doing i decide case law? more public education? what do we need? >> a badly mangled part was the reference to the fact that we had all this testimony about what's really in hipaa and yet people are kille told in fact tp is something that is not. and with significant consequences coming in the, got more guidance and better ways of disseminating it so it's not come you don't have to work really hard for on the website. absolutely it's the first step we should be pursuing here. and ideally that could be done in conjunction with the professional societies who have effective mechanisms who can reach their members.

having read this guidance, like, it's clear but it could be made more clear, more examples to in this circumstance you can to ask. in this circumstance because we will look forward to getting a specific recommendation. mr. braley, five minutes. >> thank you. i should also know, mr. chairman, that ed thomas' sister is also in the audience today. this is impacted her as well. chand, i think some the things that you testament brought out is there's this misperception that the issues we been talking about today our unique the larger urban areas with a larger concentration people are seeking treatment for severe mental illness. or chris byrd as a town of 2000 people. five years ago this may was nearly destroyed by an f5 tornado. and your husband is one of those people in the town a rally people to come back, put the community back together. and one of the other things i think is so important about your

story is that mark becker is on you and ed knew very well. >> exactly. he was a member opportunity. we had known him his entire life and his parents. and another frustration in getting the treatment, but there again i agree with what they're saying. when it comes to severely mentally ill people, you can't classify them with someone that has cancer or hepatitis or those kinds of things because they're thinking is just not rational. and i think there may be need some exceptions to those rules. >> one of the other things that we know is that from the stories that have come out, you and ed went to the same church as mark becker's parents, so it wasn't like this was a stranger to your family. and i know that the becker family has expressed some of the exact same frustrations as parents that we've heard from the other panelists in trying to get mark the help he needed so that he could put his life back together. i think that's one of the most disturbing things about this is

these are stories we hear over and over and over again. and it points to a breakdown in our ability to get people who need it, the services that they need in communities all over this country. but one of the things that i'm really interested in is how this particular tragedy in your life has changed how people in your community think about the problems we have been talking about. >> it's hard to speak for other people but i do think, i think there needs be more awareness of mental health. i think there needs to be expanded on quite a bit. pictures enough resources out there for people i think the fact that no one knew that mark was released and the threat was for a frustrating to people. never a lot of victims involved. it wasn't just our family. those young kids were 14, 15 years old that witnessed the coach getting shot down at close range in cold blood, and it all

could've been prevented. i think that's a big frustration for a lot of people. he was not able to get out of harm's way and he was loose on the street because he wanted to be. >> one of the other things this points to is i lived with someone with severe mental illness 40 years ago, and i remember the stigma attached to mental illness been. and i think we would like to think that we have come a long ways as a society in dealing with mental illness as something that is just as real and impacts people's lives as much as other diseases. but i think the reality is there's still a lot of stigma attached to it. we like to avoid having these conversations unless it's impacting us personally. so i want to thank all the panelists for having the courage to come share your stories. i know it's been an incredible challenge for all of you. and one of the things that i talked about earlier is this challenge that family members have with adult children, of

being told to have a role in making decisions about their care, when there are sometimes obstacles. and dr. martini can you talk about this a little bit. one of the questions i raised earlier is whether this risk of self or others stand is still a viable way of getting patients to help they need for a truly effective treatment to you gave examples of both sides of the story. won were a families intervention was counterproductive. one where the need for family intervention was not provided that could have been in the best interest of the patient. so how do we resolve this? >> well, i think, congressman, what i would like to do is think about what you last referred to. what is in the best interest of the patient. what do we think is going to help the patient most, help them in their recovery. i understand that there are issues around the release of information and confidentiality.

and understand that patients are sensitive about that, but what we're talking that is not the release of information generally out to the community. what we're taught at is think about particular cases. looking at those cases on more individual basis in deciding if this nation is going to be welcome what's going to be necessary, what kind of information needs to be shared. should that information be shared with family members? are they in assets and can they help out this individual? would it be a good idea to shared information with a primary care physician and their community who quite often coordinates care in a variety of ways? that's also an asset that quite often is not part of the process, in some ways because the patients are reluctant to have any local connection. so it's within interest of the patient. >> think you. easter break, the article you referenced before from sports industry, would you submit that from the binder so it will be a part of the record. >> i would be happy.

>> think you. now recognize for five minutes the chairman from virginia, mr. griffith. >> mr. chairman, if i could pass this on i would appreciate it. >> we will do that. thank you, mr. chairman. the first of all, panel members, i would like to reiterate, think is much for being with us today and for your testimony. i know these are very tough testimonies to give, and our hearts go out to you. ms. levine, you suggest that health care workers sometimes use hipaa as an excuse not to share information, and not suffer because they are afraid of fines or sensors. why else would someone withhold information from inquiry and family members? >> well, because the role of a family member in the care of someone who is, as i aid, most

of my experience is with older adults, although i personally was a family caregiver for my late husband for 17 years. he had traumatic brain injury and was quadriplegic, so i have my own experiences with this system. but family members ask hard questions. they want to know a lot of information about why did this happen, what can i expect, why are you giving this medication when it's on the list that says this is contraindicated? i can't tell you, and this is not to disparage the nursing profession, because they are fabulous, but i've had so many nurses say to me, are you trying to tell me how to do my job likes okay, yeah, i think i am because my husband should not have this medication and that medication together. so there's a kind of, i can't

tell you how many physicians, nurses have said to me, family members, they are pass, they're nuisances, and they are. i am not denying that because the ask the hard questions. the patient in the bed is in pain or a sedated, not going to be trouble. so it's, i think it's a truth universally acknowledged that family members are important on the date of discharge. get them home but not necessarily in the course of hospitalization. but i really think that the hipaa scare, and i'm now concerned that there's not going to be -- i'm already getting e-mails from vendors saying, we're going to protect you from these horrible audits that are going to happen. and if only you hire us, you know, you will be saved spent every time there's a new government regulation, and industry crops up around to

provide services. >> it's not one thing, it's the things support each other. >> let me quickly go to several of the question to one of your recommendations has been for ocr to reinforce the health care providers a provision in hipaa that prevents disclosure of relevant information protected health information, the family caregivers, or others who are going to be responsible for providing, managing come are paying for a patient's care. how do you suggest ocr go about doing this? >> i think throughout, and i agree that the website is one way but not the best way. i think that there can be involving the medical profession, involving the people, the risk managers who are doing a lot of the training, involving the leaders and saying, this is not good patient care. we are concerned about hospital readmissions. one of the reason people come back from the hospital, to the hospital within 30 days and cost

of medicare tons of money is that the family members were responsible for the care don't know what to do so they bring them back. >> do you have recommendations for cms as a? >> yes. cms could definitely encourage as part of the conditions of participation, and medicare and medicaid, to make sure that the training that they are responsible, accountable for training the hospitals and other, and nursing homes, to train their staff in a balanced way. one more thing which i didn't get a chance to say speak quickly, i'm running out of time. >> just quickly. we ask, when we encounter through our contact with providers, patients who object to having a family member involved the it has nothing to do with privacy. it has to do with, i don't want, i don't want to worry my

daughter, i don't want her deado have in response of those. >> okay. mr. kelly, you've observed that a clear culture of fear pervaded one of the facilities your son was admitted to. how does this culture of fear impact decision-making by those health care workers in facilities tasked with taking care of your son? >> and it's more than one hospital, sir. but essentially we are not in a position to prevent horrific things from happening, and we have some candid discussions with staff and doctors in multiple hospitals, whether they will acknowledge the use our hands are tied to hipaa privacy rules. so we tried to go further and emphasize the inability of the patient to take of themselves and make the decisions, and it doesn't phase them. so what happens if the patient gets mistreated actually. so our son was on the wrong medication and has been in horrible condition. it's pervasive.

it's not just isolated. >> thank you. i yield back. >> the gentleman's time has expired. ms. degette for five minutes. >> into very much mr. chairman. and i would like the pedal to know that i have read all your testimony, even though i wasn't here to hear you say. for those of you who've lost loved ones, i deepest condolences. i know as i said in my opening statement, i know difficult it is to have a child with a severe illness. my child has a physical illness, and not a mental illness. and she is now a freshman at college, so i know what you been dealing with in terms of, and dr. martini, i know what you are talking about in your testimony, too. of the parents paying the colleges, the college tuition, parents of the child and are deeply concerned. and yet the child is over 18 and they are wante wanting to become independent, and they did have issues. it's a really hard balance, special when you're dealing with some of these mental illnesses

which, as we learned in our previous briefing in this panel from professional, bipolar disease manifests which is at the root of some of the violence, most notably suicide, that evidence is itself in young men between the ages of 18-25. and in young women at a slightly older age, but this is right at the age where they're becoming independent from their family, and most of the time there over 18. so it's a hard balance. because on the one hand, it's like ms. mcgraw was talking about, you want to show you people do not feel the stigma so that they will get medical treatment. and on the other hand, as parents, we want to know if they are at risk to themselves or to others. and so it's a balance. dr. martini, something you said just a moment ago really struck me, which is, you know, and

trying to grapple with this issue you said that we need to look at the individual, that the doctor, we need to rely on the doctors to look at the individual cases and to see if this is a situation where having parental involvement or involvement of another responsible that would be appropriate to let them know. and i guess, i guess i agree with that but i guess i also come in listening to the testimony of the last panel would, that's exactly what they were saying. what they were saying is, in their interpretation of hipaa, that's exactly what medical providers are allowed to do. and so i think what we need to do is, we need to, providers need to understand what their abilities are under hipaa, wouldn't you agree? >> i think that's a very

important part. i think educating providers about hipaa, also in a way that makes it seem like this is more of a collaboration, that there is information to be gained. and for example, the state of tennessee has created a review panel of physicians that delicate cases and can override aspects of hipaa if the panel, and it's an objective help them decide this protects their situation is what of the. i think those kind of initiatives where hipaa is seen as less of a government regulation, but as a process, something they can participate in, i think outcome would be speeded i agree with that kind and we still have our hhs witnesses here. yes, we do. some of them. i think we should also have our federal agencies work with the colleges. because a lot of these problems seem to come with the colleges trying to balance the important privacy protections for the students, and also letting parents know. and again, i think they would

have some leeway, but would have to work with them to let them know that. >> i think it's a good point. i think there also needs to be some help for them because coordinated mental health care for students, some thousands of miles away could be a challenge. >> this goes to the last thing i want to talk about, because it's not just a hipaa issues. it's also access to treatment they got i think some of you probably seen this in your communities. i was actually at the eye doctor and the assistant came in and she said she had a 19 year-old son, diagnosed with bipolar, and he had become violent. he actually put himself into a 72 hour hold, and then he was released. and he actually, you know, involved his parents and they were involved in this. they couldn't find any mental health treatment for this kid. in denver, colorado. and this is another issue as well. once you are diagnosed, you've got to be able to find trigger.

i think, doctor, you probably agree with that. >> absolutely. i think workforce is a big issue, certainly in pediatric mental health service. we also need to work on access to primary care. the thing to remember is a majority of the mental health problems are actually treated by local physicians in the community. we need to work with them, we need to help them, educate them so that access begins locally. >> thank you. thank you, mr. chairman. >> that recognize the gentleman from virginia, mr. griffith for five minutes. >> thank you, mr. chairman. i appreciate your patience. dr. martini, you were talking about local health professionals being involved and try to make sure people get treatment. is it your opinion for what are your thoughts, hipaa stand in the way of -- trading and a patient's general care physician? >> i think there have been cases that i've worked on where the family, the patient is not what

the local physicians to know about these psychiatric problems. apart because the local physicians indicated know a great many people. i think that, i think a good bit of that anxiety is misplaced on the part of the patient but i can understand but i also think that what we need to do is we need to work with these clinicians and physicians to embolden more in mental health care, to educate them to make them part of the mental health system so that families recognize that the help that they provide is going to be in the patient and the family's best interest. >> one of my concerns we heard from a previous hearing, it took 18 months for the average person with a mental health problem to get to see a mental health professional. and that's of concern, something we need to address. but it would seem to be at your primary care physician might be in a position to shorten that time. just on making the referrals by

saying this is not such a big deal. when it is a trusted family physician, a lot of times they can be helpful in that regard. also in following up, if the professional is not in the immediate community, i've are present a row community, the professional may be in the next committee over, 30, 40, 60 miles, maybe more. if they can then communicate with the local health care providers, it does create some benefits there. from the perspective of the patient, why do you think such an occasion, free communicate between health care providers is important? >> i think, i think on the part of the patient what they will allow them to do is, as you were pointing out, receive services i think more efficiently. i think that the local practitioners understand what's available in the community. what's available not something from the standpoint of medical services and other health services but also from the community, within schools. they are fully with it. what we need to do is mental

health professionals as we need to work with them to teach them what they can do to get them comfortable what they can to end practices. and also teach them when they can, when they should refer to us but as part of that we need to be available. we need to make ourselves available. that's a big question. we do need to increase the size of our workforce but also we need to do this and much more efficient and effective way. >> thank you very much. ms. mcgraw, i noticed in your testimony that the fear of liability for violating hipaa's provisions can be a recipe for not sharing. and i'm just wondering if you're for me with and i hate to ask ms. thomas, but i would ask, are you familiar with suits that go the other way, where permission coulcould've been granted? in ms. thomas this case, the police asked to be notified. he clearly, the police made a determination he was dangers to the 20. they didn't want it out on the street.

the hospital use hipaa as a shield to say we couldn't tell the police anything. so i'm just wondering if you, ms. mcgraw, effort of any suits, and this thompson, did you all even consider suing them for money this dangerous person back out on the streets when hipaa would have allowed at? >> i can tell you that hipaa does not actually have any provision that enable anyone to sue. on enforcement of it. so either patient in terms of privacy rights or someone else in terms of overinterpretation to keep in mind also that hipaa's allowance of disclosures for these reasons we talked about is permissive. it still relies on the detriment of health care providers to make a judgment call about what's in the best interest of the patient. having said that we need to keep in mind that hipaa is the floor and our state laws that may provide good protection, they have medical privacy statutes that could be used to impose liability, but i certainly have never heard of anybody being sued for not releasing

information except in the case of information that a patient asks for it is about them. because you are required under hipaa to disclose the information. you can be held accountable spent i guess my concern is, and i was a practicing attorney for a lot of years, but my concern is that that's one of the ways people like you hate lawyers, and i spent the competence with which you sometimes get recommendation. they can bring anybody back. but it may keep somebody from making that mistake again. here we have an individual in your case, ms. thomas, who the police bring in. is just one car into the back of a garage. is go to either a danger to the or to others. they bring them in, and what psychological evaluation because he is a threat to somebody, and the hospital just lets them walk it even though the police asked for notification. i get everything else, if any that's the classic definition of negligence. i'm very sorry and, ma if you want to answer you can.

>> it was considered as far as looking into a lawsuit. however, we were unable to get mark's records, and we just decided it probably wouldn't be, it really wasn't going to benefit anybody at that point in time to pursue with a lawsuit spent and i respect that decision. thank you. i yield back. >> thank you, mr. chairman. first of all, i just want to say that i hope in future hearings and other events that we will include testimony and participation from the patient community. and i know that there are some -- [applause] i know there's a discussion right of speakers excuse me. we cannot come we're not permitted to have any outburst and i would ask that members -- i ask the folks -- just

continue. go ahead. >> i know there's some discussion about including testimony, written testimony, highly footnoted come into the record. i would certainly recommend that that be done without much ado. i wanted, and let me thank especially the family members who came here with your stories. i know it's got to be very, very hard, very, very hard to do. and it's much appreciated. so i want to understand the examples, the couple of examples that you gave. you had a patient, a former patient with a mild form of autism, and eventually his parents went to court against his wishes because they said their son could not care for

himself and must remain dependent. and you conclude unfortunately the subsequent ruling in their favor was countered you our goal of psychiatric treatment and derails his progress in therapy. so are you saying that that was a bad decision that the son should have been able to do what he wanted to do? >> know. what i was saying was that because the sun would not allow his parents to be involved in his affairs, nor would he let them be involved in therapy, so he couldn't incorporate them into any of the programming that is trying to organize and to treatment i was trying to organize, couldn't involve them in the medications that he was prescribed. and they had serious concerns about how he was going to function because we could negotiate that, because he continued to allow, this was the only recourse that they had.

it went counter to our therapy because the purpose of the therapy, for me, was to make it more functional, that michael -- >> i understand that, but at the point that you are saying if they had been in the earlier, and i understand that. but at the point of someone making a decision, an adult making a decision about what they want to do, is there, i'm trying to understand what a better outcome might have been and could it have been done without having to go to court? >> i think that's one of the reasons i put it in there is because i was searching for another way to have a better outcome without having to go to court. if there was a mechanism, for example, similar to the thing i mentioned in tennessee where there was an opportunity to appeal, or to present the case in front of a review board come

and fall that hipaa, to say this is what's going on in this case, i think it is in this individual's best interest to have the parents involved, have been actively participate because i think it's more likely that this individual would be successful, treatment will be successful, and his life i think will be less traumatized if you have an opportunity to do that. and there's a means to modify what's happening with the hipaa regulations in these particular cases but i think it would be an advantage not just for the family but also for the patient. >> so you asked a question, if there is a bias in these situations, should it be towards parental involvement rather than away from it? >> pardon me? >> what do you conclude? if there is a bias in these situations, should it be towards parental involvement rather than away from it? >> i think that if there is a bias in a situation, my advice

has been to involve families. we involve families as often as possible with treatment and i think that for a variety of reasons, and i think this is going to be a bias in that situation, my recommendation would be a be toward family involvement, particularly if there are no specific reasons within the family, no contraindications within the family, nothing that would adversely affect the patient. >> i'm not weighing in on either side but i think there are people in the independent living community that we feel that a young adult with autism, that there may be some better ways for the individual to live in the community with support, health, et cetera, rather than as you used the word independent at home. do you see that as part of the negotiation that might involve

everyone? >> absolute. in this particular case the goal for this patient was greater independence. what the hope was in treatment was that he would be able to manage his affairs, that the level of anxiety that he felt in these situations would go down, that we would increase the capabilities that he had to manage his medication. the sense was that having his pairs involved i think would have expedited the process. >> ms. ellmers, five minutes. >> thank you, mr. chairman. and i would also like to say to the panel, thank you so much. i'm going to get emotional. for coming and sharing your stories. because this is the only way we're going to change anything in mental health. and then difficult it is for you to come forward. i can just say how much we appreciate your input so that we can make the right decisions and move forward.

without i would like to start, ms. mcgraw, thank you for your comments to my colleague. you know, one of the areas, again, as a nurse in a ms. levine, i completely, i associate myself with your statements because i think sometimes it's easier to just give a blanket, you know, hey, you don't know what you're talking about. you are the founding member. anyone who knows better for your family is you. so unfortunately that's one of the downfalls of nursing. sometimes we share our opinions a little too openly. i am concerned about the misconception of lawsuits. because as we know, there are some in a frivolous malpractice lawsuits out there, and that this is one of those gray areas where health care professionals do not feel that they are protected. and certainly hipaa violations

can be weighed against them. but yet at the same time as farce malpractice, that that is not necessary an avenue that would be taken. am i correct with your testimony? >> certainly there's nothing in hipaa that would enable someone date back again, to the extent that you've seen sort of any lawsuits in the space around privacy violations, they are filed under state law provisions. i don't to malpractice work but again, if you are being come if you're facing a malpractice lawsuit, that's a state law action. >> perfect, thank you. and i would like to ask you a few questions. with your situation, especially and as sensitive as it is, and again i thank you for being brave and sharing that with us. i read over your testimony to find that you were in a

situation where you knew what was happening to your son. you knew that there was a drug addiction, and because of that behavior on his part with the ease, then the election that they do so well, he was able to manipulate and then kind of get his way. and then you were able to get into a treatment facility, but then you were told that they could not share information with you because of hipaa, correct. >> exactly. and the manipulation, the line that goes along with addiction from what i've learned from my son, and some others since this has happened, was just give you one quick example, i wanted him to go to into an inpatient for the program immediately and he said to me, dad, i don't want to go into treatment because of don't want to start using heroin or crack cocaine. and i as a parent have to make the decision, what to do.

and i did my research and i did hear people do smuggle in heroin and crack cocaine and there are a lot of other users, percocet, indicated what he was doing. not letting us know that he was doing the heroin. so, therefore, the lies and manipulation unfortunately we send into an outpatient which he said he would agree to go to. and when i try to confront the patient counselor for the first couple of weeks i was denied any access to any records to be told why he was there. >> that unfortunately is a story that we continue to hear. and i do agree with you. i do think that there are some changes that need to be made. more clarifications i think than anything so that those health care professionals, family members and patients can all understand a little better what can be shared and what cannot, so i thank you. dr. martini, i have just about

30 seconds left, but i do want to say just very recently i was inrltynorthnership for children . i represent the second digit of north carolina. we had a lengthy discussion about mental illness, especially in relation to children. i have a very good friend whose son is autistic, and now is starting to show signs of depression and beginning signs of mental illness. they're having an incredibly difficult time trying to find the correct position for him because of his autism that had already been diagnosed. quickly, could you just say a few words about that? >> i think that availability of service is a critical issue to we need to spend our workforce, not just amongst psychiatrists but among all child mental professionals. we need to work with community physicians. we need to work with schools.

there are ways to provide services for children locally that can be efficient and effective constantly going to tertiary sector. >> thank you so much. i appreciate, the chairman give me a few more seconds. >> mr. scalise, i think he will allow doctor cassie to go first. >> thank you, mr. chairman, and thank you, mr. scalise. every one of you, thank you for your note of reality. ms. mcgraw, clearly we are all concerned about privacy and yet you can respect there's a certain ambivalence that we must have. that's exhibited by this pic so thank you all. ms. levine, the way said that hipaa law should be written is something that a patient understands, i put exclamation mark, exclamation mark, exclamation mark because it is written to avoid liability, not to inform people of what their rights are. now, thank you all. dr. martini, what a great name for a psychiatrist.

>> i like it. >> i asked mr. rodriguez a question, and you put here, if you have a patient who was, if it is used for bipolar and if the level is declining and the patient is to compensate, would you feel the current hipaa laws would allow you to speak to the parent of someone who is emancipated by age or by law that, listen, if this lithium logos and level -- lower, they will have a break? mr. rodriguez seem to indicate that that would be permissible. would you accept that in your practice that's what most psychiatrist or whomever are doing? >> if the patient explicitly stated that he did not want that information should, i did most psychiatrist we believe that if the patient was not an imminent danger to self or others i think most psychiatrist would believe they should not share the information. >> if the patient has a history of being noncompliant with lithium and having bipolar episodes and creating some of

these terrible heart rendering stories occurring, would that change the calculus or would it still be no, we cannot do it? >> i think that when i talked to colleagues of mine about the situation and picketing with the patient that they know is dangerous, if the noncompliant with medication, they inform families and others and to take the risks that they may be in violation of hipaa because they believe that it's in the best interest of the patient. >> is interesting because you say they take the risk, and yet that is a perception and yet some of what we've heard is that that should not be a risk. it should be kind of like wow, don't worry, it's not a risk. that tells me there's ambiguity even among people who are full-time professionals. >> i think that's true. i think the problem is that, it's that idea of waiting until imminent danger. a patient can be noncompliant on

medication for a period of time, look pretty stable, and you know that eventually -- >> not to be rude but we know that there's going to be a pattern of episodes. and so we know, he is on this lithium. i see his level going down, boom, it's going to happen again. he doesn't pull a gun to me doesn't do anything terrible but he does live under a bridge. it does leave his family. he does so all his possessions and run down the street, whatever. in fact, we did the attitude among your colleagues? >> i think it's that if, when there seemed patient, if the patient is stable and is doing well but they know their noncompliant with her medications, understanding the mood disorders are quite often episodic but i think it would be some concern if they told the family but they understand that in many situations they need to do that because the patient has history -- >> so again there is a perception they're running a risk? >> i think there's a perception they are running a risk. >> ms. mcgraw, mr. kelley use a term i'm not quite sure how to pronounce but i think were

awfully with if we hav have a teenager to death in his is far more dramatic than that. a year of no insight. now, this gentleman said that his parents could not know and yet he had the insights. you were on a speaker not quite sure how to address the. by the way, i was also struck, as smart as you are, and you're an expert in privacy, you learn something from mr. rodriguez testimony. i will tell you, seeing 20 patients a night, it was not in your specialty, not tearing this testimony, there is no way that er physician, no way that she can actually be as -- what suggestions would you have as regards bill mr. kelley? >> so, one of the things without a lot of conversation about and when i said i learned something from director rodriguez point was how the concept of incapacity place in the capability to share information with family members, which is

not contingent on serious or imminent risk. but circumstances under which mental health professional can make a judgment about talking to family member when they believe it's in the best interest of the patient, which is in circumstances when the patient is not about to object or incapacity. looking to the guidance that is right in front of you about the ability to talk to family members, the issue of the incapacity which is, in fact, in the predatory language is not really explored in very much detail. so it does leave a lot of uncertainty on the part of providers about how do they comply with and what does that mean. it certainly would be helpful to have the guidance to explain the issue a little more detail. >> i yield back. >> mr. scalise come you are now recognized for five minutes. >> thank you, mr. chairman for having a hearing. and especially want to thank those sentiments have been impacted by mental illness for

coming and sharing your stories with us. we had i thought a real hopeful forum back in march 5 where we had some other family members, including pat mileage was from my district whose son matthew took his life, was being treated for mental illness. they thought they were making progress. they both, they were trying to get information from the doctors and the treatment centers, and were not able to get that information. and hipaa was being thrown out as the reason that they couldn't get access. it turned out after the fact unfortunate aftermath he took his life that it has filed he had actually authorized his parents to have access to information. so it was incredibly come an incredibly frustrating, angering for us getting this as a form we have but especially to them as parents who are trying to get the right kind of help for the

kids, for the son and just couldn't, couldn't get that access. and so when we hear these stories, i know ms. degraw, you talk about them, ms. thomas, that people hiding behind hipaa when it turns out the hipaa may really not be the impediment. how do we get some clarity in hipaa to remove this great area if it's even in fact gray, that stopping vital information from being shared with family members, even in cases where these patients want their parents to have the access and yet it is being denied? anybody from dr. martini, maybe go across it if we do try to figure out what is this disconnect that stopping this information from being shared when the law by many people's own interpretation doesn't preclude that information from being shared. >> i think i think that the thing that is missing in situations is a discussion of the clinical presentation, in

looking at these cases on much more individual basis and providing within the law some flexibility for whether it is a. of whether it's in followed by clinicians so that there is an opportunity for psychiatrists and psychologists to present the case to an objective body to make a request for modifications in hipaa in those particular situations but again, thinking about what is in the patient's best interest and to have that objective body will on that process. i think somehow making it feel as though this is not simply the government telling people what to do but it's the government giving people an opportunity to protect the rights but also to ensure that patients get the best care possible. >> ms. levine? >> i think we need to start with medical education, nursing

education, and all other kinds of education to have objective people presenting the rules of hipaa, what is permissible, not the risk managers. i'm sorry if anybody here is a risk manager. but i think people, i think this perception of the legal liability, yes, anybody can sue anybody for anybody -- anything, but the real risk is in the security of the electronic data. and that seems to have been ignored in all of this at the max care. the "washington post" speed is i apologize but i believe that one minute left and i want to get the remainders. >> do the education in an objective way, balanced way and think about the patient's best interest. >> i just want to say that i feel that the parents, it's very important for parents to be apprised of what is happening with their children.

even when they're legally emancipated and i think that's important to put into come because of the obamacare, we do take care and to the age of 26 under our insurance, i would not have lost just and if i was made aware of what he was going in fort dix i think the parents have to be made aware we are the best caregivers with regard to actual -- it has to be an exception in regard to that. >> thanks. mr. kelley? >> i would like to ask the committee start expanding the definition of a family member beyond a parent. this, other members of the family that are in these roles. but quite frankly change is hard. and i want to thank ms. mcgraw from the bottom of my heart because it's taken so long to hear what she just said. we need to change things. sometimes you can't get change unless you change things. >> ms. thomas? >> i guess i would agree with what he said.

i think we need to be made more aware of what the mac actually does prohibit. and i do think there probably should be some special clauses therefore the mentally ill. >> ms. mcgraw, filed? >> more guidance, clear understandable disseminated to places people can easily find it. maybe a hotline for questions. >> thank you, mr. chairman. yield back the balance of my time. >> the gentleman's time has expired. at this point we'll finish test want to understand that the ranking member has unanimous consent request. i do want to state this. this committee has a practice of only accepting sworn testimony to we are going to be asked to accept a letter signed by a number of organizations which state in his first paragraph that there's a statement for the record, i want to say that we only became aware of it at 7:15 a.m. this point and we've not had time to fully review this statement. in this case it is not a letter,

but as i said before a statement for the record. which does not follow the traditions of committee for sworn testimony. moreover, this is what a person privilege for the chairman. one of the groups have signed this letter for the record has circulated false statements about the chairman and ranking member, and have repeatedly and purposely misrepresented the serious and important work we're doing here on behalf of patients, families, health care providers and the public. they have repeatedly and deliberately mr. percentage equity work with false statements. thus, in this case to make a statement for the record without it being sworn testimony is of concern to the chair. and i yield to the ranking never. >> mr. chairman, i would ask unanimous consent to place a letter dated april 25, 2013 about the position of these organizations regarding hipaa, signed the mac and civil liberties union, the artistic self advocacy network.

and i would ask again the consent to put this in the record as the opinion of these organizations. as we've discussed before, i've been on this subcommittee now for 16 years, mr. chairman, and it's always been the practice of the committee to take testament under oath, and you're absolutely correct that this letter obviously is not under oath. it is also been the practice of this committee do to get extensive information from folks who might have expertise or opinions or otherwise. and i've seen this happen numerous times from both sides of the a. simply accepting a document into the record does not necessarily imply agreement with the position stated in the document by either the chair, the ranking member or any other member. but rather it helps to give a more full picture of what people think. but i agree with you. i do not consider this april 25 letter to be testimony or to

substitute for testimony. i believe that it is a statement of the crewcut and we've done that. i get many examples i could give but in the interest of time, i send as for the chair's comment of putting this in a look forward to working with you so that we can clarify documents that would be put in the future. i would also note, we also did put an article from sports illustrated in the record today. so seems to me this letter would be appropriate spent i think the ranking member. out of my respect for the ranking member, with unanimous consent we will accept this into the record. at this time the majority will also put a statement along with that. i do want to thank the panelists today. continuing our series to do with his critically important issue for the american people. not since john f. kennedy was president i think have had such a focus on the issues of mental health and mental illness in this country. your statements today, the

statements of family members, again, our '70s and prayers go out to you. the expertise, dr. martini and ms. lene, ms. mcgraw and those are for s.t.e.m., i ask that you stay in contact with this. we have a great deal of respect for what you've given to us today and look for to working with you. i almost, i would also like, i am very proud of the committee members on both sides of the aisle. i think that the members here have shown absolute dedication to working on this. the statement we heard earlier, 30,000 suicides, 700,000 emergency room admissions from people have attempted hard to themselves, all ages in fall. this committee is focused more than any other subcommittee i think in congress in memory, has worked on this but i deeply think the ranking member for her compassion and her passion on ththis but also think mr. braley for bringing ms. thomas today. thank you all very much. in conclusion, i remind members

that 10 business days to cement questions for the record i ask the witnesses all to agree to reply prompted the without the committee is adjourned. [inaudible conversations] >> two house subcommittees today held a hearing examining the status of islamist terrorist groups in chechnya where the two boston marathon bombers have root. subcommittee chairman dana rohrabacher was critical of both the administration and congress for the handling of the region.e >> does anyone else have desire for an opening statement?ent. if not let me note that we did try to get the state department representative here with ustry

today. get a we wanted them to send a witness to tell us what they thought was going on in central asia andhat chechnya and the caucasus going on region. i but they declined. and they are too busy to send someone here, united states congress, and to speak with thed american people through public hearings like this.here, ugey are just too busy on othero matters.hearin like that may well be part of the onr problem and that this region has not gotten the attention that it deserves. there's a map of the region over there, but let's just note that central asia as we're describing in the caucasus, represent a huge chunk of the planet. and if that area comes under the domination of radical islam tha. makes it its job to attack thedl united states or to attack othe

countries, not just the united states but other non-muslim not a disastert would be for every person on this planet. that would be, usher us into an era that will be of violence and mayhem.us that will be hard to get out ofn so we need to pay attention to d the caucasus, and when he to work with those people who will. work with us to see that that does not happen. th and i don't believe that we have worked, number one, paid attention that does not happen, and i don't believe hat we have wo here until it stuns us as it did in boston and did on 9/11, and we've also not been cooperating and working as hard as we can with those other countries. i would put my finger on russia where we could have well worked

a lot closer with russia than we have been. as the judge pointed out and as the ranking member pointed out, we can do so without giving up our commitment to human rights and not complain if the russians are doing something wrong, they can accept some criticism as we can if we're doing something wrong, but that should not prevent us from joining forces against radical islam which threatens to kill our children >> yesterday, president obama delivered remarks at a memorial service honoring first responders who died in last week's explosion at a west, texas, fertilizer plant. the death toll currently stands at 15, with at least 200 injured. this service took place about 20 miles south in the city at baylor university in waco, texas. the president spoke for about 15

minutes. [applause] >> thank you. thank you so much. thank you. please. thank you, senator cornyn, governor perry, president starr, gathered dignitaries, the community of baylor and waco, most of all, the family and the friends and neighbors of west, texas. i cannot match the power of the voices you just heard on that video. and no words adequately describe

the courage that was displayed on that deadly night. what i can do is offer the love and support and prayers of the nation. the book of psalms tells us, for you, o god, have tested us, you have tried us. we went through fire and through water; yet you have brought us out to a place of abundance. ..

the high waters. we pray for those in boston who have been tested and the wounded whose greatest tests still lie ahead. but no this while the allies of the world may have been fixed on places far away, our parts have

also been here. your time and tribulation. even admits that such sorrow and so much pain we recognize, and we give thanks for the courage and the compassion and the incredible grace of the people. we are grateful for the mayor and all of those that have shown such leadership during this tragedy and for the families and neighbors graveling with unbearable loss we are here to say you are not alone. you are not forgotten. we may not all live here in texas but we are neighbors, too.

we stand with you and we do not forget and we will be there even after the cameras leave and after the attention turns elsewhere your country will remain ever ready to help you recover and rebuild and reclaim your community. [applause] until last week i think it is fair to say that few outside of this state have ever heard of west and i suspect that's the way most people like it. [applause] it is true that the weary

travelers and now the world know they can rely on the czech staff for the stretch of highway. i want to say by the way all of the former presidents in dallas said their thoughts and prayers and george w. and laura bush spoke about the even better company as they have driven through. willie understand is what makes west special was not the attention coming from the far-flung places what makes it special, but put on the map is what makes it familiar. the people who live there, neighbors you can count on, will

places that have not changed, things that are solid and true and lasting. most of the people know everybody in the west. many of you are probably descendants from some of the first settler some immigrants to cross the ocean and kept going so for you there is no such thing as a stranger. when someone is in need you speak out to them and support them and you do what it takes to help them carry on. that is what happened last wednesday when a fire alarm sounded across the quiet texas evening. as we heard a call went out to volunteers, not professionals, people who love to surf and want to help their neighbors the call went out to the farmers and

welders and funeral home directors the secretary and the mayor went out to folks that were tough enough and selfless enough to put in a full day's work and then be ready for more. together you answered the call. you left your family, jumped and fire trucks and rushed to the flanks. when you got to the seam, you fought back as hard as you could knowing the danger buying time so others could escapes. of about 20 minutes after this first alarm thus by shuck and the west changed forever. today or prayers are with the

families of those we lost, the proud sons and daughters who live on in our hearts, parents who love their kids and leaders that serve the communities. they were young and old from different backgrounds and walks of life. a few of them were just going about their business. an awful lot of them ran towards the scene of the disaster trying to help. one was described as the kind that was always ringing with folks in need of help. help he always provided. that is just who these folks were. our thoughts are with those that face the long road, the wounded, the heartbroken, families that lost their homes and possessions in an instance they're also going to need their friends in

texas and all across this country. they will still need you to sw that call. they will still means those things that are lasting and true the scripture teaches us a friend loves at all times and a brother is born for a diversity. for the people just as we have seen the love you share in better times with brothers and sisters, these hard days have shown your ability to stand tall in times of unimaginable adversity use all the leaders that lost close friends and you saw it in the hospital staff that spent the night treating people that they knew toiling through their tears as they did what had to be done. we saw it and the folks that

helped in nursing home and putting one man who drove an elderly resident to safety and then came back to do it again twice. we saw in the people so generous that when the red cross set up a shelter for folks who couldn't go back to their homes, not that many people showed up, because most had already been offered a place to stay with their friends and colleagues and neighbors. firefighters from surrounding communities than the station's so the volunteers could recover from their wounds. students stood in line for hours to give blood and a nearby school district opened its doors to the students who can't go back to their classrooms putting

welcome signs on lockers and in the hallways. so that's the thing about this tragedy. this small-town family and extends beyond the boundaries of the west and in the days ahead. there will be the temptation to wonder how this community will ever recover and the family that lost such remarkable men of the sort that we lost in that video. there will be times when they simply don't understand how this could have happened.

but today i see in your eyes what makes west special isn't going to go away. instead of changing who you are, this tragedy has simply revealed to you have always been. it's the courage of deborah. the courage would be west bank. [applause] it's the love of carla who used to live in west but now lives in austin and last week she drove all the way that. i had to be here, she said. you have to be here for family.

that love will keep us going. for someone like john that will sustain the good people for as long as it takes this church was damaged in the explosion sunday the congregation to read what happened is all full he told them, but god is bigger than all of this. [applause] dhaka is a bigger -- god is bigger and he is here with us. he's bigger than all of us and he is here. it's not just your town that means your courage and love and faith, america does, too. we need towns where if you don't know what your kids are up to then the chances your neighbors do, too and they will tell on those kids in the second.

america needs towns that will fund raisers to help pay the medical bills and then take the time to drop off a home cooked meal because they know the family is under stress. america needs communities where there is always somebody to call if your card its stock or your house gets flooded. we need people who love their neighbors and themselves that they are willing to lead on their lives for them. america needs towns like west. [applause] that's what makes this country great is the towns like west. you have tried us. we went through five year and water yet you have brought us out to a place of abundance.

you have been tested and tried. you have gone through fire. but you are and always will be surrounded by an abundance of love. you saw that in the voices of those videos. you see it in the firefighters and first responders who are here. [applause] all across america people are praying for you and thinking of you. when they see the faces of those families, they understand these are not strangers, these are neighbors and that's why we know

that we will get through this. make doggett brandt piece on those who lost their families and may he continue to bless of this great state of texas. may he continue to bless the united states of america. [applause]

as an act of faith. i dedicate this library with an unshakable phase in the future of the country. the honorable to lead the country as brave and noble as the united states. what effort challenges come before us i will always leave our nation's best days ahead. god bless.

the house foreign affairs committee held a hearing focusing on the president's 2014 budget request for u.s. foreign assistance programs. the proposal includes $20 million for the u.s. agency for international development and 898 million for the millennium challenge corporation. witnesses include the u.s. aid administrator in the millennium challenge corporation ceo daniel. this hearing is just over two hours. >> the international affairs budget request. given the deficit we must be rethinking how and where and why

we provide for an aid. it must provide the security and support our national economic interest and must be efficient and it has to be effective. it must advance space principles and develop reliable trade partners and must be implanted in a way that breaks the cycle of dependency. over the past decade, u.s. aid has seen its mission to the way. the global coordinator that manages the largest u.s. global health program in history is housed in the state department. the mcc is created and has been created as an independent agency with a mandate to reduce poverty through economic growth. so it has been a challenging time for usaid. indeed the bush administration stood up in the millennium challenge as an alternative a way to break with of the tie-year-old development

approaches for decades had failed. but it has had its challenges, too. so called compaq's in the early days were big and complicated and overly optimistic. this has improved some, but they may stay true to itself. getting pulled into countries where you don't belong could ruin the recipe for success. bye demanding that the countries we are aiding have great policies in place buy strictly monitoring and elevating impact, m. cc served for a lab that does and does not work. it is getting countries on a path towards graduation from foreign assistance and that is why many of the administration's initiatives are borrowing from the model. this is progress if it is well implemented. the president's proposal to reform the international food

program helping more at less cost is a bright spot in the budget request. for much of our food aid this proposal with remove conditions that commodities would be u.s. bought and shipped. studies have shown these conditions only make for slow and inefficient program, and i will add that in terms of being a flagship they are owned by a carrier in scandinavia. it is elementary that buying food closer to where the humanitarian crisis is taking place is faster, it's cheaper, it helps save more lives. only in recent years has the u.s. been able to experiment with a small pilot program to buy food close to the crisis. this regional purchase effort has been found to be 11 to four weeks faster and it's also been found to be 25 to 50% cheaper.

essentially the administration proposal would in a process called monitor is asian. this is when washington by as american grain, gives it to international charities who in turn sell it in poor countries. congress is investigated called this process inherently inefficient and found that resulted in loss of $219 million over three years that is an average of 25 cents on every tax payers dollar. it's not just the waste that should bother us, but the harmful impact of dumping such commodities which can destroy local farming and increase the dependency on aid that we would like to see ending. i look forward to working with the ambassador as well as the ranking member to advance this

ambitious timely program, and i will now turn to mr. sherman of california to recognize him for his opening remarks. >> thank you mr. chairman. i don't know if any of my democratic colleagues would like me to yield a minute to them, but if they would like i will. if not, i will give a hastily created opening statement. that opening statement is appreciated and its quality will effect the number i've had to prepare. our development is the right thing to do and that is reason enough for us to pay for it. but the american people are also told that it achieves our foreign policy objectives. one of those is to lift all boats in the world because it's

in our foreign policy and economic interest the countries of the world will be able to afford our products. it is said often by the proponents of foreign aid that it is the most poor dispossessed that have become terrorists and wage a war against us, but the vast majority of the 9/11 hijackers came from one of the wealthiest countries of the middle east. one element of improving our image in the world is whether we tell people who are getting the aid that it is in fact american aid. one thing that disturbs me with our aid with regard to syria but also other places is that we are deliberately obscure in the fact that it comes from the united states to the american people will occasionally face the choice to provide aid to people where who live in communities

where there's such antagonismto america that if they knew it came from the united states they may not want coming yet syria is of course a difficult situation for us. i will be asking our witnesses what we are doing to make sure the recipients know that this comes from the generosity of the american people and where there are circumstances where an order for the aid to be effective, accepted, in order for people to be willing to work with us or for the workers to be safe, we have to obscure the fact picking up on the comments about local sourcing i will want to year your comments there. one thing to keep in mind is that one element of the coalition in support of american food aid is american agriculture. do we give up some of that support in order to be more

efficient perhaps spending a few less dollars less efficiently to provide food aid aroundhe world. as it is pointed out so when our commodities as price of the program and they drive the prices down and disrupt local markets and they're also circumstances particularly where there's been a disaster nearby where we have to buy food and by eating a lot of food which might seem to help the local economy can disrupt and bid up the cost of food and those analyzing the spring have pointed out that much have been caused by anything the increase in food prices in the arab world and the increase in the commodity prices. looking for some indication -- i yield the remainder of my time. >> thank you.

usaid supports the moral values of our country. the diplomacy is sharing that abundance with the rest of the world. it is the program not only for the agricultural sector and the farmers but for the goodwill of the united states and i look forward to the testimony. i look forward to looking at how to make this the most efficient possible as well as continuing to support american diplomacy through the usaid program. i'm very interested in the testimony and looking for ways the congress continues to partner. with that i yield back. >> the chair is pleased to yield two minutes to an opening statement from mr. smith and the

global health. the emphasis that they're giving to the nutrition and food security and particularly our foreign assistance to ensure proper nutrition and the first 1,000 days of children's lives from conception to the second birthday to reduce the impact of the malnutrition that leads to a myriad of health problems including stunted growth and the development of an estimated 165 million children under the age of five in the world today. in september of 2010, i joined seven african first lady's in new york city at a round-table initiative launch of this initiative. what was abundantly clear then has been reinforced by the empirical data that shows that the first 1,000 days of life is a unique once in a lifetime window of opportunity for better health. and it is without parallel. much has been achieved.

obviously much more needs to be done. unicef issued a landmark report and the call for further action called improving child nutrition and the imperative for global progress. the executive director says it is the first 100,000 days of a child's life can last forever. the right store in the life is a healthy start and it's only the start from which children can realize their promise and their potential. he says we owe it to every child everywhere. the report further reinforces the growing international consensus that this nutritional focus deserves a much higher priority in international development initiative than was genuinely were previously realized. the report emphasizes, and i quote here, insuring adequate micronutrient status in the women of reproductive age, pregnant women and children, improving the health of expectant mothers, the growth

and development of unborn children and the survival and physical mental the look of children up to five years of age u.s. aid feeds the strategic focus on improving nutrition during the first 1,000 days of life as one of the most important contributions in our foreign assistance can make to the global health and works synergistic with initiatives to mitigate malaria, hiv/aids and other devastating diseases around the world, but including and especially on the subcontinent of africa pete thank you. >> thank you mr. smith. in our last opening statement will be made by wrote island for one minute. >> thank you to the witnesses and welcome to the committee. i want to just begin by thanking the leadership, and as we all know, our investments in the development are not only important for us to do in our national security but they are important because the american people benefit when we help to create a more stable and space world, i particularly want to

compliment you on the work is being done to reform the food aid and the whole u.s. aid for word and the great work that mcc has done in other places around the world and this is an opportunity i think for us to really reinforce our responsibility to make these kind of investments around the world which is what the great strengths in america that we bring these values and director values and i just want to compliment both of our witnesses for your outstanding work and i look forward to the testimony. >> this morning we are joined by rajiv shah and the chief exhibit officer. dr. shah is the 16 that a master of the u.s. aid and previously served as the undersecretary of research education and economics at usaid and chief scientist at the u.s. department of agriculture.

welcome, dr. shah. and then we will hear from dr. dr. yohannes who was the director of the mcc in 2009. he was in the financial service director including the vice chair of the management committee of the u.s. bank. welcome to both of our witnesses. without objection, the witnesses for prepared statements will be made a part of the record. and members may have five days in which to submit statements come questions, and extraneous material for the record. gentlemen, please feel free to summarize your statement. we will begin with dr. shah print >> thank you, chairman americas. we appreciate your leadership and guidance as we have conducted our reforms and improved our performance. i want to take this moment to thank the chairman and ranking member for their leadership and support and representative

sherman, smith and others who've made important opening comments. i want to thank you for the continued partnership to ensure that america has the capacity to effectively protect its values around the world through our development and humanitarian activities and to do so in a manner that advances our national interest while delivering results. this is important for development drawing down from the war and how we have the ability to imagine how america project itself and its values around the world. president obama and secretary kerry like clinton before him have repeatedly commented on the elevating development as a part of our national secure strategy including as a part of our economic competitiveness strategy. i note that perhaps the most

significant moment i had in this role was an opportunity to visit refugee camps on the board of somalia during last year's tragic famine. i had the opportunity to meet women who've been through extraordinary challenges and efforts to bring their literally starving children to safety. some made it and were able to bring their children and others were not. but in that context, i had the chance to see first hand when they walk through the camp and got into a place that was safe it was american humanitarian effort and development that gave them hope. as tragic as the moment was just a few months ago i had a chance to visit malaysia and i got a chance to see a side of the other hope that is taking place there. i noticed the day before my visit, usa ied had worked with the local partners to install

more than 600 street lights and for the first time in two decades, people were able to come out peacefully and celebrate in the evenings. we were replacing piracy on the coast with small-scale fishing infrastructure and helping people leave idp and refugee camps to come back for the communities supporting the revitalization of their own agriculture in more than 400 communities in that country. that half from dependency to solve this debate is efficiency and dignity and growth is what our assistance should be like. and i hope that we get to discuss whether today this approach is delivering results. we believe it is. our signature program which started when we cut back on agricultural investments in 23 countries to focus on 19 where we thought we could make the biggest impact has reached more than 7 million households and is helping reduce stunting as the chairman noted in more than

12 million children that are previously lacking effected nutrition. in the countries we are seeing extreme poverty being reduced at an average rate of 5.6% significantly higher than in the counterpart nations. we are working with the private sector to motivate $3.5 billion of private investment to be complementary to our own investments in quoting having raised more than $500 million to development credit authority to those purposes and we are implementing policy reform along the way. this is just one example of how a large scale modern results oriented efforts can work and deliver critical outcomes. it's the result of an effort that we call u.s. aid for word of which i'm able to describe in terms of our progress today. thanks to the support of the kennedy we've been able to rebuild our staff bring in more than 1100 foreign service officers to usaid over the course of my tenure. we've been able to implement an evaluation policy that's

recognized as the best in class and today you can go to the story of download an application on your ipad or iphone and pulled on more than 180 high quality evaluations the descried in an unadulterated independent manner how the programs are working or not working and what we are learning as we seek to make improvements. we've expanded our investments and local solutions that can at times be less costly and more sustainable in delivering these results and i am eager to discuss with you today our efforts to reform food aid to bring this approach about the efficiency and effectiveness to the efforts to reach an additional 4 million shall drown without spending additional resources and to do a better job of saving lives while renewing the partnership with american agriculture. thank you for the chance to be here today and i look forward to this dialogue continuing this partnership. >> thank you so much.

>> thank you, madame cherry and members of the committee for the opportunity to appear today but my friend and colleague discuss the 2014 budget request but i would like to summarize my statement and submit the full version for the record. >> without objection. >> the president will have $89.9 million to allow the corporation. to continue advancing prosperity and stability and american values around the world they do this by reducing poverty to sustainable economic growth. our partners are selected countries that have a track record of sound space and economic governance. we asked them to prioritize the economic needs of the developed implement solutions that make a measurable difference. we are selective about which investment we will make because americans deserve to see their tax dollars deliver a high rate of return. we signed contracts with our partner countries spreading out the terms of our assistance.

during the compartmentalization will monitor the progress and required programs be completed in five years. the development dollars of the countries fail to respect human rights or space values. last, we measure the protectiveness to see what did and did not work. this is part of our evidence based approach and because we are committed to transparency and accountability. we make our findings public. madame chair, delivering achievements for the world's poor. transportation networks are shoving impact. projects in the land security and water security are connecting the poor to economic growth and opportunity and the inspired reforms are empowering women advancing and promoting space principles. the constituencies are also benefiting as policy reforms and targeting investment foster and

environmental american businesses to succeed. last fall they released the first set of independent evaluations. this year's statistical method to measure changes in household incomes of project participants. in el salvador they found that they double their incomes. in done of the income of the farmers in the northern region increased significantly to the control group over and above any impact supported another zones. even when the findings are not all public this helps us improve the design and evaluation of the preachers projects as we continue to learn and to hold ourselves and our partners accountable. in december of 2012, the board after the actor's selected five countries as eligible to develop the compact. liberia, morocco, sierra leone

and tanzania. the requests also include funding for the pressure programs from guatemala and nepal to reform the policies and institutions that will move them closer to qualifying for contact. that's why the country's our home to over 100 million of the world's poorest people. they represent an opportunity for the poverty and advanced u.s. interests. these countries have taken concrete steps to reform the government and qualify for compact. this is what many call the mcc effect. the recent study of a government officials and the countries worldwide link the influence of the policy performance greater than any other external measurement system. the request for fiscal year 2014 wouldn't allow us to find contact with all five countries.

so some would have to compete for future funding. it is important to note, however, that the affect depends on having sufficient resources to incentivize and sustain policy changes. if the funding is cut, that the fact is diminished. madame chair, with the committee's support, mcc and partner agencies will continue to play a role in fighting poverty. thank you. i welcome your questions. >> thank you for the excellent testimony and i think the chairman and the ranking member for calling this important and timely hearing. once again, we are having this hearing in the backdrop of economic uncertainty both here and abroad but here it is incumbent upon us to be responsible stewards of the tax dollars of the hard-working americans. we want to ensure that these hard earned dollars are spent wisely and strategically while advancing our national security

interests and addressing our foreign policy priorities, which brings me to the administration request of $370 million for west bank and gaza assistance. with the prime minister's resignation casting a greater shadow in the future makeup and with the knowledge that corruption is rampant within that body, doctor shah do you believe they possess adequate internal controls to effectively deliver any u.s. aid, and what assurances have we received that no money will be diverted to hamas and other terrorist organizations cracks in addition, to continue to be concerned over the administration's attempt to cut the much needed democracy programs to the cuban people? 40 of the pro-democracy activists remain on hunger strikes in cuba to call attention to the dozens who are being detained by the state

security forces. these brave heroes are risking their lives yet we are putting their support which isn't prudent especially at the time when the crackdown is actually te the island. mr. yohannes, with the millennium challenge corporation we must ensure the founding principles continue to be upheld and do not fall under the trouble providing more and more assistance without an end in sight. instead we have to focus our efforts on economic growth and the graduation of countries away from being dependent on our assistance. as the chairman on the subcommittee in the middle east and north africa, i note that the contract with jordan is coming to an end of this year and i wanted to know if you would comment on that. we will be meeting with the leaders of jordan later today. also, morocco continues to be an important ally to the united

states and is a strategic wertner in the region. must further seek ways to reiterate the strong bonds that tie the two nations and promote our shared values and vision for stability in that region. with that in mind, and shifting to another region, i am concerned about the attempt to seek a second contact with el salvador. american investors continue to have problems accessing their assets. there is a lack of public-private partnerships and the endemic corruption issues are still prevalent in el salvador according to reports the current presidential candidate celebrated the terrorist attack on 9/11 and burned an american flag so i believe that it should not be used as a political tool as presidential elections draw near so i would urge them to wait

until after before proceeding with that compact. said dr. speed if you could address that issue. >> certainly, thank you. thank you for your strong leadership on a range of issues here. the goals of our effort there are very specific. they are about creating economic opportunities to underpin the peace process, to support basic social services and we have been able to reach more than 200,000 people with food and more than 75,000 connected to improve water systems and some core humanitarian priorities as the needs arise. we do have very strict controls on how many specific transfers to the authority are conducted and we are confident that there will continue to go forward as we have run it in the past. >> thank you. and on cuba? >> again, the goal is the support for democracy with some small humanitarian efforts and

we have worked closely with our partners and we believe the budget of $15 million reflects an appropriate investment that they have the capacity to implement. we recognize and take some faith in the fact that the gao reviewed our approach to implementing this program and very strongly commented on the effective reforms we put in place to have a clear and compelling implementation strategy for this effort. >> thank you. mr. yohannes i haven't left much time for larocco, jordan and el salvador but if you can reply in writing i don't wish to rush those answers because they are important. thank you very much. i am pleased to yield five minutes to our substitute ranking member for the substitute chair mr. sherman. >> thank you and chairman emeritus for your questions particularly in regard to the palestinian authority and the democracy in cuba to i want to associate myself with your

concerns. the ngos are just there to try to provide relief for the development of our focus is also on our foreign policy objectives how do you coordinate with the state department to have our foreign policy in the national security objectives affect what you do? >> thank you representative. i guess i will offer a general point and then a specific one in terms of coordination, i think under the obama administration and under-secretary clinton and now kerry it has been a much improved. we develop the strategies for each country. they are carefully vetted down the state and we are joined the approaching the priorities and define them in a specifically then measure results and make the outcome as public and

transparent as possible. we have implemented a foreign assistance - board that has excellent data from the state and mcc that meets our transparency initiative commitments and i believe that has been very strong toward a nation. one important example of that that speaks to your opening, it is syria. we have worked hand in glove to make sure we provide now nearly $4 million of humanitarian support inside of syria, 65% of that reaches opposition control in the areas and we are reaching to .4 million people with critical during that. >> administrator i'm going to have to go into a few other things and ask you to supplement your answer for the record although the fact isn't on the flood of syria as a great concern to me to be i would like you for the record to describe what regulations or policies you have for your people on the field as to when they must

emphasize that it's coming from the united states and literally put it on the bad of the food etc. and when they are allowed to depart from those policies. i would also like you to provide for the record some studies or examples to illustrate what is the difference in cost between a local sourcing on the one hand and the u.s. carrier delivery on the other. i'm sure there will be a variation in the different -- and the differences depending upon where it's going. s to pakistan, we provided 2.8 billion nonmilitary assistance. since 2009 the government has its own objectives but we need to win the people over and my focus on this. to what degree does this on a

lot of determine where the aid is focused within pakistan and then in writing you can provide a description of what we are doing in the same province. but who picks the projects and the locations? you or the pakistani government? >> thank you. with respect to pakistan first, we have important partnerships. we design them together. we absolutely retain the capacity and authority to vote for the project and oversee the implementation. one example is we made a commitment to help them produce 1200 megawatts of energy and we have already seen through the 800 megawatts and that has been seen as a tremendous success. second we have invested a lot of effort in a comprehensive strategy for anywhere in the world. i think it is a good example where as a result of our efforts

we now have data that shows that with the awareness of american assistance efforts it's gone up threefold. there are 4,000 -- >> i'm going to try to sneak one more question but please give that analysis of what is going on. i am somewhat concerned the administration request cuts aid to armenia pivot i think you ought to increase that instead and if you are looking for a source of funds you could look at all types two azerbaijan which is thwarting our development efforts for the area by threatening to shoot down civilian aircraft but going into the new airport. i've talked to mr. yohannes about the region of georgia. we provide very substantial aid to georgia, and i hope as i have discussed with him and i had a chance to discuss with you that a significant part would go to

that otherwise neglected region. and i will ask if i had a chance to describe what is the status of our second contact with georgia and will they be a strong focus if that is concluded? >> the investment proposal is going extremely well and should be presented to the board sometime in june of this year. with the congressman please note that some funding is set aside for the language and also a number of schools in that region. >> thank you very much mr. sherman. mr. smith. >> thank you madam chair. five minutes and so many questions to ask to it i will submit a number of them for the record. let me just ask you, dr. shah, two days ago dr. friedman testified before my subcommittee and of course you work very closely with the sec and he heads up that important agency. we focus on super bugs and thus parasites that increasingly as

well as antimicrobial resistance and how this is becoming more and more of a problem but i would ask you if you could to speak to the issue of tuberculosis. it is becoming, it always has been that now is more of a problem. i know it is probably omb but hopefully that can be restored because it is so important in on the issue of malaria, we had a great discussion -- disturbing discussion in resistance to southeast asia. a very dangerous possibility of extending into africa and we also know that bed nets and all the rest of the efforts that have been herculean in combating malaria need to be renewed and new bed nets provided. there are 104 countries might want to speak briefly to that and more so for the record. second before you cannot we talked about the issue of child survival and the importance of

the 1,000 days of immunization and all these important things to save lives. you indicated you had been in india and you might want to speak to the issue. the film was released yesterday. it is entitled it's a girl the three most dangerous form words in the world. it notes a human figure that there's 200 million missing girls on the plan at directly attributable to selected abortion and to a lesser extent infanticide. they are the two most egregious violators. these are gender crimes extermination of a child in the womb or at birth has not only in and of itself lead to this destruction of girls, but its lead to more sex trafficking and that has skyrocketed in india and china in particular. but you did talk about the access for child survival and some of the health industries if you could speak to that very

quickly. >> thank you, chairman smith and thank you for your strong leadership on these i for decades on child survival in particular. with respect to child survival, last year we pulled together partner countries from around the world to get everyone to make a commitment and to prevent a child staff worldwide. the united states signed the pledge as did others and today there are more than 150 countries producing data driven report cards and scorecards tracking progress, and there's about 7 million children under the age of five who die every year as the president noted in the state of the union address we are committed to taking back down to as close as zero as possible within two decades. india in particular is a good example of this partnership model of work coming together. we have private companies making investments to traffic data and to report on outcomes we have private companies expanding precisely to create other products that can be helpful to children who would otherwise die

of diarrhea, and we know that these efforts are generating results as these ministers can together to brief me on their progress but also to describe how it has correlated with the sex selection problems to which you speak and how that needs to be incorporated into the approach. i will say very briefly with respect to -- i will just say on that i think the most amazing thing is we are not driving this process through big new investments of american taxpayers' dollars it's really american leadership and focus on science and technology and measurement and result that is allowing us to partner with others to achieve that kind of an outcome. with respect to tuberculosis i appreciate your comments and we are very focused on the multi drug and the one i think tom friedman's book about. he's one of the world's experts on that for many decades now. there are three foreign assistance accounts that provide our tuberculosis support. so, while we have led to some of our funding on the one account, we are expanding our effortsin

hiv related tv and using the global funds to make sure that our investments crowd in their resources from others and allow for more sustainability over time. finally come to the point on malaria this has been one of the biggest success stories in america can take great pride in the evaluations by boston universities and others have shown there are as a result of this annual investment we make of less than $700 million as many as 200,000 children under the age of five who don't die every year in sub-saharan africa because we have in evidence based clearly measured targeted approach, and it serves as the basis for our efforts for the reduced preventable child deaths in that region to thank you for the leadership. >> thank you so much, mr. smith. mr. kennedy is recognized. >> i'm so sorry. i'm out of touch.

i would have yielded of course. >> you are recognized. >> thank you madam chair. i'm not sure if that is the proper way to address as ambassador, administrator or doctor but ambassador is what i will use. i want to first thank you for the great leadership at usaid. the issue i would like to hear more about is we have seen come and i've certainly learned about the decline in the personnel at usaid over the last 28 years or so and kind of the breaking above some of the functions with different agencies and the government and the ongoing use of contract and services and the impact that has had i think has been detrimental to our development efforts around the world and i think you have recognized it in your forward initiative. i would like you to dhaka little about what is the goal of that, where you are on the implementation of that and whether or not there are things

we can do on the legislative side to protect that kind of rebuilding of those budget and policy and personnel capacities of usaid, which i think it's reflected in some of the questions people are asking about and understanding what role we are playing in the development around the world. i will stop there. >> thank you, a congressman for your leadership and that an accurate reflection of the situation that emerged over 15 years. between 1990 and 2005 cut our staffing was reduced by more than 40%. the policy and budget activity ceased to exist and the agency did engage in my view in quite a lot of no bid contracting with very little oversight often in war zones where that can lead to all kinds of unintended consequences, so in response to that we launched usa forward and was an obama administration effort to help rebuild as

america's premier development and humanitarian entity. with yours and the ngress strong support, we have been able to hire 1100 new officers and to the agency during my tenure those officers that helped us fill a 40% staffing gavin africa. we have in fact cut a large number going from almost 800 down to 520 specific programs around the world as we could focus our efforts in those places where we deliver the best results. we have reshaped and repositioned our stuff closing more than 14 missions around the world in order to advance the focus on selectivity we think is critical to delivering results. usa for word has three major components, a partnership component that says we should be working efficiently and effectively with partners that can create the condition where the aid is no longer needed. we released a detailed report about a month and a half ago that shows in a thoughtful and a rigorous way we've been able to expand our engagements with

local partners by more than 50% over the last few years. we have a focus on innovation and science and technology. last year we opened a partnership with seven american universities, developed in innovation laboratory puna those laboratories are producing new technologies and insights like a telescope that the transnet would be interested and i'm sure but it takes an iphone and connect it to a plastic microscope and allows you to take a photograph of a blood smear and then runs the software to diagnose malaria and hopefully someday tuberculosis, taking laboratory diagnostics out of treatment and care and in the context we work would be a major cost readers are and will allow us to add to the list of success stories in terms of serious disease reductions and difficult parts of the world. ..