we got a lot more work to do but health care inflation is not skyrocketing the way it was. and because of this new rule, because of the fact that it improves the value of the coverage that you purchase last year alone american saved $3.4 billion in lower premiums. that's $3.4 billion on top of these rebates. so that's just one way this law is helping middle-class families but it represents everything the affordable care act means for folks who already have insurance , better benefits stronger protections and more bang for your buck. the basic notion that you ought to get what you pay for. >> host: joanne kenen that is a middle-class message. who is the president trying to reach? >> guest: i think he was rich and the middle class because this bill has a lot in it for working people and people who are not -- currently struggling

to pay their health bills so this is not a message for the poorest of the poor we are going to help you. an ordinary person does not know what tempers and of the poverty line means. i have to look it up but basically what this bill does is give subsidies to people up to 410. that is two or $3000 for a family. it's not free but it's a sliding scale and people will be eligible depending on income and plus all of the people who are to get insurance whether you get it through the government or through your job or whether you buy it on your your own paratransit health place market right now that healthcarhealthcar e inflation has dropped a lot. academics and the politicians argue that wyatt is dropping and whether it will continue dropping but there is no excuse that the rate of growth year-to-year what we are seeing in health care is the lowest it's been 20 years. >> host: is the president speaking to to those hard-to-reach americans?

>> guest: you know i think he is speaking to a bunch of people. the hard-to-reach people are not necessarily going to be home watching the president on tv. some of them well but there's a whole series of other educational waves of educational data party started and it will intensify in the summer and fall. i think he is reaching certain audiences. he is hoping some people are tuning in and paying attention again. when he talks about, he is talking about rebates and regulations for insurance and i'm not sure that's the message message -- magic message that gets through but you will be seeing education and groups allied with the administration and the pen of the sympathetic and they are going door-to-door in some parts of the country and they are doing farmers markets and they are doing churches. you will see community health services given money by the federal government.

people who are low income who are eligible for some of the new programs that's one of the markets for this education so the clinics will actually start doing some outreach. >> host: let's go to the phone phone stephanie and virginia independent line. hi. >> caller: hi. i have three points. the first is that health care exchanges are nothing but the federal employee health benefits program on a state-by-state basis in the federal employee health program works great. it's endorsed by congress but heaven forbid they want to acknowledge that the federal government does something great. the second comment is the best part of this new health care law is that i can get a policy advisory board and the republicans are -- that's an independent commission that is looking at what the costs are throughout the country and republicans are blocking it because they want to keep their

donors scamming the system. the third thing and last is the president put off that one part of the law because these companies who are anti-american are putting all their employees on three hours a week so that they don't have to pay this. you know, don't go to walmart. we subsidize walmart with this tax credit because the people don't earn enough money to live off. that's ridiculous. >> guest: the first the federal employee health plan, the state markets are not identical to that but it is a similar model in that there are a bunch of plans in this marketplace that you can choose from for a federal employee. the government pays part of a new pay the rest and you can go on line. i am sure you can pick up the

plan is best for you and that's a model for this. we are not going to be at the fe but they are private plans and than they will be in this market some states are going to have a lot of choices. mississippi is only going to have one so it depends where you live and depends on a lot of factors. right now too a state like mississippi doesn't have great insurance competition and the new york state there a lot more choices so washington has a lot more choices. so it's a template for it that were not going into that plan. you are right, they are parallel. the independent payment advisory board, the administration is not tried to appoint anybody. one they would not get confirmed in two it's only for medicare. medicare prices and cost growth is so historically low right now they wouldn't have anything to do for quite a few years so that's not a crisis point. when medicare spending hits a

certain trigger they have to get recommendations and we are nowhere near that trigger and it maybe a couple of years before we hit it. the politics of that i think it will be a secondary issue that you will hear about periodically but not a make or break element is a lot this point in our health spending economy. and the third one i think it's too strong to say that everybody is making people part-time. we have heard anecdotal reports that there is some truth to the senate does. if you're an employer with 51 employees and currently not caring health care many of us can see why you might want to go down to 49 if you are a low margin and not super profitable business. larger companies with 20,000 employees are not going down to 50 and we also have this trend before obamacare that there has been a trend toward more part-time work in this country without benefits. now that whole law, that whole part of the law the employer

mandate was put off for a year for a variety of reasons including the treasury did not finish the regulations and there were still a lot of confusion about as though there was the political lobbying push on that and also the technical, that is not quite ready for prime-time element. again most is necessary to cover their workers. not all of them and not all of them have generous plans but if you are working for someone that has more than 50 employees already you are likely to at least have an offer of insurance. >> host: joanne kenen is health care editor. a story in politico about mississippi, a looming health insurance crisis in mississippi held out that obamacare is emblematic of a loss failures appears to have been a furtive. tell us why this happened. >> host: >> guest: we love writing about mississippi. it's just great saga. the commissioner has trying to implement a law.

they are both big personalities so every once in a while we say let's do a mississippi story but one of that happening in the power struggle the insurance commissioner walked out in the states not going to run its own exchange. in every state there every state they were being exchanged whether the state once and for government steps in, there will be an exchange. so, in this case a big change and no insurance company came in until it was 3036 counties or might have been 39 and this was a crisis. how do you have a health plan with no health plans and it? mississippi is poor, mississippi is rural and there are two issues. covering the sick underservunderserv ed population which the insurance companies are not too thrilled about and they're not a lot of doctors and hospitals in mississippi so how do you you create the network to serve the people that you cover? a few weeks ago my editor said we want to do a store -- story

in october on the worst date and i had no hesitation. mississippi. 36 counties had zero participation and this was going to be a crisis. last week humana one of the big national companies which is active in a few states, mississippi said all right we will do it. it's risky at the beginning for humana. they said 36 counties with no coverage in exchange we will provide coverage and everyone in mississippi will have at least one choice. is it a risky proposition? without having talked to humana i can see a few years from now people are covered and it may be a smart move. >> host: a reminder of these health exchanges were talking about on october 1 open enrollment begins and then on january 1 the exchanges kicked off. 17 states have their own exchanges, 27 states are using the federal exchange instead. here's a map we see from "the

wall street journal" that shows the federally run exchanges and yellow, the state run exchanges in blue and ingrained states that are doing a joint state and federal exchange. >> guest: those giant ones are supposed to be temporary or they call it a partner at its it's supposed to be a transition. we will see how that evolves. >> host: victoria is a democrat. hi victoria. >> caller: good morning. i have been a hospital-based registered nurse since 1966. that was before lasix and i have worked for the past 37 years for the oldest not-for-profit hmo in the country and it's a wonderful organization. last year i have been seeking a model for obamacare. electronic medical records and so forth. oregon has been doing a great

job with health care exchanges. our governor happens to be an emergency room physician. they have some really fun and quirky commercials to serve young people called cover oregon plan and they are running a lot of commercials. i think from what i see -- [inaudible] i am optimistic and i know we need all of these exchanges am particularly addressing a lot of the quality that people don't speak about, dressing the obesity and diabetes and congestive heart failure and having -- for some of these morbidity's. >> guest: oregon just like i said we were talking about what is the most troublesome state of nevada point we sit mississippi. we have to have a conference about which will be the most troublesome next. if he were to ask me which would be the most successful i would have put oregon as one of the most likely to do well for a

friday of reasons. as you pointed out, they have been doing a lot of health care reform on the state level in oregon for years. they didn't come to it overnight. the governor is a physician. when he was out he left office and came back and in those in between years he was doing a lot of public policy and your state is invested. you are politically on board. your state government has created an exchange and they supported the exchange. on line you could see what was going on in oregon and i have a link and in fact several people sent me the link to the ad. one of my reporters wrote about it. >> host: victoria's neighboring state of washington how they can educate hard-to-reach young healthy populations of head of

communications for washington's marketplace. we are picking up all sorts of ways to reach out to people. perhaps it's no surprise is thought to have gravitated to our two concerts. reading that in the washingtwashingt on post. let's go to nashville tennessee, republican. >> caller: good morning. i am a health care worker for 37 years myself, and my opinion is obamacare, it's kind of like public education. everybody gets it that nobody gets it well and for myself and the people that i work with -- i work for a very large health care facility, hospital and we are really suffering here. we have had a lot of job losses and now they are asking 30% health care professionals go prn which for those who don't know

what it means you work as needed with no benefits. so it's a large corporation and we are letting off people who have worked 20 to 30 years here. for my money, it has had horrible repercussions. that is all i have to say and thank you all for listening. >> guest: without knowing what you are and then what are the specifics, there've been a flood of hospital consolidations and that is a trend that is periodic. waves of consolidation and mergers and there are job losses when that that happens in minnesota stabilizes for a while and the market changes. that happens long before obamacare so whether there is specific elements of the law that are affecting your institution, i am not able to judge. there are going to be changes to how hospitals do business. also there will be more insured

patients of that part of it, you will have fewer people not necessarily october 1 but it within the next two years that at the same time the part we focus on in the law is the coverage and the cost of of the the coverage in exchanges and that is what we are talking about today. their huge changes in how medicine is going to be delivered and that is happening through medicaid and medicare. that's happening to state governments and private insurers and as we move away from really as we sort of shift from what you mentioned from acute diseases which take place in the hospital to more chronic diseases as we get all their- >> we are going to leave this conversation. you can find it on line at c-span.org and take you live for capitol hill for discussion about lowering medicare spending with representatives from the kaiser family foundation and the bipartisan policy center. >> slowly and distinctly so that

people can actually hear what you have to say. i want to welcome you to this program on the basics of medicare cost-sharing and a fee-for-service part of the program and i extend that welcome on behalf of senator blunt, senator rockefeller on our board of directors. medicare is an important and expensive and a complicated program even compared with other health insurance. how many americans know all the parts of it? the abc's if you will not to mention part t for prescription drugs. so when you hear policy experts warned that medicare spending is a threat to the long-term stability of the federal budget they are talking about the levels of government spending.

the beneficiary spending a substantial and it's getting more burdensome year after year. then there is the confusion premiums, coinsurance, deductibles not to mention the coverage that most beneficiaries have to fill the holes in and medicare. that benefit packages full of it i mean full of holes. [laughter] hence our discussion today about streamlining beneficiary spending cost-sharing is the term of art. there are a lot of proposals floating around with a lot of common elements and we are going to take a closer look at some of the major ones today. we will also look at how the provisions to simplify the design of medicare benefits and the cost-sharing that goes around goes along with those might affect those least able to cope with big changes, that is the beneficiaries especially

low-income beneficiabeneficia ries. our partner in today's program is the kaiser family foundation which is a font of thoughtful analysis of the medicare program some of which you can find in your materials in your packets and some of which were written or overseen by her co-moderator today tricia neuman who directs the foundation's program medicare policy. tricia. >> thank you dad and i want to thank the alliance for putting together what promises to be a really interesting program on policy options to restructure benefit design around traditional met medicare. i also want to thank this fabulous panel of experts who have come together to offer their insights on this topic. now the idea of restructuring medicare benefits may seem like a new idea because it has gotten quite a bit of attention of late

but actually this is an idea that has been kicked around not for years but for decades. it actually has gotten more attention in recent years because it could be a mechanism for achieving deficit reduction and so you will see proposals to restructure medicare in several of the debt and deficit reduction offices -- offers that and put on the table. i think we all know and it's been said that medicare provides highly valued services for people in the program. it's a crazy popular program and enjoys broad public support and it's important to this population because many have chronic conditions. many of them are in poor health and many live on modest incomes. in fact half of all people on medicare live on $23,000 or less. on the outside medicare has been complicated and you can see on this chart that medicare for people and part d history

deductibles and different co-pays and coinsurance depending on the services that people use. it unlike most employer plans has no limit on out-of-pocket spending so a concern over the years it's been a of catastrophic protection and many of the proposals he will hear about and to address that concern. now when people talk about structuring medicare they talk about hoping to achieve different goals and what you can see on this next flight is the manacles the people i've talked about. so, they have talked about streamlining benefits. more recently they have talked about using medicare benefit redesign to achieve medicare savings and federal savings. they also talked about protecting individuals against catastrophic expenses reducing the need for supplemental insurance, and encouraging the use of high value services and some of the proposals talked about this being a vehicle to strengthen protections for the lowest income people on

medicare. the challenges i think you will hear is achieving all of these lofty goals at the same time. and they think our panelists may have something to say about that. so without further ado i think this promises to be a really great session and i look forward to hearing what you have to say. >> thanks very much patricia. a couple of logistical items before we get to our program. as i said in your packet you will find a lot of background information including speaker bios more generous than we have time to give the panel and the powerpoint presentations for those who have them. if you're watching on c-span, that same information and more is available on our web site, all health.org. some of you may be watching a couple of days from now the webcast that is arranged with the support of the kaiser family

foundation and you can find a webcast and a podcast in the next day or two at kff.org and those same presentations along with digital copies of background materials in the kids and more will remain at all health.org for your convenience. those of you in that room there are green question cards that you can use at the appropriate time to ask a question. there are also microphones on both corners of the room that you can use to ask a question directly and it blew a valuation form that we hope you will fill out before you leave so we can improve these programs even more for your benefit. as patricia mentioned we have the perfect panel and we are going to get right to them because this is a complicated subject and it's great to have as many expert analysts to help explain the questions. we are going to lead off with

juliette bodansky. we will get her the clicker. all right. juliette is the associate director of the foundations program on medicare policy. she is the author of a major study of the impact of restructuring medicare's benefit designs which is sort of relevant among other medicare related analyses that she has undertaken and today we have asked her to explain in some greater detail the current structure of benefits and cost-sharing and how some of the proposals are changing that structure and what effect beneficiaries. juliet. >> thank you and thank you to all of you. i'm just going to jump right in. i have a lot of material to cover. some of the proposals introduced introduced -- sorry. can you all hear me now? in a very strange way. i'm going to jump in where he left off and talk to you about some of the recent proposals

that it then introduced lately to restructure medicare cost-sharing and make changes to supplemental coverage for people on medicare. proposals introduced in the last few years have taken three main approaches to changing medicare cost-sharing. one is to modify the cost-sharing features of traditional medicare by simplifying and unifying the deductibles and the cost-sharing amounts across the different parts of medicare and adding an out-of-pocket spending maximum that traditional medicare currently lacks. the second approach is restricting or discouraging supplemental coverage that's available through medigap supplemental policies and retiree plans offered by employers. most beneficiaries today have some form of supplemental insurance coverage to help pay their medicare cost-sharing requirements which some research has suggested leads to higher utilization and higher medicare

spending especially the so-called first dollar medigap plans that cover all of part a and part d deductibles and coinsurance. proposed changes to supplemental coverage include requiring it does with supplemental coverage to pay more of a upfront and medicare cost-sharing liabilities or imposing a surcharge on their supplemental insurance premiums and a third approach is a combination of the first two. some form of restructuring medicare cost-sharing and some form of prohibition or restriction on supplemental coverage. focusing in on the restructuring cost-sharing peace. we have seen a number of different proposals from different groups but i'm going to focus on the different options analyzed by the congressional budget office and the medicare payment advisory model paid into the cbo modeled there would be deductible for part a and b. uniform coinsurance rate of 20% for all medicare covered services and a 5500-dollar

out-of-pocket spending maximum. the key difference under the medpac approach from cbo is that rather than impose the uniform coinsurance rate, met tax suggested varying co-payments for services such as $750 for hospital admission, $20 for primary care at doctor and $40 for specialist visit. this would achieve savings for medicare and of course affect how much beneficiaries pay for medicare covered services. analysis of the cbo option prepared by actuarial research corporation for kaiser shows that the cbo design would actually increase the spending by most beneficiaries while reducing spending for a small share. seven in 10 beneficiaries would face modestly higher costs. this reflects the fact that the majority of people on medicare don't actually use very expensive services in any given

year. only about 20% are committed to a hospital for example that about 80% of all beneficiaries use doctor visits or other types of part d service is the most people would have to pay a higher deductible than they currently pay for part a but they wouldn't spend enough to reach the out-of-pocket spending limit. conversely a small share beneficiaries the 5% and 30 i you see here would have substantially lower spending and given a crushing design. this is a relatively sicker group of people at higher utilization spending that would exceed the out-of-pocket limit. but, while only a small share would see savings from the cbo design in any given me here and much larger share stands to benefit over longer period of time because while one might not have spending high enough to reach the out-of-pocket limit in year limit in your wine or your two over multiple years the likelihood of having a year of high expenditures increases from

less than 10% of tuna fisheries in year one having standing above a 5000-dollar out-of-pocket maximum and the chart you see here to more than 30% overhead 10 year period. in terms of how the cbo would affect medicare spending analysis suggests that program spending would decrease because many beneficiaries would face higher costs overall is that you showed you and that would in turn lead to a reduction in the use of medicare covered services. so turning now to supplemental coverage there are a couple of basic approaches to prohibiting or discouraging supplemental coverage that i want to walk through. one approach described by cbo would lead to prohibit first dollar medigap coverage whereby enrollees with pay more of the upfront costs and more of their ongoing medicare cost-sharing liabilities up to the new out-of-pocket spending maximum.

under medpac's approach rather than restricting the generosity of planned coverage of itself a surcharge would be added to the premium. this would allow people to buy as much coverage as they desire but it would require them to pay more to compensate as it were for the added costs that they purportedly imposed on the medicare program and medpac also would impose the same surcharge on employer-sponsored retiree plans. president obama's 2014 budget proposal took a similar approach the surcharge would be added to the part d program of new enrollees who purchased medigap policies with particularly low cost-sharing requirements and i'm quoting the budget proposal there. again these types of restrictions supplemental coverage through higher beneficiary costs lead to reduce utilization and therefore lower medicare spending.

looking at the distributional applications of the cbo option to prohibit medigap coverage analysis shows that eight in 10 beneficiaries with medigap policies would actually be expected to pay less overall. ..

because the share of beneficiaries with med gap varies widely across states. as you can see here on this map from a recent kaiser report where you see the share of beneficiaries with medigap ranges from less than 15% in six states and d.c. to a high of close to 50% in five midwestern states. north dakota, south dakota, nebraska, kansas and iowa. while imposing restrictions on the generosity of coverage offered by medigap and sponsored retiree ben pit plans or imposing a surcharge could affect six out of 10 beneficiaries enrolled in traditional medicare. so as i mentioned most proposals in this area combine both restructured cost-sharing and changes to supplemental coverage. but lately we've seen new features added to this basic framework including suggestions

to incorporate value-based, quote, unquote, value-based cot sharing in the new benefit design, charging higher cost for lower value services and higher costs for lower values services. we've seen proposals to vary the cost sharing amounts and spending limit depending on the beneficiary's income. increasing the out-of-pocket income maximum for higher income beneficiaries. there is increased attention to the burden these proposals might place on low to modest income beneficiaries. and so some recent proponents of these type of changes have suggested the need to incorporate some type of additional protections for people with low incomes which could take the form of lower cost-sharing amounts for lower-income people but also the option to expand or enhance the existing programs that helped low-income people on medicare pay their medicare premiums and

cost-sharing amounts. looking quickly at distributional impact of putting these two-pieces together supplemental coverage restrictions and cost sharing as cbo design suggested about a quarter of beneficiaries hire would pay less. much greater percentage than under the restructured benefit design alone. and this is largely because the drop in medigap and part-b premiums as a result of the higher cost-sharing and reduced utilization. so i just want to leave you with some quick takeaways from my quick overview. first and most obvious, not all of the proposals to restructure medicare cost sharing and make changes to supplemental coverage to people on medicare are alike and therefore the implications for people on medicare in terms of their costs, whether they would be higher or lower and choices with respect to supplemental coverage would vary depending on the details of the approach. as has been mentioned there are certainly savings to be had in

these proposals but there are also winners and losers among people on medicare. unifying the deductible and charging a uniform coinsurance rate would lead to higher costs, modest costs, higher modest costs for many but the outof pocket limit would be very helpful to a small share of people on medicare in any given year but a larger share of people over a longer period of time. while restructuring, restricting the supplemental coverage that's available to people on medicare would achieve savings through higher cost-sharing and reduced utilization but a major concern here is that when you increase beneficiary costs and there es an attendant reduction in utilization this could actually lead to higher costs in the long run and worse health outcomes potentially as beneficiaries are cutting back on needed services, not just what's unnecessary and not just what's optional. finally in considering these proposals if shifting more costs

on to beneficiaries appears to be unavoideddable, then careful attention should be paid to protecting those who are least-able to absorb these higher costs through enhanced protections. thank you all and i look forward to your questions. >> thanks, juliet. we're going to turn now to someone who is absolutely not a stranger to the senate hallways. i'm talking about sheila burke. she was bob dole's chief of staff as majority and minority leader of the senate. she helped a -- held a bunch of other senate posts. executive dean of the kennedy school at harvard. been the chief operating officer of the smithsonian and is one of the country's most respected health policy analysts. recently she helped shape the proposal by the bipartisan

policy center to restructure medicare's benefits and we asked her to tell us a little bit about that plan which was issued jointly with the endorsement of alice rivlin. >> host: pete demenschy, bill smith and tom daschle. did i get it right? >> you got it right. >> sheila, thanks for being with us. >> thank you. i was afraid ed was going to say i was there when they wrote medicare and sort of going down there. not quite that old. and we have a special connection in days there is announcement out of london. we want to be the first ones to let you know. i have, as ed pointed out, i want to thank the alliance and the kaiser family foundation for once again scheduling a briefing on a critical issue and discussion at a very important time. and also given the extraordinary credit for the materials that are in your packet which are really a terrific array of

proposals and descriptions that i think will be tremendously useful to you in taking on this remarkably complicated issue. i should note at the beginning that the proposal that i am going to describe for the bipartisan policy center is one that is really only one element of a much broader initiative and the four sponsors are, feel very strongly about pointing this out. this is really part of a much broader conversation about reforming our health care system and really moving towards the future in terms of driving value-based purchasing, maintaining choice and encouraging innovation in the medicare program and in the health care system generally. as ed pointed out the project is in fact the work of our four leaders of our health and economic team at the bipartisan policy center and that is in fact senator pete domenici, dr. alice rivlin, senator tom

daschle and senator bill frist. it is the second of the initiatives by the bpc the original initiative was led by senators daschle and dole and baker and mitchell. so this is an ongoing conversation by leaders that care very deeply about these issues and are deeply emersed. chris jenning, steve lieberman, paul ginsberg and i were privileged to staff the effort along with bill hoagland, katherine hayes and brian collins and lauren adler of the bipartisan policy center. brian is here and the wizard behind much of the work that we did. if anything gets tough i'm looking at brian. with regard to our proposal really, trish did a terrific job i think of explaining what the goals are of any of these initiatives. certainly to modernize and simplify the benefit, to promote predictability in materials of what beneficiaries can expect and increase support for low-income beneficiaries who

might be exposed and be discouraged from seeing out appropriate care. so our goal was to address all of those issues. i will walk through sort of the keel elements of that proposal and i would also note that one element which is meant to help finance the cost of this is a reduction in the subsidies to higher-income beneficiaries. as trish pointed out and as you've seen in the materials that you have in your packet and is evidenced here and described in the health affairs piece in your packet, with the exception of the addition of part-d, in 2006, medicare's benefit design has really not changed substantively since its inception in 1965. the deductibles and cost sharing are of course in addition to the part-b premium and the part-d premium. they vary, depending on the service. it is complicated. and at the end of the day does not provide protection against catastrophic costs. in order to deal with the

uncertainty and that unpredictability, 90-plus percentage of the medicare population have some form of supplemental coverage either that they purchased themselves, get through their employer or provided by medicaid but essentially it is to protect against what you see here in terms of the multiplicity of exposure and the complexity of navigating that system. our goal was essentially to revise that outdated system by providing the kind of financial protection from the costs by essentially creating a cap and ultimately a a cap on catastropc costs. it replaces the current system we believe with one that is far less complicated than the one today. the co-payments are designed to encourage higher-value services. we exempt physicians office visits from the deductible. we hope minimizing the cost increases likely to be borne by

relatively healthy beneficiaries as juliet points out there is a small percentage that utilize hospital services but a great part use part-b services. by exempting physician's offices so people can visit physician without having to incur the deductible we hope will reduce the opportunity or the risk of their encuring higher costs. perhaps most importantly in this benefit change we cap the cost sharing by beneficiaries so they are in fact protected against the catastrophic costs that do occur although in relatively low number of issues on a annual base i basis. as juliette pointed out over time that number will increase. this complicated but nicely-colored chart is really an illustrative example of how the cost-sharing changes might in fact take place and the way we structure the benefit going forward.

we recognize and acknowledge that it will in fact benefit some. primarilya those who use in patient services and will result in some increased costs. as juliette points out for those who primarily b services. we believe exempting physician's offices would in fact be, would in fact be helpful. in these examples you see an explanation what might occur in a traditional case in terms of someone who is using part-b services. in the case of an institutionalized patient. in the last case you see an increase again depending on the services that are used. the reasoning behind our proposal with respect to supplemental coverage, and we are in fact as juliette, one of those proposals that restructures as well as places limits on supplemental coverage

but reason is supplemental coverage, particularly first-dollar coverage does drive up utilization. again i would note we exempted physician services at least the office visits from these deductible but nonetheless recognizing that in fact these might well encourage, we place a limit, essentially on the construction of those proposals, prohibiting all supplemental plans including those offered by tricare and federal employees plan covering first dollar beneficiary cost-sharing. we require that they include a deductible of at least $250 and included out-of-pocket maximum no lower than $2500. and cover no more than half of the beneficiary's co-payments, coinsurance once the deductible is met. and would ask that the national association of insurance commissioners essentially be asked to develop a standard

medigap plan that would meet these requirements. now recognizing the fact that there would be low-income individuals, this was pointed out, who might well be exposed to additional costs, we also provided additional protection to lower income beneficiaries by essentially absorbing at the federal level a higher percentage of cost-sharing for those between 100 and 135% of the poverty line and those up to 150% of the poverty line. so again, additional support for those individuals and new protection for those between 100 and 150% of the of the poverty line. then lastly, again, we asked higher-income beneficiaries to bear some of the additional costs by redoings the federal subsidy to singles earning $60,000 or more and couples with incomes of $90,000 or more. this proposed change we acknowledge would probably

impact about 17% of beneficiaries. but again, we believe coupled with greater protection for low-income beneficiaries and the broader policety of the program and would have a broader impact on the program as a whole and i will stop there. >> thanks very much, sheila. we'll will now hear from joe baker. he, for the last four years or so has headed the medicare rights center, a non-profit organization that works to improve health care for beneficiaries through counseling and advocacy among other functions. he is a lawyer by profession. law school professor, in fact at nyu. he has a lot of years of service in public and non-profit activities and today, surprise, he has some words of caution about the plans to restructure the benefits in medicare and how beneficiaries, particularly low-income and vulnerable beneficiaries would fair under

these proposals. joe, thanks very much for being with us. >> ed, thank you for inviting me thank you for inviting me and patricia as well. i'm glad to be here on this very important topic. we had a number of discussion on the proposals out there and there are even more variations on these themes so i wanted to talk generally and dive down into some specifics about what these proposals, what their impact would be on medicare beneficiaries. you've heard some of that. i think we start for all purposes at least in our work in representing beneficiaries and many of you are doing that work as well, really with a couple large points. one is we should not be looking at this as a way to shift costs to beneficiaries. if you see cbo scores, if you see scores on various, bowls

simpson, et cetera, basically what you're seeing there is savings to the federal government because costs that have been borne by the federal government or risks of those costs are being shifted either to consumers directly, to employers who will be picking up the tab or, to other insurance products down the line and off of states, for example for the medicaid program. so we really do not think that that shifting should be occurring. if it is occurring, that's what we should be calling it. we shouldn't, language is important as we all know, so when we're talking about streamlining the medicare benefit or designing the medicare benefit, we look at that, underneath, is that really shifting costs out of the federal government ledger on to somebody else's ledger and we're particularly concerned about shifting costs to consumers. we really have to be conscious of the winners and losers here. it's hard to do this we're not

saying let's not simplify the medicare program. let's not restructure it in some way that will make it better for beneficiary, better for providers, better for us all but we've got to be conscious of the winners and losers and a lot of discussion up here under that and kaiser has done a great job of, of kind of parsing that with the different proposals. but the other thing i think we really need to consider is, what the context that we're dealing with here. and that context is really widespread economic insecurity amongst people with medicare, both disabled and 65 and older. i wanted to spend some time on that. this is, you know, very familiar to juliette and tricia because their work here has been key in keeping us up-to-date about, and the kaiser family foundation, about who people with medicare are. half of people with medicare live on incomes of less than 22, $500 a year.

that is always -- $22,500 a year that is good cocktail moment. when you mention that. people's eyebrows raise quite frequently. they have also less than $77,500 in the bank in savings. to some that sounds like a nice little nest egg. it doesn't sound like a nice little nest egg when you realize they pay full freight for dental coverage, long-term care, roof needs fixing, et cetera as we know things that hit us, hit older people. they have lessee lastty in income an savings. medicare households are spending average of 15% of their income on health care costs and actually a lot of that is premiums. they're already paying premiums for their health care. it is about 46% of their income goes, premiums are involved in that. and it is only 5% for us non-medicare folks.

so, and premiums are rising. 26% of the average social security benefit is now spent on premiums as opposed to about 7% in 1980. so when you hear people with medicare need more skin in the game, they have got a lot of skin in there already and i'm worried that the next piece of skin might be the scalp. so we've got to be very, very careful when we're looking at, about these redesign streamlining or other proposals. so, the common proposals we've kind of run through in various forms and, they have these components to it. doing a consolidated deductible. taking that 1,000 plus deductible for part a and the $147 deductible for part-b and aligning it around the 550 mark. well, as we heard, because most people only use doctors services in a year, that is effectively

an increase in the deductible for most folks. uniform coinsurance, once again, doesn't sound, this is again where winners and losers come in. if you provide uniform coinsurance across the board you will have some folks that need services that are vulnerable, particularly poorer, lower to mid income folks that will have in effect an increase in their health care costs that may prevent them from accessing that care. varying coinsurance and co-payments and this could be value-based care, once again taking a look at, can we provide incentives for folks both informational, which i would say is just as important, but also economic incentives to drive them towards high-value either care or providers? i mean that is something that can be experimented with. adding a catastrophic cap,

5,000, 5300 in that range, 5500 is bandied about a lot. talking a little bit about commonwealth part e proposal or medicare extra proposal which would actually set that out-of-pocket deductible about $3,000 which seems from the beneficiary perspective to be about the right place. that's the balance there. it doesn't necessarily save money for the federal government but it helps a higher proportion of people with medicare. income relating premiums, deductibles or caps, once again, it's a slippery slope. we already do it. we do it as you know, for part-b and part-d already. so now we're moving that line. some. proposals would bring those income, that income at which you're paying a higher premium into the 40, 45, $50,000 range over time. once again, maybe that's what we want to do but how does that not inch its way down? also administratively are we

creating a lot of administrative headaches for ourselves doing that and is it really worth the savings as it were? the first dollar supplemental coverage, prohibiting that, or surcharging that. people by it because they want it. the most important thing we hear time and time again on our help line for seniors is, i need to know what i'm going to spend in a year on my health care when i buy that medigap plan-c or by that medicare plan-f, i hate paying those premiums but i know what my health care bill is going to be for this year, that level of security, is something that seniors value very much. so i think the bottom line in all these proposals where you're seeing savings you're seeing shifts to consumers and i think the underlying piece of it is, and this is important because a lot of thee proposals not only do you say, for example, get a

higher deductible so people are paying out-of-pocket you're also reducing utilization as sheila and others were saying and certainly we need to be concerned about utilization but the real driver in our health care system overall of our spiraling costs are those, costs are prices. anything that doesn't get delivery system reform or cost or price reform but simply twiddles with the design to push costs on to the consumer without at the same time, bipartisan does have medicare networks and you know, kind of expansion of acos. that might be something do -- to do at the same time. once again if you're pushing costs on to consumers and you're expecting them to self-ration care they're in the least able position to do that. that really reduces both needed and unneeded care. guess what? increasing costs to consumers works. they will self-ration. the problem is they don't know

with what they're not get something needed or unneeded. they rely on their doctor for that. once they're with a doctor, once they're in the medical system, once they're being treated by a physician, usually that provider is driving utilization, not them. you know, they will do whatever that doctor says, no matter how much they have got to spend. if they have got to mortgage the house they will do it. i just want to talk really quickly about, i think the bipartisan policy center has some great ideas about increasing protections for low-income individual. yeah, give a shoutout there. i think we really do need that talk in any proposals what we'll do for lower income beneficiaries and not only just make a program, but make sure people get in it. woefully inadequate enrollment in extra help and medicare savings programs. finally, part-e, this medicare

essential, medicare extra, where we're combining in a public program a, b and d, financed through beneficiary premiums, preserve beneficiary choice. you get all that simplification without once again shifting costs to consumers. they are paying a higher premium for that but they don't need a medigap plan. i think there are beneficiaries, that is just -- you don't need to do that. i think these are the ways that we can talk about simplifying without shifting costs. that is our main goal in this discussion. it's unfortunate it happens in a deficit reduction environment and that's what we need to really be careful of as we talk about these proposals. thank you. >> thanks very much, joe. leave that slide up there for a second. for those of you who are watching on c-span, if you're a low income beneficiary and enrolled in medicare take note of that first item in the first bullet.

that is the medicare savings programs and extra help that joe was talking about. find out if it applies to you. you might be able to get some help not only with paying your part-b premium but also paying the deductible, paying the 20% part-b co-payment as well or you might know somebody who could benefit from that and there are a lot of folks who are eligible, as joe pointed out, who are not enrolled in those programs. so take advantage what is already there while we're talking about what might be coming down the road. let me turn to our final speaker, frank mccardle, if you were writing a commercial he nose benefits. before he hung out his own shingle if you will, frank held positions at hewitt, one. country's most reknown benefit firms. at the employee benefit research institute. at the senate aging committee not far from these hallowed

halls and the social security administration. we've asked him to share his insight today into how these proposals would affect both retires with health benefits and the firm's that provide them. so, frank, thanks very much for being with us. >> thank you, ed, and good afternoon, everyone. as you heard each of the other speakers mention, supplemental coverage is a key ingreedent in all of the proposals that are talked about today and around washington because retiree health plans are a very important source of supplemental coverage for about 30% of medicare beneficiaries but i have to tell that you these programs are at a fragile juncture. after more than two decades of relentless cost pressure and design changes in response to that and now even more changes on the horizon i think it's fair to say that when policy changes are made, employers will tell you who sponsor retiree health

benefits, nine out of 10 of them will tell you it is very important for them to understand the potential changes that are being discussed today and generally around washington. by way of background, we've also heard the supplemental coverage kind of lumped together. employer coverage and medigap. in fact the two are very different. just two differences of the one, medigap as you know is standardized. retiree health plans are far from standardized. it is hard to really know how any particular policy change will impact the many variations of policies that are out there. the second thing, this affects the idea of a surcharge, retiree health plans typically do not provide first dollar coverage. decades ago they did but over the past two decades that has largely disappeared though not completely. when you're talking about a surcharge in relationship to an assumed increase in medicare utilization i would argue the

two programs are very different. juliette did a great job ofished indicating some cost repercussions and i want to just hit on a couple of her points but in general if the employer plan, the retiree plan or the union plan is continuing to cover medicare covered services the way it did before and now medicare will pay a smaller share of those services the plan is going to pick up the cost. now juliette gave one example where the cost increase in 2013 would be about 1.2 billion. that's total costs increases for employers and retirees combined. . .

>> it's going to vary a lot depending on the design of the plan, what the medicare proposal is and the level and form of the employer contribution. so i'm going to give you three different examples. in one let's assume it is an older, more generous plan where the employer's paying for most of the cost, or the union plan is paying for most of the cost. that increase would be fully and immediately borne by the employer and the union in this example. the company or the public employer, that's their sponsor, would immediately have to account on their financial statements for the medicare law change. periodly they have to account for that cost increase -- immediately they have to account for that cost increase. so what's the incentive there? for the employer it's to look at raising premiums, cutting back

the benefit design or maybe even eliminating the plan. that is, if they have the legal flexibility to do those things. most private sector plans have that flexibility, but not all do. there are collectively-bargained plans where there's not that flexibility, and there may be public plans where the benefits are protected by the state constitution, for example. let's take a second example, a noncollectively bargained plan. but here the employer has a cap on the amount the employer will contribute toward the retiree health plan. so now the change that's assumed, the cbo change that juliette outlined comes along, and you have that cost increase. well, the employer's cost increase is going to be limited by the amount of the cap, so gradually over time the retiree is going to bear more and more of that increased cost in the form of higher premiums. finally, i want to give you a third example which is where -- and this is a common example which i'll call an access-only

plan where the plan is made available to retirees, but the retirees pay 100% of the costs. again, assume a change like the cbo option, there the retirees immediately feel the impact of that premium increase. so what would they do? well, if i were one of them and i had an alternative option to pursue, alternative coverage option, i would do that alsoing adverse selection to what is -- adding adverse selection to what is already a high cost option. so you could predict with these access-only plans would be unraveling as these changes come about. and then finally i mentioned a minute ago just in passing and i can elaborate in the q&a that you could engineer a lower spending limit and still not save employers money if you don't count toward the beneficiary's spending limit med under medicare the amounts that

the union plan pays. so if you do that, and i'm a retiree, i may ask myself well, gee, why should i continue paying a premium? before i only had an out-of-pocket limit under the employer plan, but now i can get it under medicare. why do i need to keep paying that premium? or if i'm the employer, i say, you know, this is one more be reason why maybe it doesn't make sense to offer retiree health plans. we have good health coverage, they now have a new spending limit. i could save a lot of money if i eliminate this plan. i could save a lot of money even if i give a portion of that savings to the retirees to use for their medicare premiums or for some other purpose. so i think adding the spending limit diminishes the value of the employer plan. i think employers probably would only be more inclined to keep it if the spending limit under medicare was so high that they felt that their retiree population was not protected by it. so there's potentially a lot of

disruption in the wake of a very well-intended set of cost sharing changes. i think some of that could be mitigated, obviously, if the changes were applied to future retirees and you grandfather or protect existing retirees. but there's a trade-off. if you want to avoid disruption, you're not going to realize the same level of savings in the budget window. and if the changes are instead applied to all current retirees, then i think it would be important for lawmakers to consider ways at least to transition benefit or transition arrangement where you guarantee access without underwriting. so that if a retiree, for example, has to switch from from an access-only employer plan to an individual medigap plan, that they have that option without being penalized for their health status. and finally, i just wallet to come back to some -- i just want to come back to some things that joe said because this concept of

having skin in the game which was one of the reasons given for changes in cost sharing which was not on trisha's slide, but that concept of skin in the game actually developed in the private sector in the 1990s, and it developed with respect to active employees. and we all know that that design and concept has expanded. but i think it's very different when you try and apply that to a retiree population because of their, the volatility that they a face for their health care spending not only direct health care spending, but also other health-related support services that are not covered by medicare or by supplemental coverage and the amount even with medicare covered services, there are estimates that a couple at age 65 would need to have squirreled away around $200,000 in order to pay for their lifetime retiree health costs just for medicare-covered services. i think we also need to remember

that there's volatility for retirees on the income side, and it's a downward volatility. obviously, a lot of retirees may be spending down their assets, but increasingly a lot of retirees are getting their benefits not maybe the federal employees, but in the private sector getting their benefits from defined contribution plans where the account balance, the money that they have available to them, varies with the market, with the asset allocation. and so those kinds of fluctuations in income compound the concern about volatility that joe was talking about and the need to have some more security. so i guess i would close by saying if supplemental coverage and particularly retiree health benefits are to be changed directly or undirectly for the purpose of -- indirectly for the purpose of medicare cost sharing, the preferred approach, in my opinion, would be to try and find ways that would not add further volatility to what is

already a kind of risky business for retirees and their health care. thank you. >> great, thank you, frank. thanks very much. thank you to all the panelists. and now we get to the segment of the program where you get a chance to join the conversation. as i mentioned, there are green question cards that you can use to query one or all of the panelists, and there are microphones at either side of the room. the one on my right is way on the other side of the room. [laughter] so you'll have to strike out early to get to it. and i'm pleased to recognize as our first questioner/commenter someone i need to identify not only as the president of the national coalition on health care, but also a member of the board of directors of the alliance for health reform. and i'm talking about john

rother who is also no stranger to these hallways. john? >> thank you. i want to start by thanking the alliance and kaiser for an excellent, excellent discussion. this is a tough area. this is not a simple area, and i personally have a lot of sympathy for the effort to deal with the fragmentationing of medicare -- fragmentation of medicare. it does not make sense. no one would design that program today. however, i want to make two kinds of comments. one is on messages from focus groups that i've reviewed over the past two years trying to test out some of these ideas with seniors. and i think it's fair to say that the idea of a deductible that comes every january after you've just spent christmas with your grandkids is a nonstarter. there's simply no way to sell

that to retirees. now, i do think that retirees understand that maybe there should be some cost sharing at the point of service, but the deductible is just an impossible sell is what i can report. now, i'm not saying it's bad policy, i'm just saying that a flat, across-the-board approach is a very difficult one to convince seniors that works. so i'm much more interested in the kind of variable benefit that sheila reported on from the bipartisan policy center, particularly something that's key to the value of the benefit design. and i applaud the idea of exempting physician office visits, but here again from the focus groups most seniors don't decide to go to the hospital. that's not a voluntary decision for most people. and so they don't really get why they should be charged for

something that is somebody else's decision, not theirs. so i think this becomes quite difficult, and particularly when we obviously need to save money in the program. so i have an alternative approach to suggest which is, i think, not just seniors, but all of us need to be more engaged in decisions around the care we receive. and people need the tools to become engaged, and particularly seniors because they're the most active utilizers. most seniors have no idea how to compare one procedure with another, one doctor with another, one hospital with another, and we all know that prices and quality vary sometimes quite substantially. so we need transparency in the system so that people can understand that there are consequences to these decisions and that they have choices that have a real impact. and the effort

to change behavior by seniors, i think, should not be so much economic as guidance. people need guidance, and the best place, i think, would be the patient-centered medical home where there's a care team that knows the whole situation and counsel people as to how to appropriately utilize the system. so i'm just arguing for a broader approach. we do need to simplify medicare. we do need to think about what the proper role is of cost sharing. but that's not the only tool we have and, in fact, i think seniors would be much more open if we provided some additional tools to help them be better patients. thank you. >> thank you, john. anyone want to chime in on any part of that? >> i will. >> >> joe?

>> i think, you know, certainly our work with seniors and people with disabilities on medicare, you know, bears out that they do need more information, and they want more transparency in the health system and that the complexity that they see in the health system isn't always or frequently isn't actual medicare benefit or benefit structure, but rather the structure of the health care delivery system. so i think the idea of the patient-centered medical home, the aco structure, some of these yet to be proved but, you know, on their way and certainly scaling up, i think they are the kinds of things and the kinds of experiments that we need to be doing in the medicare program in order to give seniors and people with disabilities in medicare that kind of, that place, that home base and that information agent. because i think a lot of consumers now are looking to their providers for this kind of

information. they also -- what i think will be interesting over the course of the next few years if doctors and providers have typically been seen as kind of white hats, you know, like the insureds versus the providers, you've got a coming together of insurers and providers and a mix of payer and provider now. so maybe the hats are getting a little grayer, i don't know. but you will need, i think, consumers need to know that, and they need to see that, and that structure needs to be transparent, and they may need other assistance in navigating that. but certainly, i think that can help with the utilization issues that we've discussed and also in making sure that folks are getting the highest value and highest quality care. but we've got a long way to go, and there are always going to be, i think, a large proportion of seniors, particularly folks, you know, over 80, over 85 that are going to need a lot of assistance in navigating whatever system we come up with.

they're not going to be their own information agents in many instances. >> with okay. >> barbara -- >> yes, go ahead. >> the coalition for disability health equity and the fibromyalgia and chronic pain association. i'm concerned because you are talking about disabilities and seniors in the same breath, but people with disabilities who retire on disability are not eligible for medigap insurance. and there are people who have, who are dual eligible with a $500 deductible a month before medicaid picks up, sometimes higher than that. so in figuring in doing these studies, is anyone taking that into consideration? because most of these people are very low income but not low enough to be covered for everything and don't have the options of -- they're paying dollar one and dollar two because there's no medigap. so is the study taking that into

consideration? >> i'll defer to trish and juliette in terms of the work that they've done, but i think you raise an extraordinarily important point, and that is that we often confuse or at least fail to recognize that there are real differences in that population who are serviced by the medicare program, a full array of issues in terms of impairments, those that present because of age, those that present because of disability. and the attention both to the mix of services as well as the financing of those services is one that has not gotten the kind of discussion or attention that it should have. the issues with respect to the very low income people that are duals, people that come in because their quick byes are slim, even the complexity and the method by which you qualify and the benefits that are available to you fedding upon the basis of -- depending upon the basis of your qualification

complicate a complicated question. and so your point is right. we haven't paid close enough attention to it. and as we look at restructuring and look at what the protections might be, that is clearly a population we need to spend more time on. but i'll turn to juliette in terms of the kind of work that form the basis of some of their research as well. >> well, i think sheila answered your question perfectly. our studies don't actually address beneficiaries with disabilities separate from the traditional population overall. i think you raise an important question aside from, you know, these proposals to restructure medicare cost sharing and change the rules of supplemental coverage specifically with regard to ped gap looking -- medigap looking for specifically at how the medigap rules are different for people with disabilities than they are for people age 65 and over. medicare is an issue that our studies don't address, but it's certainly an issue that's worthy of policymakers attention. >> it's kind of like if you want

to find out what's going to happen to seniors if you change medigap, you can just look at the disability population since they don't have medigap. thank you. >> joe actually raises an additional point that i would raise and that is i think there's increasing interest in looking at how the states are dealing with some of these issues because of the unique nature of some of the state programs whether it's new york and others. and so in looking at sort of these solutions and looking at those unique populations, i think we would benefit from understanding whether states have stepped in and tried to address some of these issues. >> some states do have open enrollment in their medigap plans for people with disabilities, so that's a's, and there is, you're right, no federal open enrollment. i think the second thing is we're hoping with the coming of the aca exchanges and certainly medicare rights center and we've worked with a lot of other groups nationally to try to make sure as medicaid programs are

streamlined both eligibility and enrollment processes that the programs like congresswomen by, other programs -- congresswomen by are also part of that streamlining part inserted into that exchange which is, hopefully, the brand spanking new computer system. you know, new york and other states are revising and updating these systems that have been around since, you know, welfare. and so hopefully it's a new front door for a lot of these programs. but you're absolutely right, there still needs to be, it's not consistent nationwide, and it's not going to be anytime soon. so when we're looking at these federal proposals to, you know, really streamline or improve medicare, we've got to make sure that it's there for people that are disabled and under 65 as well. >> yeah, this is one for frank. frank, you talked about the

effects of benefit design on different employer plans, but you also mentioned a surcharge. can you talk a little bit about what the surcharge would -- how employers might respond to a surcharge or what that might mean for retirees, and are there differences between employer plans and medigap? because some of the proposals would have a surcharge on both. >> yeah. i think that's a great question. one thing about it is a surcharge is a concept which sounds really easy, doesn't it? we'll just, we'll just add a fee, and then we'll have this effect. but then when you start to get beneath that idea, it gets really messy, in my opinion. for example, what triggers the surcharge? is it any kind of supplemental plan? well, that wouldn't make a lot of sense because you could have high deductible supplemental plans that don't have big medicare utilization effects. but would it be only first dollar plans? well, how do you define what a first dollar plan is?

so just a regulatory mechanism to try and differentiate among different kinds of supplemental plans for purposes of a surcharge, i think, is scary. [laughter] but beyond that i think if you try and have a uniform surcharge on all plans, then you really don't have a policy justification for that if the idea is be ped care utilization -- medicare utilization. the other question is on whom is this surcharge going to fall. there's one idea which is you put an excise tax on the plan, but there's already an excise tax on high cost plans that's built into the affordable care act. it takes effect in 2018, and it will start -- employers are already looking at how they will change their retiree health designs to live within that cap. so now we're going to have two excise taxes, and i don't know how they would correlate. if it falls on the employer, well, you can imagine what the effect would be. theloye looking for

an added cost increase, so the reaction, i think, would be pretty significant. and then if it's sort of something where you add on to the retiree's medicare premium, their part d premium, to me that's another level of complexity that makes my head spin because now you have somehow the employer or somebody's got to give a value of what that retiree health coverage is, i would guess, and we know that employers are not happy about having to report these values. they're quite burdensome. and then you can have life changing events that would affect the determination of what that surcharge would be, or would it be a tax on the retiree and subject to the income tax rules? so i think as i said at the beginning, once you get beyond the idea of, gee, a surcharge is

easy and we just impose a fee, it becomes so complicated that i think from the standpoint of retiree health plans i just see a lot of problems with it. there's kind of a back door way of avoiding a surcharge, and i think maybe it's embedded in some of the proposals you've heard discussed here which is to say, okay, we won't have a surcharge, but we're going to stipulate what the design would be of the retiree health plan. and if you do that and, certainly, congress could do that, but it would be a very significant departure from all the history that we've had where these are voluntary benefits negotiated by labor and management or just offered by the employer, and these have evolved, and they're very different for different sectors of the economy. and suddenly if you're going to have a federal definition of what those plans have to look like, you could do it. but in terms of the impact, it would be a very big, big difference than what we're used

to. >> got a related question, frank, and i don't know whether you're the person who wants to take this on or if some of our other panelists. the questioner writes: both the first and second presenters, actually, stated that first dollar medigap coverage drives up utilization. please describe what, if any, research has examined the competing hypothesis that high user beneficiaries, ie sick people, self-select into first dollar coverage, and that's what causes the utilization rates for medigap policies to be higher. or are those the same thing in. >> um, no, i think those are sort of the two competing arguments. i think the questioner sort of answered his or her own question. you know, there is research that suggests medi pac has summarized

this in a recent report that there is higher medicare spending, higher utilization among people with medigap policies. but then on the other hand, there is this, there is this belief and i think there is some research to suggest that people who are sicker are purchasing medigap policies because it does provide them with the sort of peace of mind and the protection from the medicare cost sharing requirements that would otherwise be relatively burdensome if you have relatively high medical needs. so i think there has been this question of, well, if you impose these restrictions on medigap supplemental coverage, are you penalizing people just because they're sick? are you penalizing them, are you making it harder for them to get assistance with the medicare cost sharing that they would otherwise be unable to afford, but they're willing to pay the medigap premium in order to get the financial protection. and most people with medigap

policies have the relatively more generous first dollar policies as opposed to some of the other medigap plan designs that we've seen lately that don't pick up as much of the costs of the medicare cost sharing liabilities. so i think this is the tension that we face, and it's certainly one that would need to be reconciled with if policymakers were to move forward with this type of option to. >> so this is, this is a related question. do any of the proposals have protections that cost sharing increases wouldn't result in people not getting necessary care? in other words, are there safeguards that are included in these proposals that would make sure that the cost sharing works to prevent unnecessary care but doesn't impede somebody from getting necessary care? >> you know, i think the

proposals are confronted with the same issue that we're confronting in the current program which is there have always been concerns as to whether or not even with the existing cost structure there are people who delay or avoid care because of the costs that are going to be incurred. i mean, a lot of the support programs were developed, in fact, to address the concern that particularly those with low incomes didn't have the capacity to, essentially, finance that first step. i think in the construct of the bipartisan policy center proposal we at least acknowledge that in the context of having the physician visit excluded from the deductible so that you don't have to, essentially, meet the deductible of $500 plus when you walk in the door. you have, essentially, a fixed co-pay for your visit to the doctor. of again, recognizing that the majority of medicare beneficiaries, in fact, utilize part b service as a relatively small percentage utilize part a.

but again, there was attention to that question and also the addition of protection for those between 100 and 150% of the poverty line who currently don't benefit are a federal support in terms of cost sharing exposure. so, again, i think this is a problem that we've always confronted. it's a question of whether or not any kind of requirement essentially delays or prevents someone from securing care. commonwealth and others have done work on this question. it comes down to the presence of insurance, what difference does that make, and the acknowledgment that in the absence of insurance, n., people delay. the same reason has arisen with respect to cost sharing. i think it's a problem we confront now with the existing problem, and it'll be a problem going forward based on what that structure looks like. to john rother's point earlier, people now face this absurd part a cost on an episode basis which

is this bizarre construct of a 60-day, you know, you essentially pay it if you're hospitalized, and then you don't pay it if you're within that 60 days, but then you pay it again in another 60 days. so, i mean, people are confronting cost-sharing problems today. many of them have protection, financial security in the purchase of coverage or it's available because of their union or because of their retirement plan or because of medicaid. but again, this is not a problem that's new to us, it's a problem we continue to struggle with which is what the balance is. >> where i think that's right. i mean, i think a lot of these proposals -- well, some of them don't try to mediate between that at all, they're just simply shifting costs, you know, right on to consumers, and there's a nice savings number at the end of them. i think the, you know, the commonwealth part e proposal probably gets the closest and friendliest from the beneficiary's perspective with a lot of the elements that sheila

has talked about. and, you know, i think also as we know from the commonwealth work, you know, many other countries with, you know, national health systems have first dollar coverage and use other mechanisms to calibrate or provide disincentives for unnecessary care mostly through provider payments, control and provider budgets and provider directives. you know, it's a much more directive health system in that regard. >> joe, you've prompted -- there are two cards i can coordinate at the same time because you've mentioned part e, and i think a lot of people in the room have not heard of part e. so can you describe what is part e, how does it differ from medicare advantage? >> sure. >> what's medicare essentially? you mentioned that earlier. >> yeah. well, part e and medicare essential, unfortunately, i'm not the expert on this, i really do refer you to the commonwealth sides and report on this, and this is a -- there's a bit of a change in the proposal recently.

but basically what it is is taking parts a, b and d and combining them in a public government-run program. so it's not a, you know, you would say, oh, that sounds like medicare advantage, that sounds like a medicare hmo and, yes, but those are run, as we know, by private insurance companies under contract with the federal government. this would actually be federal program. the piece here, of course, would be that for the first time you would have a public part d plan. right now, as you know, part d prescription drug coverage is supplied only through private health insurance companies. so it would be bringing those three things together. a lot of, you know, folks are in the medicare advantage program. one of the reasons they're in the medicare advantage program with these private plans is because they like the simplicity of having all of those benefits kind of merge together. a lot of the streamlining that we're talking about that would occur in the government program

occurs in medicare advantage plans. you know, they like that, they don't like the limited network of doctors or they don't like some of the management, you know, care management or medical management that occurs in medicare advantage, they don't like some of the geographic limitations, but they like that simplification, if you will, and the kind of one-stop shop. you don't feed a medigap plan. so -- need a medigap plan. so this, basically, part e or medicare essential would combine parts a, part b, part d, and you would not need a medigap plan. there would be higher premiums, so it wouldn't be the same premium structure for all that because you would be getting supplemental coverage. there would continue to be coinsurance for part b, i think 10% coinsurance. so it's another, you know, we didn't go through it in detail, in our slides. it's not talked about a lot on the hill as like a viable

proposal because even though it has a significant savings associated with it with provider components, about 183 billion, i think, other ten years, it's seen as, well, that's -- we're going to put all this under the government including part d, and a lot of folks like the part d program over here on the private side. but it is a way of getting to this simplification, this streamlining and saving money at the same time given the components there. >> and i should just a small commercial be, a few weeks ago we actually did a briefing, some of you were there, i believe, that featured a presentation by the former ceo of commonwealth funds, karen davis, about proposals like medicare essential that would revamp the benefit structure as well. so you find a lot of both complimentary and critical information about and related to that plan.

we have that briefing on our web site. >> yeah. i recommend that highly as well. and i would, i also say that in medicare essential at least there is a lot of delivery system reform as well. so a real -- the patient-centered medical home, aco, that model is relied upon as well to achieve some of the savings. so i think once again it's looking at redesign of the benefit, but also redesign of the health care delivery system because that is essential to kind of get at the underlying problems. >> yes, go right ahead. >> hi. i had a question for the panel about the unintended consequences of the income-related premiums, particularly if you increase the while -- level while you're going down in terms of where these premiums would affect people. and what would be the effect if you see people not taking medicare? i mean people, for instance, going out and attempting to buy

insurance in a wider scale in through the exchanges possibly, perhaps in the state of new york where the costs have come down. and what kind of things would this do to the medicare program and the other beneficiaries who are poorer? >> could i ask you to identify yourself? >> i'm karen -- [inaudible] i'm a robert wood johnson health policy knell. fellow. >> karen, i don't think we know the answer to your question for a number of reasons. the presumption has always been and our experience has always been that medicare has been such a, medicare has been positively viewed as compared to private insurance for this population. as much more accessible, much more affordable. of course, part a is required, i mean, it occurs. part b is voluntary and, of course, d is as well. and so our experience has been that when one looks towards turning 65 or one is disabled

that medicare is an inevitability and viewed as a positive one because historically people weren't able to purchase in the market anything nearly as full isesome for the price they pay because it's trust fund financed under a and a combination of supplemental trust fund on b. so compared to what you'd buy in a private market, it was always viewed as a value. now, what will occur in the new world order in terms of what might be available in an exchange structure, one might imagine that given the role of the private sector largely in the individual small group and large group market that is employment based or an individual market as compared to sort of the financing of the elderly as a population which hasn't occurred since '65, again, you'd have to look at are the benefits comparable, is there a security there? what does the benefit structure

look like in terms of what the premiums are going to be? i don't think we know the answer. in terms of the changes on the income side which was something that was introduced, obviously, after '65, relatively recent, again it's relatively higher income to the point that was made earlier, the large majority of these beneficiaries are at 22,000 or less. the income targets that are viewed at least in the bpc proposal are at 60,000 for an individual down from 85 and then 100 plus for a couple. so, again, it's not targeted at very low income individuals who are, make up the bulk of the medicare program or people who are very low income or duals, the eight or nine million people who are in the duals because of their income or their status. so, again, i don't think we know the answer. i mean, it's a reasonable question to ask, but i think there are a whole host of reasons why medicare -- not the least of which is why the structure of the trust funds,

would continue to be a benefit and viewed more positively and what the benefit structure looks like. but, again, a question that, you know, will come up. we're looking at a whole host of proposals on restructuring the way we think about medicare whether it's acos, medical homes, you know, looking across the full continuum of care which we've not done a very good job of. we tend to focus on the acute side, but there is this postacute side which we are beginning to focus on as well. so, you know, i think it's an interesting question but certainly not one that i know the answer to. >> i think that, i think that you're right, the crystal ball's kind of cloudy on what the coming exchanges will do and whether wealthier individuals will keep that coverage, you know, post-65 which they could do. the subsidies run out at age 65. you know, you can't get subsidies for coverage after 65, but wealthier people, you know, above 400% would not qualify for those anyway. so i think the second piece is, you know, my problem with

income-relating premiums is, you know, this slippery slope idea. so, you know, some do go down to 40,000, and three years from now when we haven't controlled costs through other delivery system reforms, are we, you know, 24-5, you're a wealthier medicare beneficiary, you're going to pay more. and then it does strike me as we're setting the limit for wealthy or higher income at 60,000 or, you know, whatever, even 87 or, you know, now 85,000 when, you know, for our tax structure we're setting it at 250 or 400. no one's saying, you know, hey, yeah, let's raise taxes on those rich $65,000 a year folks, you know? why we're looking to medicare as wealthy and higher income at 60-plus in income, you know, that strikes me as a bit ironic to say the least. so i, but my main problem with it, it doesn't really solve --

it gets you money. doesn't really get you a lot of money, but it gets you some money. but at the end of the day, it doesn't solve the underlying problem which is health care costs. and, you know, there's a lot of other proposals that get there that i think we should be, you know, doing before we just kind of up the bill for people with 60 or more thousand dollars a year. >> right. >> yeah. i just wanted to add that i think people don't realize that when the medicare premium is related to income, that it's based on modified adjusted growth income and not your taxable income. and that can be a very big difference. for example, a retiree when they turn age 70 and a half the following year, they have to start taking distributions from their retirement plans. a lot of retirees don't get that rule quite right and end up taking two years' worth of distributions from their plans. and so suddenly their income is juiced up a lot, but it's not taking into account, well, what if i have a spouse who needs in-home care that i have to pay

for 24/7? there's no correlation between those two. because it's not looking at taxable income. and same thing is if a retiree sells their house and then suddenly they have a bump up in income, and now they have to pay a higher medicare premium because they saved all their life, paid down their mortgage, and now they sell their house. i mean, i think there can be a lot of inequities in applying that, and it's not just getting higher income people, it's people who fall into income situations with a certain degree of variability. >> we have a bunch of questions related to income, i guess related to income-relatedness. one of them is very quick, quickly responded to if i can ask some of our panelists to respond. for the analyses that have been cited, the 50% and sheila just mentioned this again, 50% of medicare beneficiaries have

incomes of 22,500 or less, do the income figures include social security benefits and pensions? >> yes. >> there you go. i knew that was easy. okay. >> i have a question on this income-related issue. some of the proposals have an income-related, out-of-pocket limit, and the idea there is let's give greater protection for lower income people but not so much to for higher income people as a way of conserving federal dollars and resources. in this would be really new for medicare in many income relating a benefit not just for those with low incomes. i have questions about how this works for employers, i have questions -- i don't know if, sheila, you've thought about how medicare would administer something like this, what's it mean for beneficiaries? does anybody on the panel want to speak to what it might mean to have an income-related limit? because i know it sounds

appealing to people who are trying to provide greater protections to those with modest incomes. l so anybody want to jump in on that one? >> good question. >> well, i guess so there is this question about income relating the out-of-pocket spending limit. there are also proposals that have suggested income relating other features such as the deductible modifying the cost sharing amounts depending on a beneficiary's income. i think there are several questions from an administrative standpoint in terms of, well, just backing up a little bit, you know, we've referenced the income-related premium so there are already, you know, aspects of medicare that are income related. so people with incomes above $85,000 a year as an individual, people with incomes above $170,000 a year as a married

couple, they hire monthly premiums for part b and part d plans if they're enrolled. so there is a mechanism if in place currently for, you know, medicare to know a beneficiary's income, and that's administered through ffa. they know, you know, how much medicare beneficiaries are making if they're paying these higher premiums. but it's very different when it comes down to income relating lots of other features of the benefit in terms of does your deductible drop to 500 or, you know, to 400 or 300 depending on which income bucket you fall in, and and how do you red carpet that to medicare? is it based on your taxable income? what if medicare thinks you have more income than you actually do, is there a process for you to appeal so that you get placed into a lower cost-sharing category? there are, i think, a host of questions. and then it raises, i think, a set of privacy concerns for some people who may be worried that,

you know, if they are paying a lower co-payment, they're benefiting from this income-related provision, but then the doctor might know how much their income is or at least what category, what income category they fall into. and i i think that raises real privacy concerns for some people. so i think this proposal, again, it looks good on paper and it seems like a great idea, and it certainly is a way of making it less painful, less onerous, less burdensome for some lower income people than, you know, the average medicare beneficiary, but i think it also raises concerns that haven't yet been fully thought through in terms of the the administrative complexities of making it work. >> well, from a retiree health plan perspective, there's no way that the employer is going to know what the retiree's income is going to be. so, basically, the administration of this would all have to occur outside of the

employer plan, and some administrative entity would then have to communicate it. but in addition, typically the organizations that respond sorry tire' health plans often offer defined benefit or defined contribution retirement plans as well. so they would be higher income on average than the average beneficiary, or it may be state government employees who have good benefits and good pensions that go along with it. so they might be more likely to be impacted. and in a way the retiree plan if you think about this, is in a sort of passive situation which is social security will determine, i presume it would be social security although they are very overburdened now with administrative duties with the growing baby boom generation, so social security would be administering this, and there would be sort of an unknown.

and so functionally for everybody whose higher income in the out-of-pocket limit is higher, it's like that example in juliette's study where the spending limit goes up to 7500. so in effect -- and i'm just picking that number. so in effect it's picking the cost of the plan for everybody who's got that additional income out of pocket boost. so i think that would be hard for employers to know. i think they want more certainty about their costs and what their costs are going to look like. so i could see that adding another complication. and then finally there is the same thoughts i expressed about income variability with respect to the premium. i think that would also be applicable here to the out-of-pocket limit with sudden changes in income suddenly putting the income -- the out-of-pocket limit up when there may be other reasons that wouldn't necessarily justify that from a tax ec bity

standpoint -- equity standpoint. >> i think everybody has said that, you know, the pluses and minuses of this, i think it comes back to, once again, you're trying to simplify the benefit, and you're making it more comply -- complicated at the same time. and the poet vegas is certainly good when we're looking at more vulnerable, poorer folks. but then you step back and say the way that the real treasure of the medicare program in a sense is its uniformity across all classes. it brings americans who like social security together in a big social insurance program. and so as you kind of chip away at that, i think you start to have some problems. i also go back to saying, you know, we always say medicare, you know, a lot of people say medicare is unsustainable. no one seems to say the defense department is unsustainable. you know, if we want to, you know, if we need more money in the medicare program, in the health care system or we need to enhance benefits for lower

income folks, you know, we can use the tax system to do that. and i would say our history of getting these kinds of better benefits to poor beneficiaries isn't that great. once again, quimby and slimby, very low enrollment rates. that's why ed had the commercial at the beginning for learning about those and telling your friends and family about those. yo, you know, it's the right motivation, but be i think at the end of the day it overcomplicates, and it's administratively very burdensome. >> and that at the -- i'm sorry, we need to get you to a microphone if you're going to ask a question. let me just take a ten second break here. we're coming toward the end of our time, and i want to make sure that you have a chance to pull out that blue evaluation form and fill it out as we go through these last few questions.

and i think from what joe has said that we know how you would answer this next question -- [laughter] what do you think of the mccaskill-coburn bill which would lower the income threshold for income-related premiums from $85,000 to $50,000? >> well, i, at the risk of repeating myself -- [laughter] once again, that's a good example of a slippery slope. we just keep going down the slope until we get to a number where we're raising enough money, and once again i would say we've got a tax code, we have a very robust debate about changing that tax code every time we decide to change it and where that money should be spent, and i reallity that's where we should -- i really think that's where we should be focusing on income and where, what folks should be paying for the whole array of services that our government provides to us as opposed to now focusing in very narrowly on medicare premiums

for folks that are either at some level of income that's considered wealthy or not. these numbers move whether it's 50,000 or 60,000 or 87,000. it's really, you know, to raise money. and it seems like the tax system is the best place to do that, not medicare premiums. >> ed and i -- >> i'll take that for a don't like. [laughter] >> i, obviously, it's not dissimilar from the approach that the bipartisan policy center took. it's lower. but i think i would go back to my earliest comment which is the bpc proposal is one that is part of a much broader set of recommendations that include reforms to the program. broadly. and to, essentially, move towards making it a much more cost effective program and is not dependent on in this as the only med of essentially rethinking the way we reorganize in this finance services. so it is an element. it is not, i would say, the most

important element by any stretch. i think there are far greater elements that are important to consider including the simplification of the benefit and the structural changes in terms of moving, maintaining choice but moving towards more coordinated systems of care. so, again, i think the value here is in looking across a wide array of things rather than one specific thing. i don't imagine that any of our principles would support that as an independent element that is simply to change the premium. i think they would only consider it as part of a much broader strategy that would also result in reduced program costs and would, hopefully, benefit everyone in terms of reducing those costs. >> yes, ma'am. now that we've made you walk to the back of the room. [laughter] >> thank you. >> do you want to identify yourself in. >> sure. maria schiff with pew charitable trusts. i have two related questions about individuals who buy first dollar medigap coverage. one is whether we know what, do

we know what their income profile is, whether they're part of the 22,000 income group? but a related one is, is if we know if people who buy first dollar coverage tend to use more services, but we don't know if it's sort of a chicken and egg kind of thing. it would seem if they are using more services, we could see if those are the nondiscretionary, presumably in the nondiscretionary like more hospitalizations where you don't think that that's particularly discretionary or at least it's discretionary at the part of a physician and the hospital admitting, you know, department. but not the type that you think of as discretionary services in general. >> [inaudible] >> let me answer the straightforward question, first, which has to do with income. so people who purchase be medigap are not the poorest on medicare generally because they have medicaid, and they don't

tend to be the highest income groups on medicaid because they tend to have employer coverage if they were affiliated with an employer. so you're really talking about a middle income population without as many people in either tale. in terms of service utilization, the studies that i have seen have not teased apart whether -- what types of services people use more when they have full cost sharing or what services people forgo when they are confronted with cost sharing. and i don't know, maybe anybody else on the panel might be able to help them, whether anybody has really looked at it in a more refined sense. rand obviously did some rocker years ago. there's been a lot of research on the version of brand and cost sharing. so there's some research related to cost sharing and utilization,

but i don't know of any research that answers your question directly. >> yeah. it seems as if there's serious discussion about limiting or prohibiting first dollar coverage, that it would be -- it's knowable to know what kind of services those individuals are using, and if it's strictly -- if it's large hi hospitalizations, then -- largely hospitalizations then you think of them as sicker as to ezed to just -- as opposed to just morally has art. >> yeah. i think your own statistic is 46% of people with medigap have incomes under 30,000. i'm quoting from a kaiser, you know, brief on that. [laughter] so i do my kaiser homework. >> i'm sure he's right. [laughter] >> i wrote it down. and i think once again going back, i think there should be more information available about, you know, what this effect is of first dollar coverage. once again, time and again -- and this is anecdotal based upon

our help line. we help about 15,000 people with medicare a year, and what we see is they may once again -- they're very confused about, you know, what's needed or unneeded, and we don't provide health advice to them or health information, we coverage only. but what we -- and i think studies bear this out -- is that once they're in the health system, their utilization is not necessarily driven by themselves, it's driven by a provider, and, you know, a provider's recommendation. that's why you go to the doctor, right? to find out what you need to do. so, you know, by not -- what we're concerned about, as i said earlier, is that initial visit you don't know if it's unnecessary, necessary. i think much of the literature around this is looking at imaging as a new driver of costs, and that's certainly something that you don't toddle

off directly to the imaging center, you know? that's something that -- maybe somebody does, i don't know. maybe i should be doing that. [laughter] but you coto a doctor first, and that doctor says, you know, x-ray, mri, cat, whatever it is. so that, to my mind, is, you know, before we jump on this like get right at first dollar coverage bandwagon, i think we need a lot more information, and we also need to understand that there are, it's quite clear the statistics show it, it works. it prevents people from, you know, going for that first visit or walking through the door because they're going to have to pay money up front. i mean, that's why preventive care is, you know, a zero co-pay, you know, to encourage people to go get it. so i think that is the concern. a lot of the value-based designs, you know, i mean, that's what value will-based iso dollar for preventive care and less for generic drugs, etc. and we're not at a place and where -- and certainly mark and

mike have done a lot of work on value-based and the private, you know, insurance market has experimented a hot with it, but, you know, and when we need to continue to do that. but, you know, as we all know, getting a bunch of doctors to agree on, okay, this is high value and this is not so high value, it's tough. and it's going to take time. so, but i think we do need to have some time. you know, fortunately we do have some time, i mean, you know, even though medicare we're all concerned about medicare's financial future, it's in some of the best shape it's been in in decades. and be that does give us a window of opportunity to allow some of these things to be experimented with, you know, before we go off and, you know, cut off the first dollar coverage just because, hey, we need to save some money in 200. $2030. >> one question that kind of has come up inferentially throughout

this discussion and it's because i wrote it down, i can repeat it. that is, isn't it likely that any of the proposals that we're talking about with or without safeguards for low income people are only getting consideration and only get serious consideration in the context of trying to save, generate savings in the medicare program while we discuss deficit reduction and medicare being if an unsustainable situation? -- in an unsustainable situation? >> i mean, maybe yes, maybe no. i mean, these proposals have been talked about in the context of deficit and debt reduction. it would be with conceivable that they would be talked about in the context of the sgr, the physician payment reform fix where there's a question about how to finance the payment reforms for physicians under medicare. so i don't necessarily think it's a debt reduction frame that

would drive these policies. >> i think i did articulate earlier that my concern is that we are talking about these in the context of debt reduction, and you certainly see numbers in bowles-simpson and cbo and others where there are significant savings, and those savings are primarily driven by significant cost shifts to consumers, you know? i think, you know, there are other, you know, more moderate and, i think, more long-looking, if you will, proposals like at the bipartisan policy center, you know, that would still shift costs. there's always going to be winners and losers, you know, in any of these redesign, there's always going to be an adjustment period as it were. and i would say as a consumer organization, you know, i've been crying wolf a lot and we've been very negative. i think there are proposals that are out there that would generate some short-term savings to pay for sgr, you know, like drug rebates being back for low income medicare beneficiaries

which would save a significant amount of money, about 140 billion over ten years. it's in the president's budget. you know, whether they're politically feasible, you know, or not, you know, is another matter be, but i think they're there, and can they're worth the debate while we have time to kind of look at these, these proposals in a more -- i hesitate to saudis passionate because we'll all get passionate about it, but not looking at them to drive savings. i don't think we're ever going to calibrate it so that, you know, everybody's a winner. you know, there's going to be some level of adjustment where someone will pay more in a certain circumstance. but i see these proposals, many of them as, you know, taking this opportunity of deficit reduction to do some good things. but at the end of the day, they're saving money, and a lot of it is because of shifting costs to consumers or to other insurance programs. >> i would agree with trish that

it's not entirely clear to me that the only reason to drive this discussion is, in fact, a budget discussion although it could well occur in that context. but i think any of us who have spent the bulk of our professional lives thinking about, worrying about and studying the medicare program recognize that we are in a period of time where there is clearly the need for and the desire the relook at the program. certainly, all of the work that's taking place in terms of restructuring the financing, restructuring the delivery system, the relationship between providers and payers, the relationship between beneficiaries and provider and structure, the development of acos, medical homes all suggest to you that there is a growing awareness of the fact that the program that was developed in 1965 is not a program that is suitable for today. no one would today create it, and it is certainly not related to or similar to any other kind of system in place. it has enormous benefits but also has exposure as well as to

beneficiaries. and so i would hope that the conversations would occur with a mind towards improving it for those of us who are boomers who are not long from qualifying to maintain it for a very long period of time. i mean, the program has done a great deal over the years, but it needs our attention in terms of moving it forward. and on that point if i could take a point of privilege, because i know he is a c-span watcher, today is bob dole's 90th birthday. [laughter] >> happy birthday. [applause] >> all right. well, that's a perfect end note, if i can take that opportunity. [laughter] following up on this discussion, i should give a shout out to the national health policy forum which has a program devoted to this issue specifically as it

connects to low income beneficiaries. i think it's august 2nd. so you can pick up the thread of the discussion in that context as well. let me just take a moment to thank you for your very thoughtful questions and your attendance here this afternoon. thank our colleagues, trisha and juliette and their colleagues at the kaiser family foundation for making this program so rich in its background and in its content and ask you to join me in thanking our panel for a really good discussion. [applause] ..

secretary of state said last week that both sides are meeting soon to set parameters for of renewing negotiations. former president carter will be joined by the former president of finland and the special envoy to syria. and on capitol hill, the senate has passed an immigration bill and house republican leaders are working on how they will deal with the issue. this morning during a discussion about the issue, the brookings institution, panelists said immigration might be an issue driving detroit's decision to file for bankruptcy. here's a look at that conversation. >> i will mention detroit. i don't know a time about detroit's economy other than what you might read in the national press. i would say that immigration

reform is that the only thing that will help detroit comeback to be the great city that it was, but it is one of the things that will help to make that happen. anytime that you have a group of people living in the shadows afraid texas law enforcement to maybe not able to pay taxes were not contributing, who maybe not getting the education they need, not having english as a first -- you know, to learn english. that is a problem that creates a subset of people living in the shadows, and that will drive down any community to have these two different groups of people. so that is just immigration reform, national immigration reform is not the only thing that will help detroit, but it is one of the things. and every city, no matter where your local economy is, this is something that will help everyone. >> so detroit has a lot of immigrants, has a metropolitan -- metropolitan detroit, i should say. yes, metropolitan detroit. most of living outside the city.

a long history of immigration. it was one of the big gate weighs in the early part of the 20th century. the legacy, the culture of immigration, although the groups have changed over time. it is strong. and over there, there are strong participating in the economy. an impact toward the scale. stay in those kinds of occupations and industries. there is also an initiative called global detroit. it is affiliated with global michigan. its main mission is to attract immigrants and has a number of different strategies within that it is something that has become an important part of the initiatives of throughout the great lakes to develop these kinds of programs. because of the energy and investment that immigrants bring

. >> you can once that event in its entirety on line from the brookings institution today, and you can find it at c-span.org. [silence] [silence]

[silence] >> on capitol hill this senate will be meeting tomorrow at 10:00 eastern time. there will begin work on transportation, housing, and

community development spending for the next budget year which begins october 1st. the centers may also vote this week on a plan for federal student loan interest rates. rates for new low-income student loans doubled at the beginning of the month. you can watch senate debate live here on c-span2. >> no a hearing about military sexual assault. victims testified friday before a house veterans affairs subcommittee about health care and the treatment options available for victims. the defense department says that in 2012 there were 38 sexual assaults among went to five men and 33 among women every day. this hearing is about three hours. [inaudible conversations] >> good morning. we will come to order. before we begin i would like to ask unanimous consent for my friends and fellow committee members, ann kirkpatrick, and

our other colleagues to participate in today's proceedings. without objection so ordered. with that i welcome you to today's hearings. sixty-four survivors, care and treatment for military sexual trauma. i am grateful to you all for being here today. when the men and women of our armed forces sign up to defend our freedom there willingly accept the threat of danger from our enemies. what they should never have to accept is the threat of sexual assault on their fellow service members. perpetrators of military sexual trauma should be aggressively pursued, prosecuted, and punished. i along with many of my colleagues here are working to advance legislation reform and improve the military justice system. this is just as important as the one that we turn to today, listening to, caring for a, and supporting the healing of those

who have suffered this terrible crime. according to the dod there were 38 incidents of sexual assaults among mail service members and 33 incidents of sexual assault among the mill service members per day. let me repeat. last fiscal year there were roughly 71 incidents of sexual assault every single day among those who wear are uniform. to say this is unacceptable does not adequately describe the terrible reality of military sexual assault lasting effect that this can have on the lives of those who experience it. a service member who is a victim of sexual assault as often hesitant to disclose the experience or seek the support services that they need. this is troubling to me, even more troubling, the list of personal stories from those have taken this step to come forward and find that those departments tasked with caring for them, the

department of veterans affairs, department of defense, unresponsive, and coordinated, unable to meet their obligations of the survivors. in january of this year the accountability office issued a report which found among other things that dod sexual assaults coordinators' work this single point of contact for sexual assaults, the task with managing the medical need within the department of defense. not always aware of the health care services available to sexual assault victims at their respective locations. the gao also found that military health care providers do not have a consistent understanding of their responsibilities to care for sexual assault victims. further, a viejo inspector general report found that among other things that the actual -- sexual trauma coordinators, the single point of contracts for -- contact within the va facilities

report as little as two hours a week to conduct our reach to and monitoring of those veterans who are screened positive for military sexual trauma. what compass -- confidence can assault survivors have when they are at their lowest moments, dod and va failed to understand their responsibilities to provide care, fail to provide health care options that are available, fail to empower their most directed points of contact with the knowledge, authority, and the tools to be effective, not just present. the actions that i question lies in the voices of our veterans themselves, preparing for this hearing we spoke with many veteran survivors of military sexual trauma and those who work closely with them. there frustration. i am honored to have for such veterans with us this morning. these veterans represent foreign branches of the services, army, air force and navy, marine

corps. the areas of service from the vietnam war to the conflicts in afghanistan. these brave men and women have endured firsthand the heartbreak and pain. they know better than anyone how very long and difficult the journey to healing can be. each of them has braved public scrutiny to be here today to share with us the experiences and the hopes that we might do better for those that come after them. your contribution here today will bring out of the shadows and into the light a much-needed call for change. i think each of you for your honorable service to our nation and your fellow veterans. a service which began in uniform years ago and continues to today. nothing that says a lot about the importance or lack thereof that the department of defense places on the topic. i will now yield our ranking

member for any opening statements you may have. >> thank you, mr. chair. good morning to everyone. i would like to thank all of you for attending today's hearing focused on examining the care of and treatment available to survivors of military sexual trauma. the subcommittee will also be looking at the coordination of care and services offered to the victim's of ms t through the department of veteran affairs and the department of defense. many victims who have suffered through an ordeal such as sexual assaults oftentimes are reluctant to discuss their situation and seek help. those that finally gather the courage to speak up find that there story is often dismissed court treated in differently, unjustly, becoming the victim again. as many of you know, the pentagon reported earlier this year that it estimated 26,000 cases of unwanted sexual contact

occurred in 2012, up from 19,000 in 2011. with only 13 and a half percent of incidents reported, it is clear that we must do a better job in both preventing and treating ms tea. these service members and veterans often continue to experience debilitating physical and mental symptoms from ms t which can't follow them through their lives, focusing on prevention, however, is only part of the solution. it is critical that we do everything that is necessary to make it easier for victims of in s t to access needed benefits and services and receive treatment. compassion and care are a significant part of feeling those that have been sexually assaulted.

i applaud the legislative efforts of our colleagues to have introduced legislation, h.r. 1593, the sexual assault trending oversight and prevention act and h. r. 671, these bills seek to ensure a stronger protections are in place so that the safety and well-being of our men and women in uniform is a short. we must begin to take these important steps to end sexual assault. as a proud co-sponsor of both bills, i believe we are headed in the right direction, but we still need to do more. i was saddened to read the testimonies of our first panel. the pain and suffering was evidence and the personal stories written. i know that this is hard for all of you, and i commend all of you on your bravery to speak up and be here today. we need to hear firsthand the experiences of veterans to have

found this system unfriendly and intimidating so that we can make it better. i look forward to hearing from our witnesses today. again, thank you for being here. this is a very important issue for us to tackle here in congress, and i thank you, mr. chairman. i now yield back. >> thank you, ms. julia brownley. i would now like to formally welcome our first panel to the witness table. will the panelists please come forward. joining as today is victorious sanders from nevada, california. a veteran of the united states army and a former registered nurse. thank you very much for being here and for your service. i will now yield to my friend and colleague from indiana, jackie walorski, who introduced our next veteran what this. >> thank you, mr. chairman. at thank you for yielding and for your commitment and the commitment that we share with this committee.

i want to think every member of pier voting yes on the bill that we passed through the house. many of the co-sponsors are sitting here today. it is my honor to introduce this awoken from westfield, indiana, a united states air force veteran who was sexually assaulted and consequently 100 percent disabled as a result of the trauma injury from are horrific attack. more than just a wonderful wife and dedicated mother, a survivor , a survivor who has made a mission to bring other victims out of the isolation and the shadows that they suffered through. she is also a veteran and has the right to receive access to meaningful treatment. lisa, victoria, bryan, and terra, thank you for having that carries. thank you for your tireless efforts to hold the va accountable for treating victims of military sexual trauma. mr. chairman, i yield back. >> thank you, jacki. thank you for being here today and for your service. my next veteran witness is brian

lewis from baltimore, maryland. a veteran of the united states navy in the recent graduate of stevenson university. thank you very much for being here and thank you for your service. we are also joined by karen johnson. born and raised in new jersey and currently resides in lake mills wisconsin, a veteran of the united states marine corps and currently serves serve fellow veterans as an army wanted warrior advocate. thank you very much for being here. thank you for your service. ms. sanders, would you please proceed with your testimony if you have some? you have five minutes to testify . would you like to try to do that? be polite with our time. thank you. >> thank you. thank you, mr. chairman, representatives, and panel. want to thank you for the chance to speak before this committee. it is like a birthday gift from congress because yesterday was my 30th birthday. thirty years ago on my 20th birthday i arrived at my only

active duty station in fort carson, colorado. one month later i was raped. in the middle of the legal battle around the rate i was thrown into the custody battle. after basic training has separated from my husband and had one child. no 20 year-old private in the military should never have to fight these battles alone, but that is what i did. i was diagnosed with ptsd in 2004. has been a long, hard road, and i'm hoping my testimony today will help me come full circle. my rapist confessed to enough of his crimes that he was reduced in rank, lost pay, and was confined to barracks. this is an example a chain of command harassment because the barracks was confined to was the one where i worked, and he still worked in the office next meet. when you report a rape, you become public enemy number one. no one will talk to you, and if they do it is to tell you that you got what you deserve. you are called names, internalize what happened, and it feels like it is our fault. even if your rapist is punished,

harassment is limitless. follow me through three transfers in nine months. i had an out because of a custody battle that may be a single mother. at the time single parents were discharged quickly. they let me go, but i began the slow decline in mental health known as posttraumatic stress disorder. when you are raped it takes a piece of your soul. being raped by a fellow service member is a double the trail, but not being backed up by your commanders is the hardest the trail of all. because the innocent are treated as criminals we have lost good people on the stub of this journey perry today and want to mention to. they did not live long enough after being raped to become veterans. my experience with the viejo mental health was at first supported, caring, trained professionals . a great ptsd clinic in san jose. i watched it go from a thriving program for both men and women into a ghost town. i was one of the group of five women who were not eligible to

go for in-patient treatment for various reasons. the doctor and her students started a process group for the five of us. this is usually only done in an inpatient setting. three weeks into the program she was told by her doctor about boss that she could not continuous therapy with us. she did finish out the 17 week program. she was not going to leave us. our world was crushed. the students who worked with her what steps and as she watched, she decided to change the focus to trauma and specifically military sexual trauma. she went to work at the va after she completed her studies. melia worked there until she was offered a job at stanford that allowed her the time to spend with patients to be available and consult farm program in santa barbara. intensive therapy using emdr processing therapy and many things not available at most va facilities. this shows me grief patients are powerful, but only one allowed to have meaningful therapy, not just the same basic skills.

how many times can a person take the same and permission in the same form from a student reading from a book. that is not therapy. since i have moved my care to the san francisco va i have only seen to actual full-fledged doctors. the rest were interns, residents conduct or candid it's, a doctoral fellows, not licensed and trained in specific trauma therapy. i was read traumatized on many occasions. all that is outlined in my written testimony. i believe paula was right when she said being devastated by an assault is not a mental illness. furthermore, it has been well documented that psychiatric diagnosis is not scientifically grounded, does not prove the outcome and does not reduce human suffering and carries tremendous risks of many kinds. ..

the number of failures this year alone is too long to list. this climate must change. everyday 71 more people are assaulted, and 20 veterans commit suicide, and will not many of those are because of assault and rape. >> thank you very much. i truly appreciate your words. ms. wilken, please go ahead. >> i'm the united states air force veteran. i was medically separated after sexual assault, and i'm

currently rated 100% service connected by the department of veterans affairs. i'm a wife and a mother, and more importantly, i am a military sexual assault veteran. in my opinion, that is the dod and va's way of categorizing us as we are rape survivors, of friendly fire. and i use those terms not to make a joke of it, but to bring it home that we were assaulted by someone who wore the uniform as we wore. and not all people where this uniform as honorably as you do. thank you for giving me the opportunity to speak today. i've struggled for many years to be proud of my service because of the experience that i had in the military. but speak out about this topic makes it so that it, if another better doesn't have to struggle with the things i've struggled with, it's importantly -- for me to do so.

not a day goes by that i don't deal with something that is a result of the sexual assault. why is ptsd and sexual assault so long last the? i believe the reason for that is that it's not properly treated or dealt with at the time, the treatment that we receive when we report an assault in the military, it is as if we are the perpetrator. we're the ones are put under the microscope. and that's something that needs to stop. it's almost as if your chain of command sets out to do some type of emotional blackmail on you, or emotional trauma. and that's something that a rape survivor can't handle at that time. you are in a closed society. most people don't realize how much of the treatment facility near our military treatment facilities. and so that's one of the big hurdles that the va must start

with is recognizing that there are a lot of men and women that will not come to the va for treatment because of the experience that they had in the military. or because of the time it wasn't the whistleblower protection and they didn't report it. but now that they're older and having problems, they won't come to the va because of their experience in the military. you are going to hear me speak a little bit about outside treatment facilities. we need the ability to go outside of the va if services are not a table for us at that va medical center. so that we don't have to suffer in silence. we need groups at our va medical centers for support and we need groups outside of va facilities. most people don't realize that sexual assault is not something that you can be treated for. it's not like a broken arm where your arm is in a cast for six weeks and then you are fine.

military sexual assault or sexual assault in general is something that changes a person from that point forward. it takes the opportunity of what you could have become and changes it to what it makes you. why is it so important that we speak out about this topic? the reason that it's so important that we speak out about this topic is so that other men and women who are currently wearing the uniform understand that they're not alone, and that there are people out there that will stand up for them. one of the things that's important to realize is in our treatment, we need better resources. and those resources can be outside of the va in our local communities. right now at our indianapolis v.athe medical center, the way o get in to see someone to treat you for military sexual trauma is almost two years. if we could utilize our local health care providers and mental

health providers, i know the men and women in indiana would utilize that. unfortunately, getting approval from the va to go outside is a difficult process, and it's not something that is done easily. we have mst corniche at all of our v.a. facilities. unfortunately, they are generally just one person. and they have other assigned duties. we need military sexual trauma coordinators at all of our v.a. facilities that have a staff that they're able to do things more than just push the paperwork for those veterans. that they are able to interact with that veteran and make sure that the veteran is receiving the care that they need. and if not, have the ability to stand up for that veteran. because those are the things that we didn't get while we wore the uniform. and being able to have the services available to us now can change people's lives. thank you for your time.

>> thank you very much for your testimony. mr. lewis, please proceed with your testimony. >> chairman benishek, ranking member brownley, distinguished members of this subcommittee, and members of congress sitting with the subcommittee, it's a privilege and honor to be testifying before you here today. i would like to thank my partner who could not be here today. our significant others allow us to do so much, and they receive so little credit for the time, effort and energy for they put into us as survivors. and i want to acknowledge that before i start. i would also like to thank the subcommittee for treating the should military sexual assault in a gender inclusive way. as the chairman pointed out in his opening statement, about 14,000 of the 26,000 sexual assaults on active duty are male victims. this gender-neutral conduct

places the subcommittee for the head than the white house and very much ahead of veterans administration to indeed is the mike spears as a veteran health and administration disgrace against male survivors of military sexual, solely because of their gender. this is a practice that needs to be brought to light and stopped by the subcommittee. currently, the veterans health administration operates about 24 residential treatment programs for post traumatic stress disorder. only about 12 are designed specifically for the treatment of military sexual trauma. of those 12, only one accepts male patients. at the facility, it is coeducational. put simply, male survivors have no single gender residential treatment program designed specifically for military sexual trauma. i know. i tried. there was nothing available for me in a single gender capacity. this made it very difficult to

process the issues when i was at v.a. i joined the american legion in saying that the coeducational model of residential treatment programs needs to be overhauled, and quickly. in the outpatient environment, and care for male survivors of military sexual trauma can be spotty, at best. while there is counselors available for us, receiving care such as your support groups and being allowed to speak about military sexual trauma in mixed gender, mixed gender and/or mixed trauma groups, by which i mean, that, ptsd and mixed together, can be very difficult for any veteran, male or female. this needs to stop.

male survivors are the equals of female survivors and need to be treated as such by the veterans health administration. i have placed more substantial data in my written testimony about my personal treatment at v.a. datelines and at the baltimore v.a. medical center, and i believe that into. the next topic out like to touch upon is the overall supervision of military sexual trauma. the overall supervision of metrosexual, programs within the veterans health administration has been vested in the direct of mental health family service and sexual trauma. this oversight protocol denigrates the experience of male survivors and reinforces the concept that the voters health administration sees no to sexual trauma as a quote unquote women's issue. that is not the case. male survivors have just as much right to seek and be treated at

the vs any other survivor. another harmful practice is personality disorders. as the subcommittee is well aware, personality disorders have been used along with adjustment disorders, bipolar disorders and many other forms of eric and weaponize psychiatric diagnoses to push survivors of military sexual trauma out of the military. and it has far-reaching consequences. for example, survivors attending the topeka, kansas, facility are asked to defend their discharge and explain it on the application to enter topeka, kansas, program. a survivor who has been pushed out with one of these weaponize diagnosis does not want to do that. so i strongly urge the subcommittee members to support h.r. 975, the servicemember mental health review act offered by representative tim walz. this legislation would give veterans like myself have been misdiagnosed with personality

disorders to apply for potential military retirement and shift some of these costs act to where they belong. in conclusion, the veterans health administration fundamentally fails male survivors of military sexual trauma every single day. they've proven their inability to adequately care for us. that is why me and several other survivors have found -- an organization designed to help an advocate for male survivors. we respectfully request congress to legislate equality in practice for male survivors of military sexual trauma. thank you, mr. chairman. >> thank you, mr. lewis, for your testimony. i truly appreciate your efforts here. ms. johnson, could you please go ahead? >> chairman benishek, ranking member brownley, and members of the subcommittee, thank you for the opportunity to speak today. i proudly served for 10 years and achieved the rank of major. i am now 40 and this is the first time i have ever disclose

my experiences regarding mst and the care i received, or did not receive from dod and v.a. i joined the marine corps because i wanted to serve my country. my first incident of msdn urbanizcardwhen i was an officee and i was sexually assaulted i a senior officer. throughout mike are in the marine corps i endured several more incidents of mst. i did not disclose these experiences as i had seen the other treatment of those who had reported incidents to the command. despite these experiences i excelled in the marines. i spent almost eight years in active duty. return as a reserve in 2000. again, experienced an incident of mst. i began to suffer from depression, anxiety and panic attacks. during this period i did find the courage to approach my command regarding this incident to my statements were sent to dismiss and i endured even more harassment and abuse. i sought and received medical treatment for panic attacks, medication, but i was never asked about mst by medical

personnel. i was put on medication to relieve depression and anxiety. it got so that i requested early release from active duty order because the situation was just so difficult, i felt i could not endure it any longer. this decision to leave active duty early placed me as well as my children in an extremely financial -- fragile financial state for a very significant return. the complete pride i have felt as a marine in the past is now riddled with shame, self doubt and distrust. in october 2010, i sought treatment from the madison, wisconsin, v.a. i received extremely limited treatment for the depression, anxiety and panic. i was mainly prescribed medication. while it was evidence, i'd say their symptoms of ptsd i was never asked by provide if i had experienced mst. so basically i came in, i had undergone these screenings, ptsd, but yet i wasn't a combat veteran yet, no one looked at

these symptoms and these screenings and said what is causing them. what's happening here? so the first time in my life i contemplated suicide. but i knew i needed to continue to cope for the sake of my children. while the psychiatrist i saw was helpful, it was extended difficult for me to receive treatment at this time as let's not get service-connected and i received little to no medication monitoring. and i sincerely feel that the medication caused even more depression and more anxiety, was the reason i contemplated suicide. in december 2010 i had my conference example mental health or i entered this exam with the hope that the provider would address in this day and i would finally be able to receive no. the doctor spent 20 minutes with me. he was extremely abrupt and in person and do not once asked me about anything related to mst. i was not given the opportunity to disclose my experiences. he ended our appointment very quickly stating he was sure i would be fine, and my hope

deflated. the next few months as i waited for service connection i was informed that because of my income the prior year, even though i was currently unemployed, i would have to pay for any care that i received from the va during this time. i was not yet financially stable and could not afford extra costs as a single mother. i then contacted madison annexed -- female he contacted the regional office and attempted to have mst added to mike lee. i was directed by the regional office to prepare and submit a statement that described the details of my salt and other incidents. though actually difficult, i completed and submitted a statement. is hopeful the information i provided what i made receive another examination where i could address my experiences with mst. despite fulfilling the request i was not granted another eccentric i continue to struggle with symptoms and memories as well and memories as most side effects are of medication. because mst was not addressed, i was told i was not able to

utilize the local veterans center. several months later i did receive my service connection and was able to meet with a provider. during intake for the ptsd program, they v.a. provider again did not ask about mst, but i decided i needed to disclose my experiences. i was extremely detailed and candid. this provider inform me that i did appear to have severe ptsd and would really benefit from treatment. my sense of relief with the disappeared as she informed me the wait list for ptsd treat treatment was at least four months long. when i did get the opportunity for trade in my provider was only at the va twice a week. i was a working single parent and it was difficult to schedule appointments. they are instance i would take off work and arrived at in deployment on to be told it was canceled. i was made aware that even the hospital had canceled his appointment, my patient record reflected i had no showed or cancel myself but this was something of the truth. i grew more distrustful and frustrated. i was then informed i was

noncompliant because i felt i couldn't participate in the therapy called a long exposure therapy, for fear that it would increase my symptoms and affect me personally and professionally. throughout this period i also received limited medical care at the va through the women's health program. now be a nurse or doctor ever asked me if i had experienced mst though several things were correlated with mst. understand i was employed at the va. in the same program. mse was not addressed and although there was a cornea at the hospital i've never had the opportunity to speak with her and i never witnessed any collaboration between the women's health program manager and the mst courtney. i attempted to speak to my program manager several times regarding the need to address the issues of mst weather better but i was unsuccessful. in 2012 i decided to attempt to engage in treatment in the va once again but i was assigned a mail provider who is new to the va. in my first appointment through tears and fears i can disclose my experience with mst. the provider looked at me, sat

back in his chair and said, do you really think you were raped? i cannot bring myself to return to the va. and it was at this time that i began to utilize my private insurance. i now pay out of pocket for all of my therapy. based on my experiences and those of other veterans i've worked with and spoken with, i recommend the va reconsider their approach to mst screening, acknowledgment and treatment to the va needs to become a safe and vibrant where mst is acknowledged. if i'd only been asked about my experiences with mst i would have provided full disclosure. i, like many, was never asked. thank you. >> unfortunately they call votes on the floor. so we will be back in session as soon as that is over with. i truly appreciate all your testimony, and the bravery of all shown to come here and testify about these deeply difficult and personal event.

we will be in recess until i get back. [inaudible conversations] >> [inaudible conversations]

>> [inaudible conversations] >> the subcommittee is called to order. i'm going to >> the subcommittee is called to order. i'm going to yield myself five minutes for questions. frankly, the testimony that i heard him all of you today is, you know, really, really revealing, tragic. and i know that this bipartisan support in this subcommittee to really make significant change in the way the dod and the va treat victims of sexual trauma. i can think maybe the most interesting, and i heard this

before in other cases, the test without heard from you, ms. sanders, was the fact, i think it sort of that came out and all of your testimony, that you never get someone at the va, if you ever get into counseling, or that you have a consistent provider. i think, i know how difficult that is trying to talk to somebody that doesn't know your case. can you expand on your testimony there, ms. sanders? kind of make us all aware, how difficult it is to get a consistent provider. even once you've gotten a provider, or is it been so bad that you've never been able to get anybody consistently? >> when i first entered the system, there was a fantastic clinic, and they treated us very well. they went out of their way to make sure we got the treatment we needed, but it was led by a

very dynamic person. that was dismantled come and we were left with scraps. i ended up, i was the only person going to the clinic and was seeing a social worker. and, unfortunately, she passed away so i was left with no care. i moved north of san francisco because i had a grandchild, and i started care at the san francisco v.a. because i can't drive very far, and i've had no real care in two years. i asked for the basis. i got a fee basis at one point. i took it to our local county. they closed the county office, the second day i was there. and it was the this or that treated both civilians and military sexual trauma victims, and people who are coming out of jail and trying to get off of drugs and trying to get their children back.

i have since asked again for a fee basis. i was told, you've got a few bases for two sessions. i was never told where to take that fee basis but i was never told who to contact. i attempted to say, okay, i have medicare. can we get some movement on that? i received a phone call. they said, go on the computer and look up caregivers in your -- >> that was all the guidance you got? >> excuse me? >> that was all the guidance that you got? >> i have in front of me a fee basis that i'm supposed to receive from me. i never got the letter in the mail. i called after six race because i was told, we don't how long it will take. and she said oh, it's already expired. so they send it to me, and it expired july 17. i still have no one to take it

too, no help to find anyone to take it to. i asked if a social worker could sit down with me and make the phone calls if they didn't want to do it. but that i am on cannot just sit down and called every provider in my county to find out who will take the va's fee basis. the one person i contacted said it would cost me $450 for the first session, and $280 for every session after that. and she had to have the money up front, and i had to go get the money from the va. and then i came here. so i'm hoping that by coming here and telling you guys that, a measly two fee basis is not going to get me anywhere. no decent provider is going to say, oh, yes, i will see twice, and they would we will wait to see a long it takes them to get back to us. a real provider wants to give you care consistently and comprehensively, and that can't

be done with to fee basis at a time. >> of course. >> does that answer your question? >> well, it gives us a feeling of what's going on. because it's just so frightening, frankly, you know, the testimony that we have heard here this morning. i know that there's great bipartisan support to make this better. my frustration persists. i thank you, and i'm out of time. ms. brownley, you have five minutes for questions. >> thank you mr. chu. and again, i want to thank all four of you for being here today, and sharing your story with the spirit its extreme and poured in terms of our work moving forward. i just, i want to say, certainly as a new member of congress i and many member of congress and

i just want to personally apologize to all of you. and because we should have done, and we need to do, a much better job in support of what is happening to you as you served our country. your bravery today is to be commended. and your duty as soldiers in the military and your service to our country, but the bravery that you demonstrated today i think is really beyond the call of duty. and i'm very, very grateful for your participation. and there's no question in my mind that there is a lot of work that needs to be done. i mean, we need to address the culture that takes place in the military. that needs to be fixed. we need to address the transition from leaving the

service to becoming a veteran, and then certainly if there is trauma that takes place, then we need to eradicate that from happening in the first place, but if something does happen, then as a veteran who has served our country, we need to figure out how to best provide and serve -- service all of you to the very best of our ability. antonin make best practices that are happening outside of the va, and what's really happening, you know, in facilities across our country when one is sexually assaulted. i'm not even really sure where to start on the questioning. i certainly would like to hear your positions or your suggestions i guess, vis-à-vis how we can improve. there's been conversation about sort of case management so that

if someone is sexually assaulted in the military, that we transitioned them with continuity of care to make that transition as best as it could possibly be. but i would just, you know, i offer suggestions really from all four of you in terms of, as you've had your own expenses and knowing what the system is today, how can we improve upon it? >> thank you, ranking member brownley. my first suggestion is that fee basis care needs to be made available at the request of the veteran. as our testimony has demonstrated, v.a. is fundamentally incapable of providing care for survivors of military sexual trauma in the current environment. there is provisions in section

17-20 d. that allow fee basis care to be offered if it's clinically inadvisable. ani that's currently the case ia lot of v.a.'s. i know one v.a. where male survivors of metrosexual trauma are seeking care in the women's clinic. that is not best practice. that is horrible practice. these ladies as survivors deserve a space to be safe and do not be triggered potentially i mail veterans -- potentially by mail veterans. icon in turn, deserve the same place to go, if my perpetrator were a female, which happens a lot more often than we would think. i deserve that same place to go and not potentially be triggered. i also deserve to have in essence my manhood respected.

by not having to seek my care in women's clinic. i also deserve to have a treatment program designed specifically, investing a where v.a. can do a lot more research. there is very little medical literature out there as an sure the chairman well knows about male survivors of sexual trauma of any sort. and that's in every v.a. can be a leading research income and they're not doing it. the other suggestion i would have is to make sure there is continuity of care, as the previous question suggested. just today i received a phone call from my provider. he's been out of the office intermittently on and off due to health care problems, but still that makes it difficult. when i returned back from bay pines, their facility was to ensure that i received continuity of care. they failed at the. i went for two months after

leaving bay pines without seeing a medical doctor or a psychologist. what sort of system do we have where we consistently fail our veterans? i cannot in good conscience recommend be a to any survivor of military sexual trauma at this time. thank you, ranking member. >> doctor wester, you have five minutes. >> thank you, mr. chairman. in the ennui of an acronym, leadership, selfless service, personal courage. that means addressing wrongs that take place. wrongs do not don't exist in the world of military but wrongs that exist within our military. and what has happened to you is a form of devastating trauma. and i know i speak for all my colleagues on this committee that taking care of our troops is not just a nice thing to say and not just a nice thing to do. it's our obligation to do so.

i really appreciate your courage today, and i think it is up to us to have the courage to change policies and attitudes. my question to you today, and i think i know the answer from your testimonies, but i would like to hear from you directly on it. do you feel that currently that should be more comfortable getting care inside or outside of the va? and i think you just answered that. >> outside. >> receiving care outside of the va accomplishes a couple of things. one thing that it encompasses, it puts us in the hands of people who are trained to treat sexual assault victims. unfortunately, the va doesn't have a protocol set up to train their employees of how to interact with military sexual trauma veterans. therefore, a lot of times they trigger symptoms and make our ptsd worse. also with fee basis being sent

outside of the va, fee basis reimbursed at medicare rates, and so i have a fee basis card. i received that car because i had an unnecessary surgery at our the hospital in indianapolis due to inertia looking at the law -- look at the wrong lab results. as a result of that my mental health care provider, my psychiatrist and my ob/gyn and try medicare physician wrote consult for me to be able to be seen outside of the va. originally it was denied. the second decision, they approved me to go outside for gui in services, but not for any other services. when i appealed that decision, then i was given my fee basis card and it says, all medical services, all medical conditions. the difficult part and that is finding a provider in your local area that will accept that fee basis because there is no partnership with the va. and so if they are a provider

that does their own building, they don't want to see because they don't want to have to deal with pushing the papers to the va are waiting for that reimbursement, or if you're a provider and you can build a private insurance $85 for an hour's session, but you going to get back $19 from medicare, at the reimbursement rate, would you as a treating physician take that patient on? so there needs to be a partnership between fee basis in our local community. and more importantly, also with a national chain of pharmacies. because if you're seeing an outside provider and you're given a prescription for medication, you have to mail back into the va and wait for them to mail your medications to you. a lot of times those medications need to be started immediately. you have the option of going to your local pharmacy and paying for it yourself, but then you

are uninsured and you pay the full rate for that medication. you can then have the va reimburse you, but as responsible veterans, the majority don't do that. they mail it in and they wait for it to come back. it seems as though the va doesn't look for those commonsense solutions. that's what i would like to ask the committee to do today. >> thank you. go ahead. please go ahead. >> in speaking very briefly about my employment and time with the women's health program, one of my primary responsibilities was to do outreach calls. the outreach calls were literally to get numbers for women veterans who are up-to-date on mammograms and pap smears. and if they were not, the process within to go outside of the va through fee basis and through working partnerships with hospitals, in their more remote areas was so simple i was dumbfounded. but yet there is still no simple way for someone who is

experienced in st to go outside of the va and receive counseling and therapy and medication. so if we're doing in one program that tells me that it's possible to do it for others, too. >> thank you. that's exactly the type of input i wanted to hear. >> congressman, one thing i would like to address briefly before time expires is the use of interns and the use of medical students to provide care in the va. i know at my home the day, they are heavily dependent on medical students. and that is simply not a good practice with survivors of such complex trauma as military sexual trauma. it is a place for medical learning. when i was at bay pines, my primary counselor there was a psychology postgrad. and i found her, when i was sitting there trying to disclose

details of my trauma, sitting there clicking her tongue ring as i was talking about my trauma. to me that's horribly disrespectful. and another instance at my home v.a. in baltimore, a psychology student was running a group and was allowing combat veterans to talk about their trauma while not allowing a misty veterans to talk about there's, me and wanted to others because the va focuses on combat trauma come in her own words. quite honestly there is some for a 500 words i could say to that, but for the purposes of the committee, we need to be looking at the proper use of students and residents in providing msg care. and we need to be giving a hard look at that. thank you, congressman. >> thank you. >> the gentlewoman from new

hampshire. >> thank you very much, mr. chair. and thank you to all the members of the committee for convening this hearing. i was one of the members requested that this happened, spoken to veterans in my area in new hampshire. one message i want to convey, along with ms. brownley and others is that we are recently elected. kirkpatrick coming, but we are new members of congress, and so we are arriving your right at a time when the public is very focused on this issue. i want you to know we're going to work with ms. speier been working on this issue a long time and a number of other members of the house and this senate. i appreciate the chair for holding this committee. we have made a real strong commitment to work in a bipartisan way. i want to thank my colleagues

for leading what was truly an extraordinary effort on this whistleblower protection, and i want you to know that we take that very seriously. we passed that bill two weeks ago 423 to nothing. in the house. that's the kind of support you have when we come together and find common ground. so i know that we can help you. and i joined ms. brownley in apologizing to you that you haven't been heard previously. so my question, i've been trying to jumpstart my education on this by going and visiting facilities. new hampshire is deal with it without a full-service veterans facility, hospital, but fortunately we show the hospital in vermont. they have a brand-new, newly opened care center, and i hear, mr. lewis, your concerns and i

want to address that. but in this case it is a brand-new women's support center where they have listened the victims and survivors about literally the architecture, but particularly the programming that they want. i also visited a manchester's center where they have really outstanding treatment and provision of counseling, groups and such there. and so i want to ask you, i respect the recommendation for care outside of the va, and if that's the direction we go, then that makes sense to me because i understand we can't bring the training of all across the country. but if you were in a position to advise us of what best practices would look like, if we could get to that place in the va system, what is it that you would

recommend be included, and this would either be in a hospital setting, and i met center, in a veterans center setting come in a clinic setting, what are the components that you would recommend to us? >> congresswoman, appreciate the question. and to hear about the program, almost makes you want to cry. >> it was truly incredible, and i was given a tour by a victim that had been a part of a task force here and they had addressed a lot of the issues that you are talking about, including literally the entrance, making sure that its class, that the women can see who's coming in. the only treatment providers are females in that entire section. and so what are some of the elements that we could be addressing? >> i will defer to some of the women veterans sitting here to

talk about the components of the women's veterans programs, but i think that the first thing that white river junction would do to bring it to your area is to do that same thing for male survivors. we don't deserve to have to walk through the same see that the women veterans have complained about and below that any demeaning tone because we are not combat veterans. we also don't deserve to be mixed in with the women, only because v.a. cares about little about male survivors. other components that i would suggest a misty programming needs to be conducted in mental health. as a man, if i go to women's services, they are triggered, i'm so intricate because i feel a lot less than a man being

respected as a survivor. i would also recommend getting away from the current practice of teaching by the manual and hoping our objective scores go down. that's not right. it is an experience that could cause psychological damage and it deserves to be looked at holistic way, not out of a manual where you go from a one method to the next to the next. and that takes a whole person concept. that takes pure supporters. that takes a whole range of things, and i would be happy at some future point to talk to you about that and i will defer to the lady survived to about the women's. >> i would like to see satellite clinics. my mother lives in kansas. they have a satellite clinic that comes. it's only a distance of 35 miles to the hospital, but twice a month they come and so people can come to that satellite

clinic and get their medications renewed or get whatever it is they need. and i think that that model should be used for military sexual trauma. i think that if you could say on mondays, we have a women's clinic at this address where it's not the v.a. and it's just for women, or men, and you can rent a room. it's an expensive that way. you're not building a facility. we are not asking you to build us the taj mahal. we are just asking you to provide us a safe space close enough to our home that we feel comfortable in knowing that distance. for me, and our a way is too far at this point. i can't make it. the vet center in my county has one man that works there, and he can't even answer the phone because he is so busy. he is afraid to work with the male survivors because he's

afraid because he's a big bodybuilding men, that they're going to be afraid. when i came out in the newspaper, we had a long discussion and he said, i'm afraid of what will happen if you come out in our local paper and people, women call expecting there to be a woman here. and there isn't. the vet centers need to be supported, and the idea of a satellite clinic needs to be explored, which could eliminate some of the fee basis but if you take the train people you have, send them to trinity county for wednesday's, and humboldt county for tuesday's, and provide the care where the people are. i was a nurse and i was taught, you always meet the patient where they are. you do not expect the patient to come up to where ever you are. i said in my written testimony, at times it feels like you are saying to us, if you get close

enough, i'll fix that broken leg of yours. but until you walk over here, i can't help you. >> thank you. >> mr. chairman, i have gone over my time. >> thank you. [inaudible] >> and while i agree with the other witnesses here and there suggestions, i think it goes back to basics, too. is i was never asked. i was never screened. i was never given the opportunity or the trust building period to disclose my experiences, for whatever reason. if you can't get your foot in the door and doors keep slamming in your face commute either going to give up, you're going to go elsewhere, or something worse is going to happen. so i think we need to look at the basic and start with -- i'm reading test money from others that are going to talk today saying a misty screen, mst screening it in my experience, i didn't receive it. so if we can find a more consistent --

>> make that be the standard. >> then they can decide whether treatment comes in but we need to look at the very, very beginning of putting that first step, putting your foot in the door of that the hospital. the people that are supposed to know everything and help you. >> thank you so much for your courage, and thank you, mr. chair, for your and old gents. >> the gentleman from indiana, ms. will oversee. you have five minutes. >> thank you, mr. chairman. again, to you all for coming today, thank you so much. i would like to echo what representative kuster was saying. we are committed to eradicating sexual trauma in the military. and we are new. we are all young members here, but our passion and our commitment to you today is that the bravery that you have exhibited by being here today, and the courage on shining a light in the darkness makes a difference. we get calls every day now that we've talked about this from the time we've been here, every day

there's new people coming forward and share their stories to ensure stores are going out today around the country and that's why we're thankful that you made the trek, and just let you know we're standing with you and we're fighting for you. and thank you for your service to our nation. it's our turn to fight for you. you have my commitment to do this until we eradicate this from our military. lisa, i want to ask you particularly because you are well-informed and you've made it a nation in the state of indiana to find out the scope, the witnesses, the strengths of the v.a. how would you describe overall in the state of indiana treatment for mst victims as you pursued it, not only from your perspective but because you have a wealth of information about how our state runs? how would you overall say the conditions are with treatment of mst? >> overall, over all in a state of indiana if i have to rate it on a scale of one to 10, i would give it a three. because they're making an effort. we have a military sexual trauma coordinator at the v.a. medical center in indianapolis who is

wonderful. but she is one person. we need more services of what has been talked about today, weather satellite clinics or using outside treatment facilities. but the issue needs to be addressed not only on the state level, but on a national level. >> i appreciate the. if i can follow up on that, lisa. the information we've heard today is tragic. it's just such a tragic story. we hear all the stories and we see all the data and we're listening to you. there's such a growing need to treat victims of mst. why do you think as you gone through this maneuvering process, what do you think the biggest issue is with the v.a. being so resistant to this information? and despite the pleas from veterans, thousands of veterans around the country? >> i wish i could answer that indeed an answer of why, but i can't answer that because it doesn't make any sense to me.

if the treatment is already set up in your local communities or you have avenues in your local community but the v.a. doesn't have the services available, common sense would tell you treat the veteran. treat the survivor. and we are not seeing that right now. and so going out into our local communities while the v.a. is developing their process would be something that would be beneficial. >> let me ask you this. our hope is, we pass this whistle blower protection larger for me with and you were helpful, with that as well. with whistleblower protection, hopefully being valid and signed into law in january 2013, or 14. and if we can move this congress to get those outside services and those things provide outside the vad think we'll see an influx of folks supporting because they'll feel like have a safe haven on one and from retribution, and on the second

not being incumbent upon going to the v.a. for services that don't exist? >> i think you'll see him as he veterans and survivors come out of the woodwork. there are men and women across this country who wore the uniform and were proud to serve, but haven't been proud of their service because of the experience they had. if you give them the opportunity to give them skills to deal with years of unattended ptsd symptoms, i know these men and women will reach out and want to help themselves and their families. >> does anybody else want to chime in? >> thank you, congresswoman. you asked earlier about treatment at v.a. one of the main province is there are simply too few providers. i go to the baltimore v.a., and we're talking a big city here, and there's very few mst providers that are specifically trained in this area. you've heard all of us talk about our mst coordinators.

it's a collateral duty. at a big city become even at the smallest v.a. that's a full-time job. i guarantee you we could fill this room to overflowing with veterans who could talk about horrible treatment at the v.a., and we are given one collateral duty to one person. that's wrong. so let's get a lot more people in there that are trained and are willing to provide quality care, and let's get to researchers in there that are willing to do the research, especially with male survivors. >> thank you, mr. chairman. >> my colleague from california. >> thank you very much, chairman. i first want to say into so much, ms. sanders, ms. wilken, mr. lewis and ms. johnson, for having the courage to come up and tell your story once again. and what is have very proud i am that you, today you have given voice to so many women and men

who have suffered of this atrocious experience. it's a triple assault that many of our veterans face. one is the trauma of war or the trauma of feeling that they could die at any moment through an experience from war, which is ptsd related. the second is the trauma of the mst experience. and what i'm hearing is that we have a third incident, and that's the trauma of the lack of coordinated, sensitive and appropriate care that as a physician sometimes i know that the treatment can make things worse. and so as a physician, it is absolutely unacceptable. as a congressman, absolutely unacceptable. and i know i speak on behalf of

everybody on this panel. i know the hardships that many patients face, men and women, who come to the emergency department because of sexual trauma. i agree that sexual trauma is a holistic illness that is not something a cute they can be treated with a pale. it's not a one time shot. it's not a one time treatment. it's a lifetime struggle. and part of the illness of this is a sense of powerlessness. and part of the treatment is to regain that power. as an individual to be empowered, to feel like you're back in that control room. and so i appreciate it because what you are doing today is giving that empowerment to a whole lot of people around our country. and i thank you for doing that.

aside victim in all of this is the family. and relationships that you have with your spouse, your significant others, your children, issues of trust, issues of being able to communicate. and i know that it's very difficult. has the v.a. addressed treatment with your significant others, your families and your closest friends? >> i will answer that. not to my knowledge. i don't know that there is any type of programs set up for family members, spouses or children. but thank you for bringing that up. it's something that most certainly needs to be addressed. we all talk about as military sexual trauma. we are all rape survivors. no one wants to use the word rape because it brings with us

-- with it all the ugliness that rape brings into your life. it was brought into our lives, and we brought that into our families allies. and our families need support. they are our biggest support network. issues need to be addressed with our significant others, and with her children. it could be modeled after and al anon program against support to family members of alcoholics. we need that support so that we have a strong support system. they need a support system also. intimacy issues need to be addressed. that's something that we don't like to have to talk about our intimacy issues that we have with those have stood by us and those who have loved us through this process, but it's important and they deserve that. and so if i could ask the panel to take a look at that issue, it needs to be done. >> if i could follow up on that. >> sure. >> a significant barrier in that

is veterans who i'd identified as gay, lesbian bisexual transgender. services in that department can be very difficult. i do know the v.a. in st. louis through the work of terry odom is starting in that area, but it's not a national trend yet, and that really needs to be addressed because there can be a lot of gender confusion, a lot of sexual confusion after a sexual trauma, and that really needs to be addressed. and i would also like to pick up on your point about survivors having power again. a lot of times the v.a. takes our power away from us, or asks us to use it in inappropriate ways. i was asked to take a nerve block to relieve some of my chronic pain, and i was asked to take this nerve block transrectal the. imagine a male survivor being

asked to take a nerve block with a doctor, you are in an ob/gyn sure. your legs are up and you're having something inserted through your rectum, and pushed into it a nerve and your prostate to remove your pain. that's the type of paint i live with. my psychologist would not step in, knowing what the procedure would do. that power should not have been needed to be exercised i need. that should've been my psychologist stepping up and say no, this is contraindicated. so sometimes that power is used in both ways. and you are right, congressman. you know who was there for me? it wasn't the v.a. it was not anyone at the feet but it wasn't even the doctor gave me the injection. it was my partner that got me out of that building. and he gets no recognition on

the v.a. for that effort. and they need it badly. thank you, congressman. .. this was the training they gave me to treat us. i can tell you in the military that i received nine. one of the reasons was it was a military sexual, that occurred, it didn't start then, but it wasn't recognized.

logically thinking about it, we knew that it occurred outside of the military and white when it occurred inside the military. logically i am not in the civilian world one day and then i get drafted and sent to the military and the next day it is not an issue. in today's military, a lot more are serving. it is amazing how many women are doing a phenomenal job in the military. so there is that issue better. there. so i think that what we have to do as a scientist, identify the problem, you identify and determine what the problem is and then you try to-based solutions from that problem. ms. sanders, i don't think the d.a. has ever been equipped to do that.

it has woefully undergone this. i can tell you that there is no way on the surface that there are not folks not willing to do it, it just means that they are not prepared to do it adequately right now. i think that ms. sanders as a nurse brought this out very eloquently and your testimony and answer should be that if you want to get that as close as home until safe is possibly as much as you can. it's intimidating enough to go to a large medical center thinking that i'm going to have a physical next week, and i have sweaty palms about it and i understand exactly what you're saying. i think that either the -- we take the treatment to the patients or as doctor phil roe said, you have done them harm and i think that is what he was going on. we look for victims who suffered military sexual trauma and we

come up with a plan of how to better treat these patients. right now we don't have that. whether this book says this is outside the d.a., that is where the patient should go for the best treatment. ms. johnson, i was looking at your testimony and you said that the treatment he received at the madison wisconsin area was extremely limited. what did you mean by that? >> had to do with with the fact that i was not fully connected and i was told that i could not receive treatment for my service connection was verified. that being said, the problem lies set the mst -- especially when i started having this to include not mental-health and as

i said in my oral testimony, i was not a combat veteran. so to have all of these symptoms going on and still not be screened for mst so i could receive treatment while waiting for my service connection, it really put me behind and it was very much a tragedy. every time i had to go there, i built myself up for a week before saying that i'm going to be able to do this and it will take me another week to really come down from that experience. you know, it was different providers, more than i have ever seen. >> before i was elected to congress, i had patients that were 20 or 25 years.

there was one individual that knew me very well. and it was like a load of bricks had been listed from their back. and i think that he could see their life open up and follow. i didn't see that one time, i saw that multiple times. as i pointed out to you all, i did meet numerous sexual, valuations on patients that had been assaulted in the private sector. as i think back to my time better spent in the military, i didn't do a single one. but you know was there. it was just so under the carpet but nobody talked about it. the fact you have although none has really been helpful, may be the most helpful thing. the other things you can all do is give us ideas about how we can help the va be better. we found out how doing this individually helps. i suspect that your story.

>> ms. kirkpatrick? >> thank you. thank you for your courage to testify before congress. i'm so stammering transactor what has happened here. i just want to know if any of your perpetrators were ever charged? >> my perpetrator was charged. he went through the rest of the investigative process and he was given a special prosecutor that prosecuted the case and explained to me the night before that we were headed to trial the

next morning and they called me in for another meeting. and they said lisa, i can prove that he raped you. at the rate wasn't violent enough for him to get any real jail time he knew what i had been through. they let me know that we can go forward with this, we can prosecute him, but what we are going to do to you is not at all going to compare to what they do to him. but he would not agree to giving him an other than honorable discharge. and i was 22 years old at the time with no victim advocate because they didn't allow them at the base at the time. and i agreed because i knew what

i was in for. and if it wasn't going to result in him getting any jail time, there was no reason for myself through that. so they had him processed and added to the united states air force and off the bases in one week and then i found out that he had attempted to do the same thing at his previous base, so they put a repeat offender out into the civilian world with no criminal history. it is important that you are having this hearing today so the victims have an opportunity to realize that people are listening now and hopefully we can make a change so that someone younger than myself doesn't have to make the same mistakes that i have made over the years trying to deal with ptsd. >> thank you for sharing that with us. ms. lisa wilken, thank you so much. the perpetrators have gotten away with it and i suggested to

determine if we can have a future hearing on this. they got away with this, it's just not right. again, i am so sorry. >> if i might, the decision of which cases that prosecuted right now is currently part of the chain of command, something that the congress is hopefully going to continue to pick up. the whistleblower act is a wonderful thing to the victims can feel confident that if they do decide to report, that they won't be retaliated against. common sense tells us that if you can't get a commander to prosecute rape, a crime of violence, why would a victim have any confidence that the commander is going to protect them when they come forward? thank you for bringing this topic up. it is important. >> that is exactly my concern. i feel that spirit ms. lisa

wilken, i hate to use the wrong word here, but very -- she has been some measure of justice. a lot of survivors really don't see justice at all. i know in my case, i was threatened under the don't ask don't tell policy. that is a huge concern in the male survivor community. regardless if you're pushed out of the military, you will be given some kind of diagnosis like personality disorder or other aspects of it. another aspect is the current process to change or discharge. the military's favorite line is if this person is dissatisfied with their discharge, tell them to go to the board for correction of military records and i am here to tell you that that is a joke. but that is really deserving of

this congress we be attention. less than 10% of all agreed petitions are adjudicated favorably. imagine the psychological damage that that does with those who are privatized in the military. these people have ptsd and these people give us a general discharge in the military says oh, no, we were totally right in doing it. that is another area totally needs to be addressed. so it is really important to enforce the whistleblower laws. if you go ahead, especially in the military, you're going to be pushed out. then you're going to be told that you can't get your discharge changed. thank you.

>> thank you very much, i yield back. thank you, mr. chairman. >> the gentleman from new york. >> mr. chairman, thank you. i think the ranking member for such a deep and committed interest in this issue we owe you a great debt of gratitude because you're speaking on behalf of 500,000 veterans who had been sexually assaulted, raped, and the military. i will ask a series of questions that we can get a sense of this. it would be important for all of us to go beyond the numbers. 87% of victims don't report. and they don't report for very obvious reasons. because they don't get justice.

how many of your volunteers? how many were under the age of 25? how many were under the age of 20? >> i was 20. >> how many of you are raped multiple times? and how many of you were victims multiple times over eight? how many of you were sexually harassed? and how many of you endured a hearing. an article 32 hearing in the military allows the attorneys question the victim about the prior sexual history. now, we have rape shield laws that prevent them from going on in civilian society. but with an article 32 hearing, they are able to raise that.

how many of you were in the chain of command -- that your assailant was in the chain of command? >> this is really important. because if we keep it in the chain of command from the likelihood of any victim getting the kind of fair evaluation that they deserve is just not going to happen. how many of you -- how many assailants were known by somebody of the chain of command? okay, so you're the only person that was raped outside the chain of command. how many of you were treated by medication? how long were you discharge

after yours all? >> when you're. >> one-year 29 months. >> six months. >> how many of you have a personality order diagnosis or a emotional disorder something like that? >> how many of you believe that for this issue to be resolved, we have to take it out of the chain of command. >> how many of you when you enter the va system were asked physically if you had been raped or sexually assaulted in the military and how many of you had

an ms tee program that was reflf your >> it was a rape survivor and incest survivors group put together. >> okay, very briefly this is a level that we have no conception of. >> one of the men was brought inside of me. he pushed me down.

there was evidence that they could have collected. he was given nonjudicial placement. >> i was locked in that room by the outside. his two friends were not to open it until he sets out. >> this walk in? >> some people might say that i am lucky as a victim. i was asleep when the assault started and there are parts of the assault that i was awake for or someone may be able to put themselves inside of your body without your permission. and it is very violent.

so a lot of people think it is not as bad if you don't know exactly what happened to you. but not knowing sometimes makes it worse. to bring up the point that you have talked about using your sexual history against you, i was abused by the office of special investigations in the united states air force. i was interviewed for four hours so i had to get through my entire sexual history from the time i lost my virginity until the night i was assaulted. and i had to answer questions about that and every victimizes him.

>> might perpetrator used a weapon. he used a knife. had i resisted, i would not be here. i would be 6 feet under. and i knew that looking in his eyes. and it is very scary when you cannot file a report. that is a victimization almost as bad as the first one. one guy hit me over the head and knock me knocked me unconscious. i have been trying to get evaluated and have had issues

ever since in the va has never done. so there is physical violence and there is the violence that comes after when your command says that you're not going to do this and then the doctors in the military say it, oh, you're fine, let me push you a bull load of pills and push it back out to sea or the doctor that we go to in the military says oh, you are lying about what happened. by the way, here's your personality disorder in the back of pills less united is on your way out. a token of pills when i was stationed in san diego to float a ship. i often called it a shovel because i didn't go to my feet touch the floor. that is violence as well. but that violence needs to be addressed as well.

there is no gender sensitive care for male veterans anywhere. that is why me and a few other survivors are standing up and then recovering from sexual trauma because men don't have anywhere to go. we are emasculated when you have to talk about this. and we don't deserve that in this culture. men deserve the right to be supported as well. thank you, congresswoman. >> my situation as a young officer candidate so for whatever reason, i was given some things so i would not remember or be more compliant. growing up is a dream come i was

a very compliant anyway, but i don't remember much of it. but if someone comes too close to me but i feel that someone has invaded my personal space, i tend to become very agitated and scared and i feel like i'm going to throw up and that it's going to happen anywhere. and i was told that it was not rape. no, it is not rape. so while neither incident was outright violent, it is the violence in the that was pressing in my judgment who i was as a person.

and then i felt like it was my fault and i couldn't tell anybody. they very much impacts the way you look at things. i knew that i would never want my son to treat a woman like that. and at that point, i knew that what i had experienced, and i'm still traumatized from it, i was wrong. completely different situation. sumac mr. chairman, thank you for your indulgence. >> i want to thank you all so very much for coming to washington and telling your stories.

it is particularly frustrating for me to hear the stories one after another. while your individual differences are unique and the challenges that you spoke of and facing the d.a. and the vop are very similar. i hope that the administration officials were listening as closely as i was to your testimony. thank you very much, and you are excused. >> joining us on the second panel is doctor michael shepherd, it position at the va office of inspector general's. he's the associate director of

the office of health care inspections. also on the second panel is doctor jonathan ferrell higgins from the va of eastern kansas health care system. and carol o'brien the chief of the poster mattock stress disorder plan. welcome. [inaudible conversations] >> doctor shepherd. five minutes for your testimony. >> thank you member, and members of the committee. thank you for the opportunity to discuss the recent ig report on residential treatment for female veterans with mst related health care conditions.

i have worked in the health care office of inspections. the first person i would like to thank is the veterans on the first panel for sharing their experiences and insights. i want to briefly mention why we did this from review and offer a few observations. this inspection was undertaken in response to a request from the senate veterans affairs committee. the report was intended to describe the terror of female veterans discharged during a six-month period assisted by the va is having the ability to treat mental health conditions related to mst. although the report focused on the treatment of female veterans, i would like to ask about and discuss the treatment of both male and females that are survivors. i believe the average age was

45 to 44. 44% were under 25 and a quarter were veterans with the remaining three quarters of their service as a veteran. i think this demographic data highlights the impact of cross service errors and highlights the system to simultaneously plan for and growing mental health needs of aging vets. second i want to comment on the complexity of patients served by these programs. 96% of the patients in my review had two or more mental health diagnosis is in addition to multiple physical diagnoses. in fact, 80% had common eating disorders. after treatment in the programs, patients tended to return to the clinic facility for preprogrammed care. twenty patients were readmitted acute mental health units or

between other residential programs. for me, the real take away is that for these patients, effective treatment is not an intensive program solution, but requires a coordinated effort, building the foundation of outpatient setting and having the ability to optimize residential treatment and integrate that treatment back to the outpatient setting to build on gains achieved. largely all but three programs to patients from all over the country, if there was a national drama these programs. we found that difficulty obtaining travel is a consistent thing. mst policy dictates care for veterans and that residential care should be available. but the been the very

beneficiary policy is restrictive on the eligibility requirements. this made delay program access. we recommend the policy pertaining to authorization for veterans seeking mental health treatment in this program. they concurred and established work for these issues and to provide recommendations. as of the last quarterly update, the workgroup was continuing this issue. on-site visits, the coordinators consistently reported their concerns with her patient care is responsibility and they do not have time to perform the collateral mst duties, including outreach coordination and tracking patients with positive mst screenings. in conclusion from the programs

reviewed serve clinically depressed patients to cover treatment from across the system. ideally these women and men are engaged in a coordinated, integrated, comprehensive effort. mr. chairman, thank you again for this opportunity to testify and i will be pleased to answer any questions that you're members of the subcommittee may have. >> thank you for your testimony. >> thank you for having me. there are nine community-based outpatient clinics and as a tertiary facility. i am the chief of the stress disorder treatment program. a seven-week impatient you have for those with ptsd and other

stress-related problems. this 24 bed unit designed to help veterans with their military service and dramatic experiences they had. >> we provide inpatient treatment services for males and females from all branches and all areas of service, as well as active duty military personnel. , issues addressed include those related to combat, mst, nonsexual assault in training accidents. the unit is designated as a national resource rationalized inpatient ptsd unit. the overarching treatment goal is to help veterans maximize their poster mattock treatment

and reintegrate them back into families and communities. it has mft, issues. 100% of the identified admissions have had a ptsd primary diagnosis. more mst cohorts are scheduled for mention in the fourth quarter. of the fiscal year 2410 14, 86% have been men and four or 14% have been women. transportations include those who have served in other locales. of the mst referrals, males outwait females. as if common in residential programs, we experience a high

addition of no-shows and cancellations than for other thomas. this speaks to multiple issues, including readiness issues and travel difficulties. the program is that 24/7 by a terrific multidisciplinary treatment and they provide multiple evidence-based psychotherapies and gender specific care and same gender therapist and diverse educational program, complementary medicines, such as yoga and meditation or exercise, and medication management. as a national resource program, mst referrals are nationwide. it is employed where an mst referral is admitted in many cohort groups in order to provide for maximum comfort and group cohesion. we have not encountered any aborted missions due to safety or comfort or acceptance concerns. treatment highlights include these things. first, the program's core value of treating diverse individuals

works. amnesties destigmatize via side-by-side, treatment and is not guarded as a second-class source of ptsd but a primary problem. second, the program achieves a powerful sense of community and all those individuals with ptsd and, demographics. the aspect of this treatment environment is normalizing and essential to the veterans recovery efforts and facilitates reintegration into the real world. treatment outcome data supports the, model. outcome data is comparable to non-mst patience patients for ptsd, anxiety, and depression symptoms.

transportation, some referrals have struggled with transportation to our program and other programs. one distant these female veteran has eventually flown to and from our site by a volunteer veteran support organization. the specialized programs are best to share admissions practices that prove that utilization. last, research. more multisite, multi-program research is needed to best discern the robust treatment outcomes. i'm pleased to be part of the

mst and i appreciate the opportunity and i will respond to any questions that you have. >> providing a general overview of our health care system, the fourth busiest va health care system in southwest florida. we have a pint and a outpatient located in communities within this area.

this includes residential outpatient services to keep the ptsd from resulting in sexual trauma. it is the section of the programs that specifically treats ptsd resulting in sexual assault occurred in military service shortly after the passage of public law 102 -- 805 come as a result of our experiences, a colleague and i requested and received in innovative programs grant to establish the bay pines treatment program in the year 2000. we initially had capacity for eight female veterans and subsequently expanded the program to treat an equal number

of male veterans. at present we treat military sexual, cases each year through a residential program and approximately 400 veterans anyway. it provides evidence-based psychotherapy for ptsd, as well as gender specific treatment interventions and others to treat the unique aspects of mst related ptsd. it is community reintegration and the residential program has a strong focus on interpersonal skill development and recovery that is defined by the veteran schools and values. we incorporate concepts from therapeutic models of care. the center for sexual trauma services was the first specific

residential program to be established within dha. in addition to providing excellent patient care from across the nation, we initiated a national clinical training program in 2001 that has been attended by hundreds of mst clinicians from other facilities and that's facilities as well. this includes ambitious clinical initiative since its inception and four in terms and many disciplines. this includes equal numbers of men and women, length of stay varies based on treatment needs and goals and patients and identifying community values we

also focus on the gender specific issues related to the military sexual. to recognize that sexual assault is not a problem of gender. through their relationships with each other, they begin to trust again and develop an eagerness to move forward with their lives. as we advance the understanding and to develop effective treatment models, i respectfully make the following suggestions. we have made huge progress in the availability of evidence-based treatments for ptsd and these treatments have been demonstrating efficacy.

but we need programs to specifically address the complex family problems and behavioral issues we need more treatment, even decades after the sexual assault. many of them tell us that it was resulted in their hope for a military career. they need to prioritize effective early treatment interventions to preserve the quality of life and the contributions of military service members who experience sexual. we need more treatment options for men. we know that for men who are raped, the reporting rates are lower and the incidence of ptsd are higher.

functioning in relationships and work roles is more impaired and treatment is less effective. we need to finally understand more about the causes and the predictors of military sexual trauma and we need additional dod collaborative research to understand the perspective of both of the victims and the perpetrators so that we can design interventions relative to the military environment to omega's problems over there are no more victims. thank you again for the chance to testify before you today. >> thank you, doctor o'brien. i yield myself five minutes. >> doctor shepherd, were you here eager for the testimony? >> yes, sir. zack is fairly dramatic testimony. is the inspector general's office doing anything?

are they reviewing with the va has been doing? it's pretty dramatic. i would think that you would have been on this. >> well, as i mentioned in my statement, we did a lot of treatment last year for patients with these conditions. we have done a review about two years ago looking at treatment for women with combat stress. >> it doesn't sound like you are answering that. you reviewed what the d.a. is doing with sexual, in view of the testimony that we had before? >> yes sierra club estimates, are you aware of the number of inpatient beds that there are in the va system for inpatient treatment of military sexual,,

mainly for ptsd, which would have availability appropriate for victims? >> welcome i don't know the exact number. >> do any of you know that number? >> let me ask the doctors that are involved with clinics themselves. are your clinics always full then? >> thank you for the question. i mentioned in my remarks that we do experience people who do not show up for treatment and the advantage of us having this format, as we do, we are able to pull people forward and fill those positions fairly quickly. >> you mentioned that you have someone waiting for the fourth quarter, i thought you said? >> we do, we are in that

territory. we hope that folks get their personal affairs lineup. it takes some doing to get family and work and so forth going. >> how long is that typically take? >> we are running about 40 days i now what is the census. >> doctor o'brien? >> we run over 85% occupancy rate in the residential program at bay pines is considered the premium program in the country and we get probably more referrals and other programs do. a couple of weeks ago we had admitted a female veteran directly to our program from the inpatient psychiatry unit with

absolutely no weight whatsoever. >> we have not heard from you. did you have anything you wanted to add a maximum thank you, mr. chairman. as far as our review, we looked at 14 different programs and we had to estimate the capacity because some of the programs are women's only and others are mixed gender. it was approximately 600. we did obtain data and we will get the data. we were told that they were sometimes underutilized. october 21, 2011 through march 31, 2012.

there are particular ranges up to 81% in the programs had a higher occupancy rate, including bay pines and new jersey and wyoming. as far as questions about how long it takes to access the programs, we can get you that information. >> within our report we do have the data certified by facilities and how long it took from the time that the patient was referred to the program. to the so the patient entered one of the residential programs. >> we are respecting how the va is doing things. it is a dramatic testimony and

shouldn't he be involved in that? >> i very much appreciate the testimony and when i turn today return today, i will speak about possible inspections or we might have in this area. >> i appreciate the follow-up in this area. >> when we initially looked at this during the review, we looked at the residential programs because these were identified as being specialized treatment resources. one of the things we did was look at this because it is so broad. one of the things that we considered was there is a

screening program where they are supposed to be doing a screening called a clinical reminder where it is once-in-a-lifetime the screen people for the presence of military sexual trauma and they consist of two questions to determine if a patient medical criteria, at which point they are supposed to be verbally part of consistency if they would like to add them to the reminder. it would actually document whether or not the person would like to seek help or further assistance there would actually be an objective way for us to measure how many veterans requested help in and we could go back and see how many got the help that they asked for and how long it took. so we are trying to keep in mind when not reminder could be ruled out. we were told that it was under process and as far as we know

today it has not yet been wrote up nationally. >> and your testimony. >> thank you, mr. chairman. thank you for your testimony. >> hearing the first panel for me was disconcerting and devastating and your response to the testimony and the sense of urgency is there. he heard about the gaps in care and long wait times and employees that didn't seem to know what the policies were. you need to get ourselves out of

the va. so it just -- it seems to me that in the data that we know in terms of the victims who are out there in the victims, 87%, i think, who actually were victimized but don't come forward, it just doesn't seem that your testimony and the data that we know about are really a line here. somehow i think that we have to find those nexus points so we are doing a better job. so i feel like this hearing is just beginning to scratch the surface and we still need to drill down further on so many of these issues on how we can

provide immediate caring service and i am sort of struggling with that. i appreciate your testimony. it was prepared in advance, which i understand that one has to do really responding to what we heard. so i would just like to hear from you and all of you, really, what some of your responses are. we have asked for mr. lewis to testify and he gets the services from your facility and if we could hear little bit from you about some of his testimony and experiences. >> thank you. like you, i reacted with a great deal of concern and compassion

for the testimony of not only the male victim, but the entire panel. and as we move forward with this, a part of what we need to do within the va is to talk with our veterans and to listen to their concerns and to continue to work with them to meet every single individual veterans needs. one of the things that we are doing right now i think will be especially helpful is that we are hiring a large number of pure technicians and peer counselors and we will have one coming to our program as well. again, that allows us to hear the veteran's perspective. this includes the words of the veterans that more will we will be able to improve and continue improve the treatment programs.

>> actually have a comment. when we did our review specifically with women at the request of the senate and we looked at specialized inpatient residential treatment programs, in a way, we have the sample because we have the patience patients who made it into a very specialized program, where i think that the veterans in the first panel he spoke about their experiences, from what we could gather from the testimony it sound like only one of the four against the specialized programs. while we can discuss the characteristics and patents from what we saw it may not be reflective of the women who are making it into these residential treatment programs we found this and we did hear about barriers, many that we heard about were

very similar things we heard about. we consistently heard that the mst coordinators, that there is one at each facility and that is what is required. but it does not mandate the amount of time dedicated but it needs to have. we were consistently told on-site but it is about 10% of their time. after they pines facility, there in this area, there is a way that wears many hats and she looked at patients in the residential program. they are reported to do the outreach that they needed to do and when you look at the examples from the prior panel,

had there been a lot more outrage and a lot more focusing on coordination and coming into the system, that could have included some of the issues related. >> thank you. i yield five minutes. >> thank you for all being here today it is always necessary to self critique ourselves. i was wondering how you would describe or rate customer service as far as it goes with mst. and what is it that you need anyone can take that. >> thank you for the question,

congressman. i believe that customer service is outstanding and we have an excellent team they are very pleased with the care that they have received from us. we are having better community resources to help you come more link in what this. i think that we can do some improvement there as well. >> is there anyone else? you care to comment? >> i have a comment from both of the panelists to mention the pure technicians and enter counseling is such a positive recovery movement that is something that we notice when we look at the medical records

there was peer counseling available we were looking at those and we only saw one female peer support technician who was working in this particular program and i believe that that was the program in cincinnati up to 15% of their population is female, however they have no set number of what the peer support technicians are. ..

>> a comment that you made about yu used a phrase once in a lifetime screening, and i guess the comment that i would have is it's very clear to me from our first panel that once in a high time screening would not be be adequate. and i think, actually, dr. roe spoke very eloquently about this of knowing his patients for 30 years, and it takes 25 years to have the this conversation. so what would you recommend that could be done across the board throughout the va to be more mindful of the challenge of bringing this situation forward that it's not just saying i

broke my arm, can you fix it? >> i think that the part of this issue has to do with the mst coordinators and the time that they're afforded to follow up on screenings and also when they are working with -- when a patient does disclose in whatever venue it is to make sure that the coordinator is aware and that the screening then gets flipped back to being positive in the record. a clinical reminder, they can be set in the electronic medical record at certain intervals. currently, this is something that occurs once in a -- once. when a perp, male or female veteran, comes into a va medical center for enrollment, they're screened for many different conditions, mst is one of them. there are two questions in the screening, and as i mentioned earlier, we were told they're in the process of adding a third question. we would probably need to defer to vha for more specific information about their future plans for the clinical reminder. we did have some dialogue with

vha staff and central office about the clinical reminder and the pros and cons of having it come up more often than annually. we did find in our particular sample all of the veterans had been screened. we did find that out of the, out of 166 patients, 161 were actually veterans, three were active duty and two were reservists. so of the 161 for whom the clinical reminder would have been turned, for seven it was still marked negative. and that has an impact on the va collecting data because they make tremendous efforts to collect data. if the clinical reminder is marked negative, then some of the data that they collect would be lost. >> great. >> could i add, also --? sure. >> that although in va we have the requirement to ask once to do the reminder, that's not the only way that we reach out to

our veterans to let them know about the availability of treatment and so on. we have brochures, we have posters, we have events for sexual assault awareness week, we have in multiple modalities we reach out to our veterans to let them know that the care is available and to seek care. i had a veteran say to me the other day that he had said no to the clinical reminder, and then he saw a poster at our facility that we have hanging right inside the door that says it takes the strength of a warrior to seek help, and that gave him the courage to come to us and say i was sexually assaulted in the military, and i hear i can get some care from you. >> great. by time is short, but i do want to take the opportunity to introduce an expert from my region in new hampshire who is

here with us today at the hearing, victoria banyard, ph.d. from the university of new hampshire. i'll be submitting her statement for the record. but with regard to your comment, dr. higgins, i think the connection to the services that are available in the community including in academia, in programming, the issue of sexual assault and rape is not new in our society. and one of my biggest concerns across the board both with regard to dod and the va is that there's this effect of a total vacuum of the military and the veterans administration seemingly dealing with these issues in a vacuum. and so i would encourage all of you and certainly we will encourage the veterans

administration and the dod to work with the civilian population because this is -- a very unique both with regard to coming forward and telling the story and all the way throughout. and so our concern is with this multiple trauma that we learn best practices from people who have worked, dr. banyard has been working for 20 years in this field, and i'm very honored to have her with us here today. so thank you, and i yield back. >> thank you very much. i'll yield five minutes to the gentlewoman from indiana, ms. walorski. >> thank you, mr. chairman, and i have to agree with ranking member brownley, in sharing her frustration i feel like we're in two -- i feel like we're in two separate worlds. we just heard absolutely gut-wrenching testimony from extremely courageous people whose lives have been ruined,

and i'm frustrated sitting on this committee. i've been asking questions about this issue to the va since i've been here with no answers. so with all due respect, dr. higgins, the customer service is going great? well, maybe for those who actually access the program, but to the people that are sitting here representing tens of thousands of people, it isn't working, and that's -- and i'm just frustrated. but i want to direct my question to dr. shepherd. in a report it's recommended that, quote: the undersecretary for health review existing vha policy seeking nst-related treatment as specialized and patient-related programs outside of the facilities where they're enrolled. the vha agreed with this recommendation and promised to have a recommendation completed with the undersecretary for health no later than april 30, 2013, has the vha provided you with that status update? >> their quarterly update which was in may, they were still working on it and haven't come up with a list of

recommendationings. >> and let me just interject, i am -- that's exactly what i expected to hear because the questions that we've been asking in the seven months that i've been here still have fallen on deaf ears. no response, no report. when we're dealing with this issue of mst, the reason these stories are so gut wrenching, i think, is because, you know, we have thousands of people falling through a crack in the system, and we can't even get answers to the congressional committee that's in charge of watchdogging and making sure that these people get treatment. >> in fact, in the last few days with a lot of pressing we got a response that they recently had developed some recommendations that the undersecretary would be reviewing in the last few weeks. so i agree with the congresswoman's comments, and i slip understand the frustration. >> did the vha give any reason for failing to fulfill their promise? >> no, ma'am. >> does their failure to address

the report -- [inaudible] in your estimation? >> it's hard to say. certainly, you know, we'd like to see a prompt response to the recommendation we had, and we'd like to see the, what they've recently proposed get implemented because we think that will help improve access for veterans needing these programs. >> thank you. and, mr. chairman, i yield back my time. >> ms. kirkpatrick? >> excuse me, thank you, mr. chairman. dr. o'brien, how many of the 3500 employees at your facility are psychiatrists? ..

>> i don't have your written testimony. i'm recalling for new testament that you said you treat 100,000 in patients at the facility and 400,000 outpatient come is that correct? >> i indicated that we have 100,000 male and females veterans who come to our facility each year. >> and how many of them are seeking mental health care? >> again, i don't know the exact number. i can get that information to you. >> dr. higgins, can you answer those questions for me fordo facility?

>> i find myself in a similar situation as dr. o'brien. on the inpatient ptsd unit we have a full-time ta, and with a psychiatrist who supervises that work. i'll have to get back to you with respect to told him a psychiatrist in the facility. >> can you give me a ballpark? >> let me get me back -- let me get back to you about that. >> do you think we have sufficient number of psychiatrist in the v.a. system to treat these issues? >> under our review we looked at the staffing specifically of particular residential programs so i will not be a blue comment on the adequacy of the staffing for the other 140 the facilities as far as outpatient services. we found that there was adequate staffing for the particular programs that we reviewed for residential and inpatient and

major. >> i'm concerned about the testimony we heard from the first panel that they are being seen by medical students, but untrained professionals, and really would like an answer back about whether or not we have adequate professionals in the v.a. system to deal with military sexual trauma. i also, in the written testimony of one of the first panel is, she says, some women are not going to come to the v.a. because of a lack of treatment or a bad experience with the v.a. and we've heard in other hearings about women being hesitant to go to the v.a. i would just like to know from the panel what efforts the v.a. is taking right now to address that, to make it a pleasant expense of women, someplace where they would feel protected and welcomed? >> thank you your i think one of the things that the v.a. has done over the years is the creation of women's health centers. every v.a. facility has a

women's veterans program manager whose job it is to advocate for women veterans throughout the facility. and women, i'll talk about the bay pines women's clinic, is a separate clinic dedicated to the health care of women veterans. and in the clinic they are also mental health providers so that if a woman veteran comes to our facility and feels uncomfortable giving care in a general mental health clinic or another setting, they can get virtually all of their care in the women's clinic. >> dr. shepherd, are you aware of anything going on within the v.a. to make it user-friendly for women's? >> i can speak to, i think ideally the question is best answered by the two panelists from v.a., but i can say that going back four or five years ago on these residential programs, there was really concerned about physical safety,

that that was more of an issue. and many of the programs he did put in a keypad or other type devices to try to bolster security. so other than that, i can offer that but i really think that is my best answer. >> do you have any comment on that, about ideas about what could be done better? >> just to add to the sentiments of dr. shepherd, we have our office of health care inspections when they schedule site visits at approximately 50 v.a. medical centers each year. they are looking at the safety security of the mental-health residential treatment programs. they found very high compliance with the standards pertaining to safety and security for women veterans in those venues. as far as required alarms, door locks, rooms and bathrooms being able to lock, building entrances and whatnot, i do know that the

oid is always has a component relevant to women's health. typically under schedule site visits. so it is something to be keeping an eye on. i cannot personally comment on the adequacy of their efforts over all as far as being more welcoming to women. >> dr. higgins, can you describe what is going on with your facility? >> i would be happy to. we also have a women's health clinic where the full comprehensive range is available with respect to our you know, we do indeed have alarms on doors. so to maintain the physical security of those rooms. i think that the message is best delivered every time we interact with a few massive comes into v.a. it's the individual contact makes the difference to our staff on the staff is well trained and committed to the. because we do understand the gravity of the stories that are work with these women, and mene

who have been sexually, tires. >> thank you. thank you, thank you for indulging me to exceed my time. thank you. >> thank you very much. i would like to yield a couple more minutes to the ranking member, ms. brownley, from california. she has an inquiry. >> thank you, mr. chair. this inquiry is really to the office of the inspector general, dr. shepherd. you know, we've heard today in today's testimony a lot, but one area that i wanted to focus on is the transition area from dod to the v.a. for military sexual assaults victims. so i know, my understanding anyway back in 2009 there was a dod va mental health summit, and from that summit that was i

think an agreed upon strategy coming out from the dod and the v.a., but we really don't know anything about it and literally what has happened. with it. we don't know what the strategy is, et cetera. so i think, i think the chairman agrees with me that i would certainly like the inspector general to look into this issue around transition and now the dod and 50 are going to work together to service our military men and women have been sexual assaulted. and report back to us. and the official capacity out of the office of inspector general, and would like that to happen and lea to have a report that wd come back to us. >> in light of all the heartfelt concern expressed and shared by the first panel, i personally would be honored to work on

that. >> thank you, sir. >> i would like to thank all of you very much for coming to testify before us today, and you are hereby excused from the panel. i would like to call the third panel. we have department of veterans affairs, doctor rajiv jain, the va assistant secretary for patient care services. and dr. jain is accompanied by dr. david carroll, chief consultant for the office of patient care services and dr. stacey pollack, national mental health director of program policy implementimplement ation for the mental-health services of the office of patient care services. that's a long title. we are also joined by doctor karen guice is a principal deputy undersecretary for defense for health affairs. i want to thank you all for being here today.

we have your complete written statements as part of our hearing record, and given the gravity of the testimony and personal experiences that we have heard in the previous panel, i would like to go straight to questions if you don't mind. you are all here for the testimony of the first panel, i take it, right? to me, it's very frustrating to hear that and to know that there's many out there that we haven't heard today that have the same complaint. and i know that i have received constituent letters about how people have been sexually assaulted in the vietnam war, but still hasn't reported it to their va person. because they are just afraid.

they didn't reveal it until they wrote me a letter. and this testimony is so devastating. i know you have a statement there, but maybe dr. jain, you can tell me, what's your reaction? what do you think your first thing you're going to do after this hearing to try to fix this is going to be? >> thank you, mr. chairman, for the question. i think there's no question that our testimony that we submitted, as you said, is already somewhat dated based on the testimony that have been provided by the for veterans on the first panel. i think they really present a very powerful story. and i think that the point out that in as much as we in the va have done a lot for survivors of nst over the last few years, we also feel that there's

significant gaps that have been pointed out by the panel that we need to really look, careful look and address and see how best we can meet the needs of all of our veterans in a sensitive manner. manner. >> wouldn't you agree that this is an emergency, that there should be, you know, rapid action taken? >> i would agree, and we would certainly go back and take a very critical look at how we have structured services and what can we do to address some of the gaps. and, frankly, they made a lot of wonderful suggestions that we also would want to consider. >> do you know who would be in charge of that, making, is there someone in charge of the va? i don't know, there's so many, i get confused, the principal deputy, assistant director. those type of terms. i get confused. so is there someone that you can

name that is in charge of fixing this? >> well, sir, as -- >> is that you? >> i am in charge of the patient care services. i would certainly be willing to take that responsibility on behalf of the vha, because all of the mental-health services and the mst services are part of the mental-health services and in patient care services. so i would certainly be personally be willing to take that responsibility to do a careful assessment, working with our leadership on the operations side to make sure that we have all of the appropriate staffing that we need to make sure that we provide the services in a sensitive manner. >> you have a lot of caveats in there, i understand, dr. jain. but i tell you the truth, i really appreciate your answer. the fact that you're willing to sit there. and i worked at the va as a consultant for 20 years and is sometimes straightforward answer

like you gave doesn't happen that often. even with the caveat. i'll yield the remainder of my time and allow ms. brownley to go on. >> thank you, mr. chair. and i certainly share your sense of urgency here today, and earlier in the hearing there was some discussion about the chain of command. and i think certainly this issue, we need to go up the chain of command within the va and within a dod to make sure that we are addressing some of these issues and that we are really providing the very best practices to our men and women who have served us so bravely and have so bravely testified in today's hearing. i wanted to go back to some of the specifics from panel one that were of suggestions.

and one is going, you know, going outside of the va for services to access services that may be closer to home, to access perhaps services that are best practices if it does not exist within the va, and it seems to me that if we do have these gaps in care and so forth and we want to address this, with that sense of urgency, that perhaps, you know, one solution could be is to go, to look at the utilization of outside services for our men and women within their areas in which they reside. it seems to me, best practices

are out there and being provided, that this may be a way in which to provide those services in a very efficient and expeditious way. and just wanted to hear any comments from you with that. >> thank you, congresswoman for that question. let me start a discussion on that particular topic. i think as you say, our va medical center leadership at all of the facilities have a range of options available to them in terms of looking at how to provide services in a timely manner. and clearly, the veterans on the panel have pointed out that fee basis is one of you is. i would also submit to you that we have telehealth services, and i think that was pointed out that we could have these clinics. as you know, we have lots of committee based outpatient

clinics. over the last several years, mental-health has now become a component of the primary care services that is provided at our feet box. what we have done over the last few years is we've added the telling of the health service to further expand the reach of the experts that we have at the medical center's to make sure that the higher level of expert services is available in our clinic. but listening to the testimony of one of the veterans, it's clear that there are some areas of the gaps. there are some areas where perhaps the veteran was not able to reach a community based outpatient clinic where there was also a combination of mental health services and other types of expert services for survivors of mst. that may be available. the issue of fee-based services is certainly fair, and clearly

as you say, is one of the options. the challenges that one faces the immediately is that you have to look at whether there are the right professionals available to make sure that that service is available in a timely manner. i think the veterans pointed out the challenge of exchange of medical record information. when the services are provided within the va or when we partner with, or when we partner with indian health services, we have done several projects now where the va in partnership is working with those types of agencies to make sure that we share resources and we provide day care in a timely manner to where the veterans are. site think there is a range of options, and clearly one of the options would have to be a fee-based services. but let me ask dr. carroll if he -- >> i would like to go further with another question if you don't mind.

the other issue is around screaming him and to me that seems like that can just be a simple fix to make sure that across the country that we are doing the screening. and it was very concerning to hear ms. johnson, who is our most recent service member and veteran who clearly was not screened. and so we say we are screening, but yet i think from the testimony we can conclude that it's not a failsafe program, that every single man and woman are not being screened. and i think, you know, i think that we just, it's something that is not complicated. it's just a matter of making sure that we're doing it. and i also think screening, it's not just at one time thing. we have to continue to sort of follow-up and there probably needs to be other places in the

process where they are screened again. so it's not a one time thing. so that it is, it's more of a check and balance and more of a failsafe system. the other thing that is come to mind in listening to the first panel is, you know, having advocates for these men and women that can access the system, to prioritize their needs within the system, to get the services that they need, and when they need it, and can help in the coordination also. and making sure that from every place, wherever it may be, that they are getting what they need. would just ask if you could comment on any of those. >> so, thank you very much for

those comments. i fully agree with you. i think that that are any points that our veterans made in terms of suggestions that we would take to heart, and we will go back and review our current policies and procedures. for example, screening as you point out, i think there are some things that we would need to look -- i was very surprised to see that none of the four veterans are now in some ways with possible explanation could be that maybe the screening was conducted a few years earlier when the screening was not fully in place. but that's still not a reason not to do that they can. i think you point out a very good thing here, and i think the veterans have indicated that we need to look at our procedures for screening to see if there is a way we could offer some kind of another chance to have the screening done in a simpler way. so i would fully agree with that.

i think your other point also makes sense, in terms of veterans having options available, i.e., some kind of a coach or a coordinator. and i think we are toying with some of those ideas in our primary care clinic, in our program. we have recently introduced a concept of coaches or health coaches. and these are the coordinators we have. as you know, the oef lefcourt knitters help in the transition of the service members coming into our system. but they also assist in coordinating care whether it's coordination with other specialty clinics or coordination between the va and the community. you know, a lot of our teams have this post-deployment counselors. they also sort of provide a similar kind of role. but i think that what we begin to do now is to add some more

coaches that can help to further this element of coordination of services because a lot of the dual care that happens in our system. >> thank you. and if it sure would allow me a little more time i would like to just ask for dod to respond to some of these issues as well. >> i think there's a lot that we have done recently. we have a new dod instruction which kind of talks about the roles and responsibility of everyone in the department of defense to specifically address sexual assault prevention and response. that was just issued in april. the services are in the process of fully implementing it. we know they are compliant with the health care provisions in there so we know that providers are trained. we know that they are meeting the standard for providing 24/7 coverage, that there is safe kids and all the -- i think

we've responded in a thoughtful way to what we also heard from survivors in our focus groups in the department of defense to can fix some of the problems that were articulated. we are just kind of seeing if we have solved some of the problems. certainty that were articulated for the health care parts of the. i know we saw some outstanding issues with regards to some of the other things that you all have articulated here. i just want to articulate my thanks to the first panel. it is only through their eyes that we actually see us as we are and that's how we fix things. so i'm very grateful to their willingness to come forward today and help us understand and see things the way they see us. that's only how we get better. >> thank you. thank you for that. and i think we all walk away today, hopefully the congress, dod and va, walk away with a sense of urgency today that we have a lot of work ahead of us.

thank you, mr. chair. i yield back. >> ms. kirkpatrick? >> our committee has heard that a stigma exists in the military that deters active service members from getting mental health care. at one of our veterans panelists suggested there be a mental health day where professionals are brought together so that service members can seek mental health care. that day and actually see professionals. dr. guice, is that recommendation been explored before? >> i've actually not heard of that particular recommendation. we have done a lot in the past several years to provide embedded mental health providers both in the deployed in targeted with embedded vehicles specialist in our primary care teams for the patient-centered medical home. so i think we're doing a pretty good job of trying to penetrate and provide our behavioral health specialist where they need to be. and so that they are not seen as something different but they are just part of your group.

and i think that that's going to go a long way. we actually have seen in the department an increase in people accessing services for mental health, which i think is a good news story. that i think means what are addressing stigma. have we totally fixed it? probably not, but i think some of the maneuvers and some of the choices we've made are making some inroads into it. some quite positive that i'll take back the idea of mental health day and we will see how people respond to that. >> i represent a very large rural district in arizona, and we're using more and more telemedicine. and i'm finding that patients are very open to that and find it's a very positive experience. i just think that telemedicine may be way for some of our veterans to seek mental health treatment in the privacy of the home without having to go to a facility. dr. jain, which you addressed that idea? >> thank you, congressman for the question. i think that the potential for

telehealth is still i would say in its infancy. so we really can take this too many different levels. i think the point that you are making and the veterans have made providing care where the veterans live in that community, i think is the message we've taken to heart. and we have done a lot but we need to do a lot more. i think that the days of asking the veterans to drive 200 miles, 150 miles to come to the mothership and be able to receive care, i think has to be a passé. we need to move on to the point where we're able to provide more services either in our committee based outpatient clinics or potentially in their homes. so yes, that a certain area that we're looking at very actively and we will continue to expand that. >> thank you. and again thank the panelists for being here today, and i yield back. >> i'm just going to ask a couple more closing questions.

dr. guice, looking at the gao report from january this year, it's as we found that military health care providers do not have a consistent understanding of their responsibilities. in care of sexual assault victims. fas.. >> those that are, those that actually perform the safe exam which is the