understand the need to be wary of creating incentives for people to gain -- gamed the numbers but we also have a serious accountability problem. how will you still hold medical center directors accountable for wait times if it's not in their performance contract? >> i think the first step that we have got to do is get the integrity and the data and so the idea behind pulling that out at this stage of the game is to eliminate any questionable motivation. i think as we move forward what we are going to find is that average wait times are very poor gauge for timeliness of care for a large integrated health system. we don't really find that in the private sector. that's one of the reasons we are boosting our patient satisfaction measurement activities. going to

become central. the veteran needs to be seen today, we have failed that veteran. >> you are looking for different ways -- >> i think we will be looking at different ways to evaluate timeliness of care, a combination of patient satisfaction, veterans waiting too long and seeing that number coming down steadily. and then as we have the system could ability to do things like you see in the private sector, metrics like the third next available appointment which gives you some gauge of the capacity of the system to be able to handle that veteran as they come in. today at least we are able to look at same day appointments. roughly in the primary care area we see about 100,000 veterans on the same day basis every single month in primary care. that's coming to me, suggests that there is capacity being maintained to take care of that veteran who cannot wait 14 days or 21 days or 30 days.

>> okay. health care from the private sector does play a critical role in making sure that veterans get the care in a timely fashion. there are drawbacks to the care that the va has been trying to overcome like not being able to get medical records returned to the department and a little ability to see the quality of care. if congress were to expand the authority for 90 for health care, what steps would be necessary? >> i will ask philippe to jump in here in a moment. one of the biggest challenges we have with purchase care in the community is maintaining continuity of care for the veteran. the ability to get information, medical information, medical record information back and forth is a vital part of this. ensuring the quality of care. i would tell you if the floodgates open it will present the department with challenges, but the fact remains we are

right now referring out roughly a quarter of a million referrals' every month to purchase care. as i mentioned before, every one of those referrals on average will result in roughly seven appointments. that is an awful lot of activity. last year 15 million visits to non va providers over the course of the year added to the 85 million outpatient clinic visits. 100 million outpatient visits per year that we are managing. it is already a very large number and a challenge for us. but if we open the floodgates it would be an even bigger challenge. >> senator, the one thing i would add is purchasing care in the community does not absolves loss of the requirement and responsibility to coordinate care in addition to the assurance that we can send -- both send and receive clinical data. there is just the hands-on coordination required to make sure an appointment has occurred, the veteran knows where to go, the family is

involved, all the rest of that. for a look at the cost of care alone, we are missing a big responsibility. >> we look at how we do this and expand, we have to look at those issues and get them right or we will create a bigger problem for the future. finally, va has had a lot of difficulty hiring providers for a number of reasons including the that is lower than the private sector and a long, as you mentioned, cumbersome hiring process and hiring in shortage areas in health care anyway. because we know there is a national shortage as well. now va does a lot of training for doctors and nurses and works closely with a lot of universities. what more can that va do to help build the health care workforce necessary to meet the needs of the department and our country? >> that is a great question, ma'am live. one of the significant opportunities where we can work collaboratively.

maybe tuition payment programs or reimbursement programs, ways that we can encourage that. we rely heavily upon our academic affiliations as a source for new conditions. we are doing things from my compensation standpoint as well where we have flexibility to appeal to meet the local markets . >> that is part of the reason for a backlog as well. we cannot ignore that side of it >> yes, ma'am. >> thank you very much, mr. chairman. >> thank you, senator murray. >> following up with a question about referrals and the private sector, i wrote this down from your statement. he said 543,000 referrals for private care. what percentage of those would you guess or mental health referrals? fifth. >> i'm sorry. i could hasten a guess, but i will take that one for the

record. >> the reason i ask that question is to my got into the atlantic va in august of last year when we had two suicides and a drug overdose. when we dug -- they were using a community based provider. va with see the patient, refer them to the community-based provider with no follow-up. and in that time when the person was determined to be at risk, in two cases they took their own life because they did not get timely service. i think there was an interesting observation about coordinated care. as we expand private options and veterans' health care, which we may or may not do. i hope we do. care coordination will be one of the secrets to making that work, not just in reducing wait times but the quality of care -- or increasing the quality of care for veterans, particularly with the number of mental health

people coming forward. that will be an ongoing process, one that will have to be coordinated and monitored. >> the memorandum. >> in may when secretary shinseki and dr. peters were here and ask them both the question had they seen it. dr. peters said he had and the secretary said he had not. i think both of them told me the truth. i don't think he ever saw it because i think the senior leaders did not let him. i think -- my experience is it lies at the highest levels of the veterans administration that insulated leaders from the problems. why else would a memorandum written four years ago that we are discovering now and 2014 not have been acted on? the last sentence of the third paragraph says these practices

will not be tolerated. it does not say look at this when you get a chance and delineates each of the programs. you are an interim director, secretary. you will be handing off this presumably to of mr. macdonald. what are you doing to put in place the type of affirmation transfer and conduits that will see to it he does not become a rookie victim of what a distinguished general was in terms of mr. shinseki. >> i will let my old friend -- are will not let my friend become a rookie victim of anything. >> let me interrupt. i am not being tried when i ask this question. >> i understand. >> for four years va has indicated its leader. >> i will tell you from my personal perspective i have learned to never have all my information filtered through a couple of people. so from the first day that i got to va asserted reaching down the organization to get additional information.

i think your sense is an accurate one. historically they have operated in an insular organization. part of what we have been doing is dismantling a lot of those barriers. since my first day as acting secretary, every single morning at 9:00 a.m. we have something called access stand up. senior leaders from across vha and the department up in our integrated operations center and bore into data are round access to care. this status, what are we doing, many contacts, appointments, the wait times, the status on many of these different initiatives i have alluded to in my opening statement. it is just part of what we're putting in place. this young guy right here -- and as said before if i was half as smart as philippi would be darn

smart. he has been doing an awful lot of the work to put in place the kind of management system the you're talking about some of the and not just relying on by chance the information filters out that we have dashboards in place to help us identify whether -- where there is scheduling malpractice from a productivity opportunities for us so bring more productivity out of a particular clinic, that we are able to identify those things and in tandem requiring medical center directors to get out in their clinics so that they take direct ownership for the consequences. the first sentence in a memo that provided that direction was , medical center directors are directly accountable for their quality of care and the timeliness of care delivered. that was the first sentence. that is part of ensuring that we have that kind of accountability and, frankly, is part of the culture change.

it. >> my time is up, but with that endorsement i have to ask this question. you are not leaving when secretary stone leaves, are you? >> i am not going anywhere either. >> i am talking about -- make sure he is at the right hand. >> there are a lot of good people building a lot of good tools. one of the things we have a team working on now is to take that memo and actually developed tools that allow us to mind gated to look for those patterns. give us -- as we are looking at art timeliness data secretary gibson has directed us to go look at and integrity score against it and read it. are there certain questions? if they persist have an audit. >> thank you both very much. >> thank you. and you are right. there are a lot of good people

at the va and a lot of them delivering damn good health care on the ground. when need more of them and to get rid of the bad apples. you said you have a concern about purchase care trumping va capacity. i assume that is during this conference committee and other times. we will put more emphasis on purchase care and not enough emphasis on va capacity. have you been able to do any sort of cost analysis? is it more expensive, less expensive? >> there are instances where we have taken what we would consider to be the mix of patients and the types of services we provide and compare them to private sector models. sometimes we do it for community-based outpatient clinics. as a general rule it tends to be more expensive. there are two different types of contract options.

they both have their problems. i come from a state where quite frankly the frontier in a lot of areas of private care mayor may not solve the problem, but it looks attractive. if it breaks the budget of the va and we don't get better health care in the private sector, which both of those are up for debate can age can be a problem. that is why i agree with your capacity issue. want to talk about an issue called project -- project march. it has worked well, not been perfect, but worked well. can i get any assurance that it will not be prematurely shut down before it is reauthorize? >> the discussion that we had the other day was exactly to that issue. my commitment is, to the extent i have the authority -- there is some question, but we will not end a program that is providing access to veterans until we have their robust replacement in place so that there is no lapse in care for the veterans being

served. that is my commitment. >> that is good. i think the project definitely works and it allows you to have control of those medical issues moving forward, which is a big concern. can i ask you, what do you say to folks that say the va work shortages are a myth and the real problem is medical personnel is just not working hard or fast enough? >> i will start and probably pass it to philip for a wrapup. i think when you looked -- i mentioned earlier in my opening remarks, older, sicker, people were. when you look at the typical va patient. when you start talking panel sizes, specialty care, you have to take into account the very different patient population that the va is dealing with.

the number of primary care patients that a commission sees at va is in all likelihood going to be different than what you see in the private sector. secondly, there are oftentimes factors, for example space. we talked about that earlier. i think the average in the private sector for primary care is to and have treatment runs for a primary care provider. and i do not know that we have good data on what that looks like a cross va but i strongly suspect we do not have those resources. in the case of specialty care, one of the places we are significantly under a leveraged addressed and these numbers in this request is on average one support person for every specialty care provider. that compares to a goal or target of three and a half to one. we are under leveraging specialty care providers and as a result they are not seeing as many patients as they ought to be able to. we get these differences. i am convinced we will see

productivity enhancement, but it means we have investments to make to be able to deliver. >> that meets the needs of the veterans that to not have access to the va? what i am saying is, i was told, for instance, va montana has 22 slots. productivity can probably take care of some of those. maybe, maybe not. but my point is that if we are 22 short, it becomes an issue of if they would be happy. >> take a moment and summarized the process we have been going through. >> we did accelerating care. we pushed up productivity data.

i may touch on panel size a little bit. but we sometimes miss the comparative patient population when we do that. we are looking at productivity, comparing it internally. hi, productive facilities, looking at how they get there. part of it is smart use of support staff and part of it is just monitoring productivity. some can be covered internally and some will require additional resources. we ask every facility to look at productivity numbers. we use that as the basis to a accelerate care. >> thank you very much. >> chairman, thank you very much . you have used the word trust.

i never asked for a cabinet secretary's resignation. this is the first. we were indicating that there was the problem with the culture , a systemic problems. it was my sense that all of that was true. i was somewhat comforted in the position, but actually very concerned by what i heard the secretary say on the day he announced his departure which was something to the point that he had been surrounded by people whose views he trusted that he should not have. the scenes that we were right. if the secretary cannot trust the people that he or she must deal with on a day to day basis.

i want my comments to be brought and not provincial. appreciate the senator from montana, but i want to use that as an example of why i have had difficulty in trust and the department of veterans affairs. i don't mean this in a personal way or to suggest that i am personally offended. handicapped by the sense that i have had fact that the department of veterans affairs does not trust us, does not share information, is not honest , and most importantly has rarely responded to issues raised. again, this is not a personal

concern of mine. it is not that i am personally offended, but when a veteran in kansas' brings an issue to me and i raise it, i think we should be able to expect an on asphalt, fair, and timely response which has not occurred. my ability to trust the department of veterans affairs has been significantly handicapped. an example of that is this program. it says if you live long distances from i va hospital outpatient facility you can access at home by the veterans department giving you the ability to do that paying for the service. that is a pilot program. five across the country i kept asking how what was going. is it working? how are veterans -- are they

letting it? is the technology work? we get virtually no answers. finally, at a hearing with secretary shinseki -- this program is about to end. its three-year pilot program is coming to a conclusion, although we are pleased to know you have the authority to extend it. secretary shinseki in march of this year indicated to me and would have an answer to my question by sunset, his words. never had an answer yet. then in march -- and incidently one of the things i have learned since then is that in the spring of 2012 year after the pilot program got started the wichita va is interested in promoting this program to rural veterans and were instructed by dca you cannot recruit and market.

my concern is we have created a program that someone at the department of veterans affairs is not like so they are out and about trying to make certain they prove it does not work. for someone at the va to tell folks in kansas, don't market this, don't encourage veterans to participate suggests that they wanted a failure. i become more suspicious as i learned this. on march 26 of this year a national program director directed the five pilot programs to notify veterans the program was going to a conclusion. at the same time -- in fact, in april, a week or so later, a senior staff at the va the shores my staff and committee staff that we are continuing to assess the program. subsequently we learn the memo has gone out. ten days later, to weeks that we

are assured. that makes me suspicious five about the inability to get the report promised by the secretary of veterans affairs by sunset i wonder what is going on in march. then june of this year we discovered there was an e-mail ready to be sent terminating the program. i, including some on this committee and ask that not to be the case. we are told just-in-time. this and russian -- send button was not pushed. a series of things have caused us have great doubts about who is telling us what, what the truth this. in a more fundamental way, programs authorized by congress, then they'd be easily undermine to my personality not apparently like the suggestion we have made, not a suggestion, the law we have passed finally, our telephone conversation.

i appreciate you reiterating what you just said, but that is the circumstance of find myself and as someone who is a supporter of veterans and they're for a supporter of the department of veterans affairs whose mission it is to take care of veterans across our country in state. >> just a quick comment i alluded in my opening remarks to an openness and transparency. i think that is central to maintaining trust and the position we are in right now of reestablishing trust. this is one of the central cultural issues that we must deal with as an organization. i would tell you that there is -- i used the word insular earlier to describes the particular vha, as i find it, coming into the department. i think that is the case.

over the last six weeks i have been pushing information out the door as fast and hard as i can. i prod behind-the-scenes for responses to congress, and we have got a lot of work to do in that regard to earn the trust back. >> is, sir. >> okay. thank you. senator. >> thank you. we know there are capacity issues at the va, and i would like some clarification on comments or statements you made. did you say that based upon your assessment of the capacity issues that you would need 10,000 additional staff? at think you were talking about -- >> that is correct. >> over two and a half billion that you would be requesting. >> that is correct. yes, ma'am. i know that sounds like a huge number. there are 300,000 people in vha alone. >> so additional staff -- and i know you broke it down to how

many doctors and within the specialties. so is that for the emergency situation we have now, or is this an assessment that reflects your long-term staffing needs? >> there was a reference made in one of the opening statements earlier about the findings of the field audit. the number one cause for scheduling difficulties was that there were not sufficient providers lots to be able to schedule patients into. so what we're talking about here -- my comment earlier -- we have not historically manage requirements. we have managed to a budget number. basically we took a budget number and did what folks thought they could do, and the veterans on the being the shock absorber in that process. >> meanwhile, if you look at your true needs you're saying that you would need to hire 10,000 additional staff. >> yes, ma'am. >> that would of course depend upon the appropriations that we provide. >> yes, ma'am.

>> if you were to have the appropriations to hire 10,000 people, how long do you think it would take for 10,000 people to be hired? one of the things i did hear about the hiring in va is that it takes a long time to hire a doctor. i hope that in your review you are also looking at your hiring process is because it should not take a long time, whatever that means. that is one question. and then, to hire 10,000, do you have any sense of how long this would take should you get the money from us? >> a couple of comments. one, every single medical center i visit i hear from rank-and-file staff that it takes too long to hire. staffing practices is one of our areas of concentration. my guess is there are some things we will find is just a function of being in the federal

government, regulation and statute we must follow. my guess is we will find a large portion of that is self-inflicted, and we have got to clear that stuff away so that we can hire more expeditiously. second, round numbers to i would say in vha we probably hire 30,000 people every year anyway. nine of 10,000 sows like a huge number. it's about 3 percent of staff, maybe a little less. but recognize that some of these are in places like primary care positions and mental health providers. we know, and you all know that those are tough to find. so it will take time for us to be able to hire. quite frankly, the other problem even if we could go out and hire them all tomorrow, we don't have a place to put them all. in some instances we will have to deal with space issues in tandem with this. we may be able to do -- there are provisions in here for what are called the emergency leases.

i authorize some of these when i go out to the field where someone has found clinics based that is local that can be occupied quickly. 10,000 square feet, something like that. >> i don't mean to interrupt you, but my time is running out. >> yes, ma'am. >> you are addressing the length of time it takes. if you are hiring 30,000 people every year, there are probably some retention issues that you also probably ought to be addressing. >> 10% turnover. >> well. >> it is relatively low. >> you mentioned that in response to a question when the ig has findings from embracing those findings. since the problems and challenges that the va has a longstanding, i wonder whether you have a process or someone in that va who provides a response to the ig findings.

should you be providing a report to congress to respond to the ig finding so that we also can provide the kind of oversight that we should provide as to what is happening at va? >> there are responses. unless i am mistaken, i believe those responses are shared. is that correct? >> yes. >> so there are responses. what i would tell you is that i don't believe that those have always done the visibility and detention. some of the examples surrounding the office of the medical inspector in those reports, quite frankly, i don't think those are getting the attention they deserve. as we look at overhauling processes, part of what we have to do is make sure the issues that need to be elevated of the way to the office of the secretary are, in fact, being elevated. where someone says we have taken care of this issue, we know what has been done and confirm that. >> mr. chairman, just one more item. i was told by the veterans i

have been talking with, many of them live in rural areas. i was told that even if they got vouchers to go out to get private care that the doctors on the big island would not take veterans, so we would not help them. have you heard that concern? >> i would tell you, there are issues of around primary-care close-knit community contract that we have got was two different national providers for specialty care, and we do find instances where -- i think we have room for improvement. a new program just launched earlier this year, and i cannot think we are executing it as well as it needs to be. there are discussions going on this week, today with the leaders of those two programs to make sure that we address those issues. i get that feed back from staff and from veterans as well when i am out of a field. >> the main thing is you are addressing that issue. >> yes, ma'am. >> thank you. >> thank you, senator.

>> mr. chairman, thank you. mr. secretary, in your requests for of lot more money one of the things that you mentioned was the facilities and the idea behind that is some of these may improve productivity and hopefully that results in better services to veterans, that sort of thing. you mentioned that there were eight facilities that would be construction projects. how did you pick those? i know of a list of there. if you have a need for a facility, new hospitals, making its way of the list, do you just pick the top eight? if you want to toss it over to philip matkowsky, that is fine, too. >> i am guard to toss this one, if i could, please. >> this is -- we have a backlog

of major construction projects. this is the major construction, not a minor distraction or nonrecurring maintenance. they're is a prioritized ranking system that has rated safety and security as the highest. seismic corrections where we have deficiencies if there were an earthquake the building would crumble, those have to be fixed. there are a number of those. we also have long-standing space shortages. every single one of our facilities as a space shortage in terms of meeting patient need visa not abstract numbers. there is not enough space. the vast majority of the va projects are sinless, louisville , american lake, san francisco, palo alto, west l.a., long beach. for the most part they high prioritized items because of structural deficiency. some to have patient care for additional space >> with this top aide be the

same topic as the list of 20-some projects that are out there waiting to make their way ? >> it is from that list. yes, sir. >> with a match if i took that list and matched it with what you just describe for me? >> if you talking about the 26 or 27 major leases? >> not leases. >> i think you're talking about the historical projects that were ranked. it would match, and it would match against that list for the most part. yes. >> for the most part. what is the most part missing here? >> for the most part, just to give you a direct answer, the ability to complete a project given the size of the required funding it would fit in whereas somewhere else that might only be 20 percent of that project. that is what i mean. >> at the committee hearing in may 1 of the things i talked

about and other members did, too, the expanded use of non va care to deal with the urgent treatment issues. you know, this is not an academic issue. it never was. it very definitely is not today because we know that people died on the va waiting list. we know that throughout the system the list was gained intentionally and dishonestly. to the detriment of veterans. now, there are a lot of ways of handling that. mr. secretary, let me be candid with you. i have sat on this committee now nearly six years. other members of hot water. this committee has been, i think, very, very generous to the va. and i kind of find it remarkable

republicans, democrats, liberals, conservatives, when general shinseki came in and it was kind of like, what do you need, general? and it was almost like we would salute when he said what he needed an out the door he would go with more money. how was the promise of reducing better. >> here is my concern. this sounds so similar to what we have heard over the years, i need more money. i need to be bigger, faster, grander, a bigger bureaucracy, hire more people and on and on and on. i think what you need personally is competition i think if someone were biting at your backside because they were providing better care, faster care, honest waiting lists people would go, holy smokes. if we don't put our act together we will lose out on this.

if we don't see more patients touring the day we will lose out on this. let me ask you, what am i missing here? >> i think -- i do not know what you are missing. and know that millions of veterans turned to va for their health care. as a number of folks have mentioned, an awful lot of veterans continue to believe they get great care, access to care is a challenge for many, particularly for new patients, but they're is a lot of great care being delivered every single day. >> i am out of time. you know, i hear this, but at the end of the day these veterans fight for our freedoms. why don't they have the freedom to make their own choice about their health care? maybe they say, by golly, i love the va. i will stay with the va until the day that i died.

maybe they say, that hospital 20 minutes down the road for i am at is just simply a better situation for me than the hospital that is 250 miles from our am at with a long waiting list. i am totally out of time, and i do not want to impose on the chairman's patients, but i just think that you guys need competition. kaj feel very, very strongly about that. if you cannot clean up your act then, guess what, you lose a help. that is what i think you need. i don't think you need more billions and billions of dollars so thank you. >> thanks you, senator. >> you will have a modest amount of additional time. >> thank you very much, mr. chairman. thank you both for being here. i appreciate it. you know, it is amazing to me. i have been here not just about

six years, but i am looking at a 2003 report, improve health care delivery for our national veterans. are you familiar with this report? if not you should read it when i turn to one page year, part of your point, although enrollment veterans have access said health care they see long waiting times for appointments with health care providers and continue to be problematic for a significant number of veterans as of january 2003. at least 236,000 veterans were on a waiting list six months or more for their first appointment , a clear indication of lack of sufficient capacity or at a minimum a lack of adequate resources to provide required care. this is not new. it is just they did not get the funding years ago, and now we are playing catch-up because you have also had almost

one-and-a-half million net new va patients. we did not do it. i was not here. somehow people missed this report. i do not know. for the record, mr. chairman, it is like somehow suddenly it is all a new problem. it just occurred yesterday. no. it is right here in this report. because they were not funded properly it build up. they knew that patients were added to the list from afghanistan and iraq wars. maybe people missed that. again not know. pretty simple. third page of the report. not complicated. down under a different administration. so i want to put that to the record because the issues you are bringing a par relevant. joy think it is a lot of money? yes. is the money will reserve -- well deserved for our veterans? absolutely. the problem we will have is hiring 10,000 people, i agree,

you have a hiring system that is great. but to get mental health providers and primary-care doctors, every private hospital in this country is behind the curve getting doctors. nurses are backed up. we do not have the capacity to fill it. so i want to make this clear because i think there are a lot of good bumper stickers being talked about today, i get it. but this is a systematic bomb that has been around for a decade or more and yet it is now suddenly and thanks to the fiasco's and others who have come forward and say, look, we have been fighting for this for years. i will tell you -- and i know my chairman gets aggravated -- not aggravated, but he knows i will bring it up all the time. we have talked about this. we saw this problem when i came into office in of nine. we said, what are we doing? we know the private sector. all of us get a doctor. it is hard enough to get our

appointments. at a veterans to the system and got it up more? we looked at our current system of federal tax dollars and how they're being used. health services delivered by tribes in alaska. qualified clinics, federally funded. what do we do? we maximize resources at our fingertips today. what is our wait time in alaska, the northwest region? is one of the lowest in the country because we now have access. as a matter of fact, an anchorage when you use a qualified federal clinic there and/or the south central clinic -- and again, you have to be on the list, up, get through the system and get on the list, for non major medical it is in day care that is pretty significant. that is competition that actually works with the tax dollars we are all paying. we shall let out to the private sector. we do closer to care program, as you know, which uses private

sector, but that does not mean it is the panacea that every veteran will get care overnight. we have to look at the systematic problems. and now you and i talked about this idea and we are doing in alaska. we have some logistic problems, billing problems, scheduling issues and how to make sure that the records are transferred properly between federal agencies and so forth. i know we will figure this out. but doesn't that seem like something we should be expanding and looking at around the country? i mean, federally qualified clinics, the one reason you have certain pay levels for doctors is so you have a controlled cost unit. now, it does mean that we will use private sector resources, as we are in alaska along with federally qualified. >> and our indian health services, otherwise known as we call the new model.

don't you think this is a model that we could go after? i mean, again, i did not mean to get so aggravated about this. it is aggravated when people tell me this is a new-found problem . go ahead. sorry. there is my rant. there was a question there. [laughter] >> i will try to address it, sir very quickly, the model in anchorage, the director -- actually, he was a trailblazer for us establishing a number of trouble agreements with local alaskan tribes, 26 of them now. a phenomenal work that he did. he literally extended the network of community providers into a seamlessly integrated system up there that allowed us to avoid folks having to travel long distances. the norm before used to be folks flying down to washington state, if you recall. so remarkable work by the

director. some of that has actually become sort of a pattern we have used elsewhere in the country with local drives and i ags, signing the agreement to extend health care services. most importantly with the tribes , the dakotas and oklahoma and across the country. we have trouble agreements in place where we can reimburse for care. it is not perfectly seamless, but it is something that has really taken root for us. >> and you do need new rules. >> no, we did not. we have certain authorities entitled 38 that we use. >> you can do that also with federally qualified funding? >> we can under sharing authority and in alaska we are doing that. one just went from private to a federally qualified connected to libertarian sort, alaska because there is no veteran care down there which is a great example of how you can do this with existing rules. let me ask you, having the va you lice -- i sent a letter to

general shinseki on this regarding positions, they use for their medical delivery system and seeing if the va can do the same thing. it is in the bill. in other words, the health care core. you tell me if your regulations allow you -- i know we talked about this briefly. i don't know if you had time to check on that. this is over 5,000 medical professionals sitting there ready to go. >> you're talking about the national health services. >> i'm sorry, national health services. >> we would have to look at credential in an privileging issues that would allow us to grant privileged and share those authorities to tree in our system as well. i would have to take that back and look at it. >> can you do that for me? >> i will. >> the last thing, senator murray talked about reimbursements for doctors in the sense of serving our va

system. i have a bill on mental health providers psychiatric care, a huge gap. have you had a chance to look at that, and if not, can you give us feedback on that at an appropriate time? >> if you would yield to me for a second. >> absolutely. >> the issues being raised are important and has to do with how we not raid other facilities and steel doctors and psychiatrists but develop more. the issues are that you have a house education assistance program which coming a, needs to be reauthorize, and it, the companies to be significantly increased. right now the maximum is only $60,000. that is what you're talking about. >> exactly. it is up to 100,000. you want to try to -- have you had a chance to read the bill and do you support the concept? >> we support the concept. we have to look at the funding

requirements associated with it, but the practice is something that would allow us to recruit and retain highly qualified staff. >> very good. >> mr. chairman, i have other questions i will submit for the record. i appreciate your allowing me to ask questions. it's frustrating when i see a report like this and people think it is a new-found problem, and it has been around for over ten years. we just have to get after it. it is going to take years to change it. >> thank you. you will have additional time as well because he did not make an opening remark. >> what i will do is just submit a opening remarks for the record it that way i will go back to my five minutes and keeping this timely. >> one of the few senators who once less time. >> if i go over please don't cut me off. having said that, thank you very much for holding this hearing, the chairman and ranking member. at risk of irritating you, you know will be talking about statistics.

i certainly appreciate a rescheduling of a hearing on the backlog information. i will talk about that in a minute. i am looking at the latest autistics. i want to thank both of you for being here. but i am looking at the latest average days of completion. i bring this up because reno has the worst va regional office in the country. i have been hitting on this and hitting on this, and i think it is a management problem. and i think the rank-and-file are at fault. i am hoping and have called for changes in that particular office, but the average date to complete a pending crime is about 340 days. have been harping on this for five years. they are making progress. they have reduced it ten days in five years. and you have to imagine, it is

pretty frustrating. i am frustrated for every veteran and a state of nevada that truly needs the help and benefits and health care that they deserve. on top of that we had an inspector general report, 51 percent of the possibility claims that or reviewed were inaccurate. i have to tell you, i appreciate your opening statement, your openness, and i think that is important. transparency is important. senator casey and i have -- tea had similar problems in pennsylvania, our staff worked hard. became up with this claims backlog of working group. i you familiar with the information in this? >> i would tell you i am aware of it. it would be a stretch to say i'm familiar.

>> fortunately i will be able to meet with the nominee tomorrow and get an opportunity for and to also address or take a look at it. i think it is very clear. it does address some of those problems. begin news is there are co-sponsors of this legislation it would go a long way so that in ten years we don't have an improvement and in less than a year we can see, perhaps, a much greater improvement. ..

then have resulted in domains. we had challenges on the procurement side of that as i think your staff has been briefed over the years and right now we are working

as well as why someone would have wound up on a further review list. it's taken us a while to do that and i want to apologize for him out of time. >> i want to make sure we don't miss the follow-up and anticipate that you would bet many can't -- do we have been a timeline? >> the question there as somebody mentioned earlier the

ig said over 70 different locations. do they want to do any additional review? they have created teams to go into all of those where the ig isn't in those are scheduled to be completed by think by mid-august is the completion time but in the meantime we are going to provide briefings on what the findings were. >> thank you very much. i'm going to be in reynaud in august. i have to go out there and speak. we will get you the dates. the dates when i'm going to be here and i will visit. >> thank you very much. >> lastly we appreciate the opportunity to provide technical input on the leasing issue. i think we furnish some of that information to the staff mr. chairman that would help us be very helpful to us to be able to move forward. >> thank you. senator blumenthal you have eight minutes minutes and there will minutes and there will be

uploaded as i understand it is 12:20. >> thank you very much mr. chairman. i really proceed you're holding this hearing and your leadership along with ranking member her and thank you mr. gibson -- mr. gibson and mr. matkovsky for your service to our nation. i think you folks are in a typical if not impossible position because you are temporarily before us without the head of an agency and my hope is that there will soon be a secretary of the va but right now in effect there is an empty desk where the buck should stop and i think that situation has to be remedied as soon as possible and that's on us, not on you. leadership has to include an overhaul top to bottom of the people who run the agency. very simply my view is that there has to be accountability

for what's been done in the past but also a change in leadership which you are commendably seeking as well top to bottom. my experience over the last few months has been that their failure of the accurate and some of what it is saying to the public is actually aggravating its credibility and trust problems. senator burr raised one incident earlier with the press release that he mentioned. i have found that there simply have been no answers to some of the questions that i have posed in letters to the agency. letters asking for site-specific information about the audits that were performed. the va officials locally and the audits seem to confirm that there have been no problems in

connection with these delays and destruction of documents and manipulation of waiting lists and yet we found a recent pattern released by the va that in fact wait times have increased over the may to july waiting times have tripled. what's the meaning of that data? i ask not only for the site-specific information from the audit that was performed as a result of general shinseki's order but also an explanation of those wait times and i have yet to receive responses from agencies that are really complete and satisfactory in writing to the questions that i have posed. now i understand you have a lot going on but i would suggest

that kind of responsiveness and providing information is part of the mission that's all the more important work. it has always existed. i would like a commitment from you that the agency will respond to my inquiries in writing as soon as you are able to do so and that you will respond in the future to the increase that i pose. >> two quick comments comments. first of all the answers we absolutely will. it might even be more effective for us to arrange a briefing. also as philip mentioned a second ago briefing material around the audits is being provided. the opportunity and there are other comments that we have been pushing information out the door as fast as hard as we can over

the last six weeks. that openness and transparency into your very point is an essential part of earning back trust. the last thing i told the president of the united states when he tapped me to be the acting secretary. if anybody is saying any behavior out of me that look like i was serving as a caretaker please let me know what it was so that i can try to explain what made you were looking at. >> i welcome that comment comments and i 2 it and support it. can you tell us anything about the ongoing inquiry internally, what its status as and when you are expected to be completed and second about the department of justice investigation? i called for a criminal investigation by the department of justice with great reluctance and regret but i do think that the criminal responsibility has to be applied if there was

obstruction of justice, destruction of documents, fraud and reporting because those crimes even with an agency as important as the va or perhaps especially because of its very important issue has to be implemented where necessary. >> as i mentioned earlier to the fact that the ig has reviews underway at 70 some locations across the organization. i should explain here before the ig goes into in a location to do any kind of review for any purpose they informed the fbi. at any point during the course of their review in wrongdoing does routinely get referred to the department of justice. in fact there is a criminal investigation division of va's ig. so routinely there are criminal investigations to be undertaken

and completed and prosecutions that occur as a result of ig investigation so it's a routine matter. i would tell you of the 70 some odd locations that the ig has been reviewing at the end of june i got the first set of reports on the first location and so we have been working more than a thousand pages of transcripts of sworn testimony. it turned out that we actually needed some additional information so we dispatched it, an official fact-finding group to go to that particular location. we have reviewed hundreds if not thousands of e-mail traffic and i expect by the end of this week to have proposed personnel actions on my desk for a number of individuals and that one particular location. there is nobody wants to see this process move faster -- move forward faster than i do. it is painstaking and i would

say the other general category here of issues have to do with the referrals coming from the office of special counsel. i've met directly with carol lin lerner. we are expecting a substantial number of those to come to us very quickly and we have agreed on some expedited processes that we will work through to ensure that the whistleblowers are properly protected and then to launch the appropriate personnel actions in the wake of that. >> my time is about to expire so i apologize, i'm not going to have more questions in this setting. i would like to follow-up on the department of justice investigation. i know you can't really comment in this setting about it and most important about protection for whistleblowers, i think one of the unexplored areas here has been the potential for retaliation. i would like to know for them in the course of a future briefing what has been done to protect

them but just one last comment. there is nothing routine about what happened here. you said that routinely the fbi is involved. there's nothing routine about what happened here and the fbi should be fully engaged and the department of justice. >> senator boozman you also have additional time. >> thank you senators and ranking member burr for having this important meeting. i want to thank you all for being here. i know that you are working very hard to try and resolve these things rate i also want to commend you mr. gibson for getting out to the places that are really struggling and also the places that are doing well, trying to figure out best practices and again why others are struggling so much. it's important in the situation and bring him on as adviser i think i was a very good move.

in regard to your request as far as additional personnel and things like that, is that based on current practice or is that based on reforms in the future that have significantly change things? both of you. >> sir the methodology we use is largely framed in the current context. senator boozman will be looked at is looking at the current volume and looking at our current delays of care forecasting through the years and trying to attenuate them year-on-year. so it's not a subsequent reform. it's in our current context. >> i had the opportunity to serve with tom a great coach from nebraska and people used to talk to him about when and he said we would never talk about win. what we talked about was doing little things and one of the little things that has to be done and i'm a little bit concerned because you said it would take two years probably

and va that's probably more like four or five. that's one of the little things that if you don't get that done tomorrow my understanding is that you don't call people the day before and tell them they have an appointment. you can catch a no-show right significantly just by doing that and then taking somebody that's on a backlog and sticking them into those slots. that's just common sense practice. it's done through the country with anybody in the private sector. so you have to get this under control and there's no reason not to do that in a rampant situation particularly targeting the areas that are having problems. your facilities that are doing okay right now by whatever standards you are measuring but it does seem like you would put that into place right away. >> you may have missed the comments earlier. they were actually four different major initiatives underway. one has to do with fixing

existing issues. there are 11 of those fixes that are in the process right now. there are four separate applications under development to make it easier for schedules -- schedulers to interface with the system as well is to give veterans the ability to directly request schedules. there is a contract that is argument led that will make major modifications to existing schedule on the 11th of july. we expect that to bear fruit in the may through august time period of next year to do with some of the toughest, some of the most difficult issues associated with the existing schedule. all of that is unparalleled while we are working to acquire a commercial author. >> is very good over-the-counter system right now in place that major medical centers are using without any problem at all? >> that's the basis of medical practice. >> can i answer this one? i would agree with you sir.

i think you have two comments. one of them is the underlying system and i think there was a reference made to a prior system effort. i don't think we are looking to go build something from scratch this time. >> no, i would hope not. that's something that people have been doing for years and i'm an optometrist by training and again that is the basis of your practice, your schedule. you mentioned that one assistant specialist and i would write down the pa system and i think he said to in-app for whatever. that might even be a little bit low but what is -- what i would like to know is what is the relationship if you take a major va medical center and a look at total staffing, you look at the staffing that it takes to support that medical center. what is the comparison with a major private entity as far as numbers?

>> i don't have the exact percentages but if you look at the overhead rate at the va or the indirect rate in the va for support staff is considerably lower in each one of our major areas are merrily and specialty medical health. >> as far as the total numbers, i'm talking about administration the whole bit. >> i'm looking at the fuel cost not looking at everything else for blended overhead rate. i think we could come up with something that would look at a blended regency where the charges come in but in terms of what we have in our facilities, the labor share is lower in the va or support than it is private. >> not as dollars by people. >> in terms of people it's lower in the va benefits in the private sector. what you may be asking as well would be could reconstruct a blended rate that looked at the overall cost factors? we could. we have not done that. >> i would like to see that. the other thing is that right

now if you go to your medicare doctor and the view our veteran and you get -- you have a physical and the medicare doctor decides that you need high blood pressure medicine and in then you go to the va. instead of filling a prescription which is a pretty good deal for the veteran, they have to have a physical in order for that to be done. why is back? is there any logical reason for that at all? how many slots with that free up if you made that one change? how much money would that save? >> i'm not a clinician so i cannot and i learned way described by that's the case that there are certain reasons why that would be appropriate and why that does make sense that i will tell you that we are looking late things to audiology and where that could be bypassed the primary care step as an

additional item billing to look at that carefully. i think folks are looking at that now. audiology optometry ophthalmology and maybe some pharmacy. not all pharmacy, we need to be careful that we are looking at that. >> i can see the scheduled drugs and things like that the to make it neck's no sense at all that the guy that is license and taking medicare dollars another entity that is licensed by the government, why a prescription can be filled for diabetes, high blood pressure? the vast majority of stuff that comes across. could you look and see? >> we will look at that but just one point would be not to overcorrect in that direction. we do have folks looking at the pattern between primary care and the pattern between primary and pharmacy. >> would the main overcorrect?

>> to not be vigilant for pharmacy fill requests coming from the private sector. that's the only thing that i mean. just to make sure we are determining the appropriateness of prescriptions filled. the descriptions you have givens seem pretty straightforward. >> there's a large percentage of veterans served by both va and medicare and so part of this is understanding what the second and third order effects are of the change you are talking about. clearly one of the impacts would a primary care slot you've got it. >> it would decrease the backlog. >> pardon? >> it probably would decrease the backlog if you have primaries. thank you. >> we have reached the end of what i think has been an

important and productive heari hearing. mr. acting secretary i want to thank you very much for stepping in clearly unexpectedly and for your very important position. thank you very much for the work you are doing and mr. matkovsky thank you for your doing and we look forward to working within a days, weeks or months to come. thank you very much. the hearing is adjourned.er: mr?

the presiding officer: the senator from new york. mr. schumer: mr. president, i rise today to discuss the protect women's health care from corporate interference act of 2004 introduced by my friends and colleagues, senator murray and senator udall. i'm proud to be a cosponsor of this legislation. we are at a critical moment. we witnessed a supreme court decision that curtailed important access to health care for employees across the country. the hobby lobby case has now opened the door for the vast majority of companies and bosses to start denying their employees contraceptive coverage if the owners have a religious

objection. we must slam the door shut. to do that, mr. president, this body must set the record straight about the law that the supreme court used to make their decision. the religious freedom restoration act. as one of the original authors of the religious freedom restoration act -- i was the sponsor, the lead sponsor in the house of representatives. senator kennedy was the lead sponsor in the senate. i can say with absolutely certainty that the law has been unwisely stretched by the supreme court to extend religious protections to corporations congress never intended to be covered under the bill. i am compelled to do so, mr. president, because several of my colleagues on the other side have come to the floor to defend the hobby lobby decision using my words. these were arguments i made back in 1993 when we passed, first passed the rfra and we were dealing with the protection of

individual -- underline individual -- liberties. the quotation they used dealt broadly with the importance of religious freedom of expression in our country. i said the rfra would help restore the american tradition of allowing maximum religious freedom. that is as true today as it was then. i believe strongly in rfra as it was written then as i do now. but it was misinterpreted and wrongly expanded by the supreme court. when my colleagues use this quotation as a point of argument, they completely miss the point of the debate. the debate is not about the conflict between freedom of religious expression and government mandated health coverage. that's a false choice. the debate is really whether or not the supreme court appropriately interpreted the rfra in applying it to profit-making corporations. as the author of the bill, i can say again with absolute certainty, the supreme court got the hobby lobby case dead wrong.

when we wrote rfra back in 1993, we did so to protect that which individuals with strong beliefs had always enjoyed. the presumption that they should be able to exercise their religious beliefs without interference from the government. but the court took that protection and misapplied it to for-profit companies who exist for the purpose of benefiting from the open market. the hobby lobby decision marks a sharp departure both from the intent of rfra and prior judicial interpretations of rfra. the supreme court got it wrong. that is why this bill authored by my colleagues from washington and colorado is of paramount importance to clarify the law and restore protections for employees that were stripped away by this wrongheaded supreme court decision. my colleagues on the other side of the aisle will continue to assert this is just another

assault by democrats on free exercise of religion or peddle other falsehoods. so, mr. president, i'd like to clearly explain what this bill will and won't do. this bill will ensure that companies cannot deny their workers any health benefits including birth control as required to be covered by federal law. this bill will make it clear that bosses cannot discriminate against their female workers, ensuring equal treatment under the law for tens of thousands of workers whose coverage hangs in the balance. this bill is not only about birth control. the hobby lobby decision has implications for other health services, and now this bill will ensure all covered employees have access to all necessary health care. not only contraceptives, but also blood transfusions, antidepressants, vaccines. the bill does not require churches or nonprofit organizations to provide contraceptive coverage even when they object on religious grounds. the affordable care exemption --

process for nonprofit organizations with a religious mission is unchanged by this bill. this bill will not allow new laws that can target specific religious groups. the bill only applies to health care. and most importantly, this bill does not -- does not -- restrict the constitution's first amendment right to the free exercise of religion. the bill only clarifies the relative weight the court should give when two federal statutes such as the affordable care act and the religious freedom restoration act come into conflict. as i continue to say, rfra was intended to give individuals -- individuals who profess strong religious beliefs what they had always enjoyed, the strong presumption that they should be able to exercise their religious beliefs without government interference. rfra was not intended to extend the same protection to for-profit corporations whose

very purpose is to profit from the open market. the supreme court's cavalier decision to grant religious rights to closely held corporations could curtail the health care freedom of women at as many as 90% of american businesses. by putting health care decisions in the hands of a woman's boss instead of a woman and her doctor, the division creates a slippery slope that could affect tens of millions of americans, our daughters, our wives, in the future. we need this bill to clarify the law and firmly protect a woman's right to access essential health care. and i thank my colleagues udall and murray for offering this legislation. i urge my colleagues to support this effort to protect women's health care and religious freedom. thank you, mr. president. and i yield the floor.

a senator: mr. president? the presiding officer: the senator from texas. mr. cruz: mr. president, i rise today to speak about one of the saddest developments in the united states senate, namely, the all-out assault on the first amendment being led by senate democrats. it's important to clarify what the issue before this body is not about. the issue before this body is not about access to contraceptives despite a whole

lot of politicking by senate democrats to suggest to the contrary. in this body, the number of people who would do anything to restrict access to contraceptives to anybody is zero. let me repeat that. there is no one in this body, there is no one i am aware of across the country who is advocating restricting anyone's access to contraceptives. mr. president, my wife and i are blessed with two little girls. i'm very glad we don't have 17. nobody, nobody, nobody is talking about restricting access to contraceptives. what are we talking about? what we are talking about is the federal government using brute force to force people to pay for abortion-inducing drugs of others against their religious faith. that's extraordinary. it is remarkable and it is dismaying. mr. president,

i'm sorry to show you what the current first amendment looks like in the wake of the democrats' assault on the first amendment. the senate judiciary committee, we have been debating an amendment some 47 democrats have supported that would repeal the free speech protections of the first amendment. sadly, every senate democrat in the judiciary committee supported it. today this body is considering another provision that would effectively cross out the free exercise rights. where have we entered when the bill of rights has become a partisan matter? what kind of world is it used to be the case that you would find bipartisan agreement that the first amendment is part of our civil compact, that we will stand together with one voice in support of the free speech rights of individual citizens, in support of the religious liberty rights of individual citizens. the proposal that we are going

to vote on in just a few minutes would go directly after the religious liberty rights of americans. let me tell you a little bit about one group of people who will be affected by this bill if this bill were to pass. let me tell you about the little sisters of the poor, a group of catholic nuns, the little sisters of the poor are an international congregation of roman catholic women founded in 1839 by st. jane judin. their aim is to offer the needy of every race and religion a home where they will be welcomed as christ, cared for as family, and accompanied with dignity until god calls them himself. mr. president, the bill that is being voted on on this floor would shut these nuns down. the bill that is being voted on

on this floor, if it were adopted, would fine the little sisters of the poor millions of dollars unless these catholic nuns are willing to pay for abortion-producing drugs for others. mr. president, when did the democratic party declare war on the catholic church? and let me note, this is not hypothetical. i'm not suggesting in theory this might be applied to the little sisters of the poor. right now, today, the obama administration is litigating against the little sisters of the poor, trying to force them to pay for abortion-producing drugs and threatening to shut the little sisters of the poor down. how far have we come from the basic bipartisan agreement in favor of religious liberty?

faith finds -- faith fines should have no place in american society. the little sisters of denver which provides approximately 67 full-time jobs has said that it will incur penalties of roughly $6,700 per day or nearly $2.5 million per year if it chooses to stay true to its religious beliefs. $2.5 million a year in faith fines, fines to catholic nuns who are devoting their time to caring for the elderly and providing health care for the elderly. that is more than one-third of their $6 million annual budget each year. what has become of the democratic party? when did they become so extreme that they would actually propose fining nuns millions of dollars if they're unwilling to pay for

abortion-producing drugs of others? that is not a mainstream position. that is a radical, that is an extreme position. i would encourage every one of my colleagues on the democratic side of the aisle to ask yourself how are you going to answer your constituents when your constituent stands up and says senator, why did you vote in favor of a law that would fine catholic nuns millions of dollars if they refuse to pay for abortion-producing drugs of others? let me make a basic suggestion. if you're litigating against nuns, you have probably done something wrong, and the obama administration is doing so right now. mr. president, drop your faith fines. mr. majority leader, drop your faith fines. to all of my democratic colleagues, drop your faith fines. get back to the shared values that stitch all of us together

as americans. i call upon my democratic colleagues to stop playing election year politics. i recognize scaring women by suggesting someone's coming after your birth control may be good politics. it's false. even "the washington post" has said it's false and a lie. but election year politics should not trump religious liberty. senate democrats should not wage war on the catholic church. it's not just the nuns who are dismayed. the catholic bishops have said the proposed bill -- quote -- "does not befit a nation to manage religious liberty and would allow the government to -- quote -- override religious freedom rights of americans regarding health coverage. so it's not just the nuns. it's the catholic bishops. the democratic party said your free exercise of religion rights have no place in a democratic senate. the catholic bishops went on to say -- quote -- "if in the

future the executive branch chose to add the abortion pill rudd -- ru-486 or even elective surgical abortion including late-term abortion to the list of coverages, those who object to providing such coverage would appear to have no recourse. mr. president, think about that for a second. the catholic bishops just said the bill this body is getting ready to vote on, if passed would enable the federal government to try to force catholic nuns to pay for and carry out partial-birth abortion. that's staggering. you want to talk about mainstream positions. there are mainstream positions, there are far left positions and there is extreme radical fringe which is the federal government forcing catholic nuns to pay for partial-birth abortions. and that's where virtually every senate democrat is today. under the legislation before

this body, the catholic university ave maria would be forced to make the same choice -- authorize abortion-inducing drugs right now or pay millions of dollars in fines to the united states government. as ave maria president jim tooey has said -- quote -- "ave maria pays 95% of the health plans we offer our employees. under the federal plan, ave maria would be paying for these drugs if we comply with the law, so we will not. mr. president, every senate democrat who votes yes in a few minutes will be voting to fine ave maria catholic university millions of dollars simply for standing true to their faith. that's a vote that should embarrass any member of this body. mr. tooey went on to say -- quote -- "we are prepared to discontinue our health plan and pay the $2,000 per employee per-year fine rather than comply with an unjust, immoral mandate in violation of our rights of

conscious. belmont abbey college, another proud religious school, founded by benedictine monks. the democrats have put them in the same predicament. the democrats' legislation would force belmont abbey college to pay $20,000 a day in faith fines. mr. president, faith fines have no place in our democracy. let me ask again why are democrats so hostile to the catholic church? why are democrats trying to use the federal government to fine catholic institutions for holding true to their religious beliefs? it all comes down to a hardline extreme out of touch position on borg. just yesterday, we had a hearing in the senate judiciary committee about legislation so broad that it would set aside state laws providing parental notification for abortion, protecting late-term abortions, mandating taxpayer-funded abortions. these are extreme radical views

held by a tiny percentage of the american people, but yet held by a large percentage of democratic activists. and this position would also rip apart the bipartisan legislation that president clinton signed into law in 1993, the religious freedom restoration act passed the senate 97-3. when president clinton signed that act, he said -- quote -- " what rfra basically says is that the government should be held to a very high level of proof before it interferes with someone's freedom of religion. this judgment is shared by the people of the united states as well as by the congress. we believe strongly that we can never, we can never be too vigilant in this work." mr. president, we should listen to the words of bill clinton in 1993, and the senate should back away from this assault on religious liberty. i want to finally note two simple things. in 1997, when the senate considered another assault on

the free speech protections of the first amendment, then-senator ted kennedy, liberal lion of the senate, stood up and said we haven't changed the bill of rights in over 200 years and now is no time to start. senator ted kennedy was right in 1997. likewise, president john f. kennedy, in an historic speech to the nation, said -- quote -- "i would not look with favor upon a president working to subvert the first amendment's guarantees of religious liberty." mr. president, where are the kennedys today? does any democrat have the courage to stand up and speak for the first amendment today? does any democrat have the courage to stand up and speak for the constitutional rights of practicing catholics? does any democrat have the courage to stand up and speak for the little sisters of the poor? does any democrats have the courage to listen to the catholic conference of bishops?

and speak for religious liberty? mr. president, it saddens me that there are not 100 senators here unified, regardless of our faith we stand together protecting the religious liberty rights of everyone. faith fines have no business in our democracy, and, mr. president, i urge every member of this body to vote no on this assault on basic religious liberty of every two-r

hearing.s liberty of every two-r the chairman is congressman paul ryan. >> the committee will come to order. to make sure that every witness knows that it's against the law to provide false testimony every committee swearing in our witnesses. please note that this does not reflect on a distrust we have for any witness and particularly

we are taking this step because of the legal recent guidance we have had from the department of justice. please just raise your right hand. do you solemnly swear or from the testimony you're about to give a pitcher the whole truth and nothing but the trip? >> yes, i do. >> let me -- but it reflected the witness affirmed to me -- we are going to discuss cbs long-term budget outlook suffers i want to thank director, darfur and their team for their hard work. this is a very important piece of work to see the odessa mayor pleased to receive it again. i have to say your report is sobering. just take the first line. quote between 2,002,000 of the federal federal government recorded the largest deficit relative to the size of the economy since 1946 causing debt to soar" math. later it says quote with deficits as big as the one cbo projects federal debt will be

growing faster than gdp at path that will be ultimately unsustainable" math. that pretty much says it right there. it's unsustainable. the national debt is already bigger than our economy. yet it's going to get even larger air economy is going to get weaker. people already can't find work and yet there will be even less opportunity. the average numbers of hours worked is shrinking. we know what the problem is. spending keeps growing. our economy can't keep up. that debt is weighing down working families in over the next 20 years were spending will grow by 27%. i would like to point something out. we'll be taking plan the attacks is frankly a lot more taxes and an even greater share than the historical average but still that's not going to be enough. we will still be spending more than we take in, a lot more. the reason that spending is going so fast is that our safety net is broken.

medicare and social security are going broke. cbo says social security's unfunded liability now stands at 25% higher than before. if we do nothing we could have a debt crisis. and if we did the most vulnerable are the ones who will be hurt the first in the worst. i understand some of my colleagues might not be all concerning other government spending more money and the soaring debt. we heard lots of factualization's but here's what you -- you can turn everybody. if we spend all of our money on entitlements we will have no money left for anything else. if we do nothing spending on social security are major health care programs and just the interest payments will take up almost all of the budget. total spending and everything else will fall to 7% of the economy by 2039. that would be a smaller share of our economy since the 1930s. here is another serious concern. cbo warns that our growing national debt that compromised

our national security. admiral mullen said the same thing a few years ago. if we don't take action now we will have less to spend on our national defense and we will be less prepared for future challenges. so the answer is very simple. repair our safety net, wasteful spending, prepare for the future. don't raise taxes. the way i see it we shouldn't force families to pay more for washington's problems. we should make hard-working taxpayers pay more for washington's mistakes and procrastination. hard-working taxpayers deserve more than that. we need to expand opportunity or everyone in this country and we can start by getting the budget under control. that's how we can make the federal government more accountable and more effective. i'm pleased this hearing -- i was going to filibuster a while longer but i will yield to the ranking member for his opening

remarks. >> i thank you mr. chairman and i want thank dr. amend our for appearing before this committee and for all the work you and your colleagues do at the congressional budget office. before we discuss long-term budget outlook i do think it's important to note the progress we have made so far on the deficit because in recent years congress has acted to reduce projected deficits by over $3 trillion which was more than three-quarters of those deficit reductions coming from spending cuts. in addition actual deficits, not just projected deficits but actual deficits have fallen dramatically from 1.4 chilean dollars in fiscal year 2002 less than $600 billion today and are expected to continue shrinking as a share of the economy in the near future. as the congressional budget office's long-term report makes clear the deficit will begin growing again in the long term and the question mr. chairman has never been whether we need to reduce long-term deficits.

the question has always been how we do it. as i look at the choices in this report it's clear the only rational way to tackle the long-term deficit is through the balanced approach that president obama and congressional democrats have been proposing for years, combination of cuts but also cuts to special-interest tax breaks and other tax expenditures. unfortunately we do not have a partner when it comes to closing tax breaks and loopholes for the purpose of reducing the deficit. our republican colleagues continue to refuse to close a single tax break including those that encourage american companies to move jobs and capital overseas in order to help reduce the deficit. in fact this year the house has already passed more than $500 billion in unpaid for tax cuts with three under billion dollars more awaiting floor action. i don't think we have seen such

an increase in the deficit in the space of 30 days in many decades. they have not paid for a single penny of those permanent tax cuts, meaning that other americans are going to have to shoulder the load in the future and by the way mr. chairman it violates the republicans on budget resolution. so, even our republican colleagues unwillingness to take a balanced approach to reduce the long-term deficit we have got to do what we can and we should all be focused on trying to grow jobs now and have jobs that pay living wages. we have made some progress on this issue. 288,000 jobs were added to the economy in june and we have seen 52 consecutive months of private-sector job growth totaling 9.7 million new jobs. we have got to do more. that is why we have to invest more in national infrastructure. we need to do a permanent fix to it.

as mr. blumenauer and others have discussed rather than a short-term mandate band-aid approach that does not allow for long-term investments and decisions, we have to push have to push the minimum wage. it's a scandal that you can work 40 hours a week all year long and still have to raise a family in poverty in this country and we should pass comprehensive immigration farmers the congressional budget office has indicated will reduce our long-term deficits and boost economic growth. so we need to deal with a short-term crisis. part of the reason we are seeing a short-term crisis is the failure and an ability of this congress to pass comprehensive immigration reform. i would note for our colleagues that we have seen some important good news. cbo has projected federal health care spending in the year 2039 has actually fallen by nearly one fourth over the last five years from 10.5% of gdp and

cbo's 2001 projection to 8% of gdp in the estimates before us today. so this is not a time to reverse course on the important gains we have made in health care policy including reducing per-capita health care costs. adjusting conclusion we should be working together to reduce the deficit. enough governing by crisis, a enough of threats that we will default on our national debt obligations, enough on government shutdowns but now let's focus on some really long-term solutions that not only boost jobs but make sure those jobs provide families with a wage that can support them and allow people to have a lifestyle that allows them to meet the american dream that are so important to everybody. i look forward to your testimony mr. elmendorf and thank you mr. chairman. >> dr. elmendorf. >> thank you chairman ryan and

ranking member van hollen. we are happy to be back today to talk about the outlook on the budget long-term. the federal budget deficit is shrinking as your to its smallest size since 2007 roughly $500 billion in our estimate. federal spending will equal about 20.5% of gdp which is quite close to its average over the past four years. federal revenues will equal about 17.5% of gdp which is quite close to their historical average. as a result the deficit will also be close to its 40 year average of 3% of gdp. however if current law governs taxes and spending stayed the same deficits will become notably larger after several years. debt held by the public would start to raise the debt more rapidly than gdp and because such debt is now larger relative to gdp than any point in u.s.

history except for a brief period around world war ii further increases in the long-term could be especially harmful. 25 years from now and 2039 the federal debt held by the public would exceed 100% of gdp we project. the upward path of debt relative to the size of the economy could not be sustained indefinitely. for this report we extrapolated our 10 year baseline projections through 25 years years and with even greater uncertainty through later decades. that extended baseline shows federal spending rising in the current 20.5% of gdp to 26% in 2039. that increase would occur because under current law federal spending for social security and the governments of major health care programs medicare, medicaid and children's health insurance program and subsidies in insurance chain exchanges under the affordable care could rise sharply. we project the spending would

represent 14% of gdp by 2039, twice the 7% average seen in the past four years. because of a combination of the aging of the population, growth in per-capita spending on health care and expansion of federal health care programs. the government's net interest payments would also be larger relative to gdp than their past average primarily because of the debt. in sharp contrast under current law spending for all other federal benefits and services would be on track to make up a smaller percentage of gdp and by 2024 than at any point did more than 70 years. plus the increase in federal spending relative to the size of the economy would occur not because of general growth and the size of the general government but because of growth in just a few of the largest programs. federal revenues would also increase relative to gdp under current law but more slowly than federal spending.

by 2039 revenues will equal 19.5% of gdp we project compared with 17.5% today. that increase would reflect a gradual shift of income at the higher tax brackets as income gains outpace inflation as well as the effects of expiring and new tax provision and other factors. ..

>> let me start with health care, the report suggested that in order to address this

medicare part b trust fund, you would have to either increase this from 2.9% to 3.7% or cut medicare spending by about one fifth immediately and permanently in order to bring it back into balance for the next 25 years. >> that's right. >> those would be very large changes. and as you know, the growth of medicare and other health care programs is the key driver and source of upward pressure on federal debt. the we talk about the unsustainability for the budget as a whole. until big changes are needed in some of these very large programs or in taxes will have to go out. and so we basically had this 5050 split between health care spending and i think in 2012, 53% of total spending came from private sources and 47% came from public sources. so the report shows that

spending is supposed to go from 60% of gdp to 22% of gdp at the long-term window. do you expect the current split to stay as it is? and what do you suggest? >> and our production, we have not quantified that enable grell most importantly because of the aging of the population and because there's more people over age 65 is old. but you don't, you don't project where the split comes down to that we have not done that. >> i think i would be helpful. >> okay, let's go to social security. this report come up all the things that i am a little bit concerned about, it's the new projections on social security. lasser you talk about unfunded liability being 3.5% of payroll, and the year before that it was 1.58% of payroll. this series saves 4% of payroll.

that means that the unfunded liability has grown by over 150% over just the last years and so for someone who is 55 years old today, can they expect to see their benefits cut in 2030 when the trust fund goes bankrupt we met. >> yes, you're right, mr. chairman. the estimate of unfunded liability for security has increased over the past two years and we've taken on new information about what will happen to disability rates and many other factors. if nothing else were done, when the trust fund ran out of money, payments that would equal revenues coming in and out of be cut at about one quarter of the benefit across our borders. and we have not done that and as you know, we are producing a more detailed long-term projection that will include that number. >> have you done the number?

because there a lot of the proposals that we have had that extend to current beneficiaries. so you exempt his current beneficiaries, will but that means to the future beneficiaries and what would that be? >> we haven't tapped into that either, but it wouldn't change that much. the new beneficiaries of the maybe 5%. so you have to have this core cut in total benefit payments and if you get nothing and you'd still need to cut the benefits to be part of the beneficiaries. after a number of years they would be coming on. >> longevity growing if it is, the pool of people is a lot smaller than the existing pool. >> yes. >> and you can satisfy if you get past that date.

and you still need to cut the benefits. >> that is amazing. it's very interesting. and your interest rates, it goes down about 50 basis points and i'm curious to the rationale that you say it will be about 2.5% but i think lasser you said about 3% and i'm curious what is behind that projection and what if we do some simulations with this. what if they go back and what would it be be done if we go to the historic average and that goes back to question number one, which is why the downward basis points. >> we did a comprehensive re-examination of the interest rate projection on this a lot of discio