the other thing was that they took all of their resources and put them into initial claims. and i focused on the decision review officer as a key point, person on these regional offices. they've taken them out of their regular job to the detriment of

the appeals process because now they're not doing the certifications that are necessary to take a veterans appeal from the regional office to the board of veterans appeals and there in limbo oftentimes for many years now which is short-circuiting whole situation. more importantly what's concerning to me at least talking to our service reps in the field is it's like the va is considering as the enemy. many regional offices are people are not allowed to talk to anybody. you have an to anybody. you're issuing acclaimed its comeback, you can talk to anybody. you just have to take it deal with it, today. i retired in 2002 until i got this job in 2005. i worked three years as a service rep in manhattan and the regional office. if i had an issue on a claim that came back to me i could bring it to the reader nevermind the decision review officer, to go over if i saw an obvious error. can't do that anymore.

plus they want to great super regional offices to take it even further away from the regional offices and the case further away from us who work in the field. so we don't get to see anybody i can talk to anybody. it's like we are the enemy. instead of working with us we are working against us. i really think what's going on right now is criminal. this whole idea that a veterans claim doesn't go anywhere and is not counted as a bad mark on the regional office and is not counted in the board of veterans appeals queue and get consistent for years. we know once he gets to be a it still takes three to five years to adjudicate because upon a time and time again and i'll point out one more time we went 70% of the time. that means that better late anywhere from three to five to seven years plus the regional office basically screwed up. and didn't do the right thing

the first time. that's unconscionable. and i think this issue that's going on because of leadership is just frankly criminal. somebody sitting on something that should taken 10 minutes to fill out and wait years and years to get it done and frankly, i've been trying to get a letter out of my operation to go to the undersecretary on this whole issue. because, frankly, we don't situation in puerto rico that was just obscene if they don't resolve this, somebodies had better roll. >> thank you for the very eloquent comment. >> is still a problem the problem. we have to put this in context. the va has dropped the backlog but they drove the car into the ditch. they drove in the ditch in order to be congratulated for partially pulling out. we still see hundreds of thousands of folks who are facing an additional system everything java properly addressed that. i would encourage everyone

watching and listening to go to the way we carry.org, website we create that allows veterans to show up on they have been waiting. you can go by state region individual stories and see how long they have been waiting so we can look at and to predict the next phoenix and prevent the next phoenix but also the key issue encourage this committee to address, we know they're working on it. what the veterans to in the meantime? that's the problem that continues to plague our community. you have financial and emotional stress where they go for help in the meantime? they can give us. we are overwhelmed with demand and other nonprofits feel the same way. i would encourage you to think creatively about how to provide support, especially financial and emotional support to those folks stuck waiting sometimes for years. >> i have one more thanks to mr. kovach and others who have mentioned the issue of expanding

access and choice to make veterans eligible in a local va facility cannot provide the service that is needed. when we measure surface, it ought to be for the medical care that the veteran needs, not simply whether there is a facility there to provide it. i'm assuming that other members of this panel are in agreement as well with that view. thank you all. >> thank you senator blumenthal. i now recognize dr. abraham for five minutes. >> i too am honored to they foster opportunity with me today. she is from louisiana and we -- going into a premed curriculum and hopefully do very well. maria, will would you stand up, please? [applause] certainly just a quick remembrance that everybody in

the room with memorial day coming up, the surviving family members of our fallen heroes. we know they still continue to carry the water and extreme burden, such as heartfelt thanks for that. mr. o'rourke and i were in a meeting this morning with secretary mcdonald and undersecretary sloan, and a whole cadre of these people that helped make these decisions that we and you have talked about today. i think it was you mr. rieckhoff, but said they don't think also have their heart in the right place. we have to be in the position, i'll use a poor term but we have to lancet before the healing start. hopefully we are in the process now of exposing the bad things. you guys know better than anybody else because you lived the life. these things of an under the radar for years and years and they're just coming to surface

and that's a good thing that we are getting them out in the open and hopefully we can fix it. mr. kovach, going back to you. i was a cosponsor of a bill that was just dropped, apprenticeship on the g.i. bill to allow some of these funds to be used in a non-collegiate funding area. i think it's a great idea and certainly it will help. the question i have come anybody on the panel, the thing that senator blumenthal just over two of the backlog of disability claims, give me one or two specific things we need to do i understand how bad it is. i'm the chair of the subcommittee of disability assistance so we see those figures and we want to fix it. we want to fix it efficiently as quickly as we can but help us out here. mr. rowan, i know you were

saying as far as the officers had no longer address these claims, but give us some specifics we can get back to our committees and start. yes, sir. >> i would add one simple change that could be done right now on the board of veterans appeals is a well of veterans appeals attorneys when they make a ruling, naked precedential. so that when somebody decide something it's now become law. any of the cases consumer to that should be adjudicated along those lines. this is really kind of legal structure without does not occur. and so we can be the attorneys remix each other making totally different rulings on the same type of case. that's number one. the other thing is figured out how to really review the whole system. it just doesn't make sense to the other thing i think is get us back access at the regional offices. stop having our claims sent

everywhere except where we are. i have a regional, one of my people is work in the buffalo regional office in new york. she services about a dozen counties in western new york. she can talk to anybody know. it's like they have said that this wall between her and all the people in the regional office on their claims. it's crazy. it would just resolve some issues if we actually had a decision review officer who could make a decision, and we don't. >> colonel? >> thank you. just two things to add briefly. one is we believe that the new bill recently introduced by senator heller and senator casey has some practical low-cost process improvement measures on the claims systems, so we commend that to your attention. the second idea is that we have been in many other groups at the tip of in working with the dav

and basically reengineering the appealed claims process to make it more efficient to speed it up basically about the veteran the option of bypassing certain steps in order for the claim to move more quickly through the system on appeal. but retain with the veteran he option of going back into the legacy system. there has been as you know at least one more hearing on this and we believe that the basic concept that put forward for a sped up appeal process is a good one and we commend it to your attention. >> thank you. out of time. thank you gentlemen. >> mr. lord you're recognized. >> thank you dr. robert i will follow your lead and acknowledged earnest to. are you here today? ernesto isn't about. thanks for joining us.

[applause] grateful that he's been a day with us here in congress, and also wonderful that he gets to hear from each of you. he's been here throughout the entire testimony. i think that can only be good. i wanted to reflect on some of what dr. abraham and i heard this morning with the secretary. one figure that just astounds me is that there are 50,000 positions opened within the va that they are seeking to hire for today. another statistic that floors me is that the ap reported last month despite this year of intensive focus on wait times, wait times have improved approximately 0% across the country. and undersecretary gibson admitted today that while access has improved, more veterans are getting seen wait times are

actually going up because more veterans are being seen. that are more providers in the system. there is, even though it's problematic, there's more choice. and so i think one of the difficult questions we need to address, and i want to get your thoughts on is is whether we should not be a little bit more strategic on what we are hiring for and then what we are referring out. mr. rieckhoff i'm struck by your top priority, preventing suicides and caring for those who come back with the signature wound of these most recent wars post-traumatic stress, traumatic brain injury. tell me your thoughts on focusing that hiring that has to take place on the va primarily on capacity to serve those transitioning service members, the mental health providers that we need to have and focus on

taking care of those unique conditions, wounds, disabilities come injuries sustained in combat or service and the trade off i think that you can refer out those things that are not uniquely service-connected. there's going to be a trade off involved if we are going to solve this. we can pretend we're going to our all 50000, build hospitals in of the committee like the one i served in el paso or acknowledge we have to set priorities. let the future take on this. >> we created a clay hunt bill after we lost clay. i left place the place a few and was on my way to the plane and found out that another suicide on the way there. this is real. it's growing and a clay hunt say that was a good step forward but no one should be thinking that this problem is a new a new close to solve the that's why we're keeping it or not one priority this year. the thing that's lacking is a national call to action it was

great where the white house sunday but most americans saw the and said greg washington to terrorism when on. we've got to incentivize event and find ways that they cannot just work of the the but serve veterans and that's good to be called action that the president should make it into our country and say we have a suicide problem and mental health crush. we need every american to step up the you can step up and work at the va work at the dod for a private nonprofit, go back to school. amazing in all of these areas i think the undervalued resource business. post-9/11 veterans are standby to help each other. >> sorry to interrupt but about what to make sure i ask this in as blunt terms as possible. what is the va was a center of excellence for pts pbi unique and connected service issues? there's 100% chance that when you see that mental-health

provider can you going to get in right away and it will be world-class care. the trade off is there's a pretty good chance that if you have the flu diabetes or something that may not be uniquely connected to service or is comparable to what the general population seas, you're going to get referred out the maybe not 100% of the time but more likely. what do you think about that? >> this is the age-old false choice. we should figure who goes to the front of the line. nobody should way. that's the bottom line. >> i don't think that's going to fix it. >> i don't think a lot of these ideas are necessarily going to work, that we've heard from congress in the last couple of years at the bottom line is suppliedsupply is growing in demand is flat or even falling. we don't have enough qualified people to deal with suicide. we've got to address the supply problem and we've also got to dress that va can do double the most of our members are torn. a lot of them will never go to the va especially after the

scandal. we encourage them to do that but we could recognize hospital networks private nonprofits church groups compared with those is taking up the slack. we've got to look at as a national health care priority. that's i think we need to start otherwise we will be middling around the edges. >> i'm going to yield back but i think we agree on almost everything. it's infinitely urgent. it's going to require everyone not just the va but the communities in which we live and work the provider population outside the va but it's something to is going to be a priority and urgent needs to be treated that way with limited resources. i think there will have to be some trade-offs. i appreciate your response and yield back to dr. roe. >> i would not take this opportunity recognize -- >> dr. roe? can i say one thing? i have to say this for the record. first of all the majority of suicides -- there's enough it's terrible and it's be dealt with immediately but unfortunately

it's the older veterans are committing suicide at incredible rates, have been for years still far and many because they are retiring out and getting into all kinds of hot water. the other thing is this. the va needs to take people right out of school which they will not do. i've had a friend of mine, she wanted to work for the va. she got her masters degree pictures qualify but they said it got at least a couple years of work service. i'd rather take a kid out of school that i could train the way i want to train them and have to rely on somebody who quit a job and work somewhere else in two or three years. they need to do more of that right out of school getting people right out of school. the other thing is this is -- the va needs to document their recruitment efforts by specialty and report to congress who it is a hiring and where they're going to look for them. >> just to emphasize, i'm glad somebody took this kid right out of school and hired him as a doctor. i much appreciated been doing that come and your correct a

misprint and i were talking about this. not that people don't want to work for the va. it's just getting hired takes forever. that's the problem. [applause] >> that's the problem. >> i yield. >> thank you. it is a misnomer just agency people that want to work for the va. they do want to work for the va. what happens if it takes too long. the process. by the time to go to the system so what else has already hired event. so let's dosage and say that people do not want to go to the va. they do come and they want to work at the va. let's be clear. we have doctors and nurses and professionals. there are veterans that are coming at the want to work at the va but our process is too long. i yield. >> i will now take this opportunity to recognize my good friend, senator boozman, dr. bos with whom he served in the superior house, which is the house of representatives, was on

the veterans' affairs committee. i know you to senator boozman. >> thank you very much and thank you all for being you and thank you so much for your advocacy. you will do a tremendous job in pushing things forward. i agree with you is to write off. the danger is in the signing ceremony everybody is patting themselves on the back, the nation is patting themselves on the back. much of congress. you forget about these things. we do have to keep at the top of the list. mr. rowan, you made an excellent point. the majority of people that our committing suicide are actually in the '50s and things, so it's just something that went to go forward with. mr. minney come you mentioned the travel for non-service-connected individuals with vision problems. what is the major disease that they have that is affecting them? do you know what the primary non-service-connected disease that is causing blindness?

>> right now it's a tossup between macular degeneration and diabetic retinopathy. .net across the being associated with diabetes, vietnam community, how they are coming down with diabetes to agent orange. so now that diabetes is calling -- >> diabetes connected to agent orange and then the resulting vision impairment, that's not service-connected? >> it's a fight to get a second and third, secondary disease associated. >> we need to fix that. that's an excellent point. one of the problems that we're having in arkansas, and i note throughout the country, there's been a problem with va reimbursing local hospitals for the emergency medicare for veterans. when this happens the hospital or collection agency hide by the hospital may go after the

pattern for the payment if they don't receive it from the va. i guess my question to the panel is this is something you hearing about? i have a lot of concern about that because not only is it a problem now again with a veteran, but also with hospitals to if you don't pay them they are not going to participate. the other problem is that we can't do it right now under this limited problem we've had in the past what's going to happen is the 40-mile rule develops and hopefully we'll see more and more people utilizing that as they get comfortable with that. if we can't do this program they will have huge problems with that program. again the danger is that if you don't pay the providers they simply will not participate. and then potentially could spill over to tricare and some of the things that we work so hard to make sure that it is accessible to veterans. is anybody having any of those things out of their there?

not so much good. >> i which is, not the maturing of that but we are hearing a related challenge and problem is that some veterans were referred outside for care, often the result in a prescription of some kind by the civilian provider, and that becomes enormously challenging because been that it goes to the local cvs or other retail drug provider has to pay out of pocket. then when i go back to the va the va will not recognize the script with this idea to come to the be and be seen by us so we can write a script on our formulary. so this is a huge issue that really wasn't addressed in the choice act. the whole prescription prescription/medication aspect of outside referred care is still an enormous gap that needs to be taken up and looked at. >> i think you make a great

point. pharmacy is something we've got to address battle in that area but also the problem with dod you know, we talked about suicide things, getting people stable while they are still in the service. all of a sudden they come out and then the pharmacy in the va those drugs not being on the formulary and all of a sudden changing people were you've had a lot of work and a lot of attention paid to try to get people on the right track. that's something that we need as a group, as a congress. and you all also that's something we need to work on. thank you all very much again for your service in summary different ways. we appreciate you. >> sergeant major walters your recognition five minutes. >> thank you, chairman. thank you all for being here. to both the folks at the table and the folks behind we always hear on challenging issues but i

leave always more optimistic than i've ever been because they'refirst what else i would want to be fighting these fights than you. i think the national guard issue with president kennedy got asked by going to the moon and they said we don't do because it's easy don't we do it because it's hard. i don't think he envisioned getting damned care at the va. effect of the matter is it's up to us to get this right and senator boozman is right on the formulary. we harmonized the formularies between dod and va. it was stripped out at the end. that's what you 2.0 and 3.0 and to keep at it. i know for all of you this has to do that like groundhog day. were back at you after your but that's the point of the. i think the etiquette feeling on this, it's different now targeted because prices. anyone who does other instances who could've predicted that courts somebody sitting at the

table not be forfeited seven we were talking with administration folks about and got nowhere. it's not a surprise to anyone nor will it be a surprise on the injuries that are coming. this bubble is coming. it peaks for years after the conflict. talk about a look at the veterans. their bubble is not coming until 2050. so for us to say to be some competency at the time saying we could have predicted it this would happen. if you could have some make the choice not. it's not a false choice. we make people accountable. we swear them in the uk agreement we send them what they need to go. we need to plan for the future and fix it. so let's do both together. this is our chance to make a generational change. it has to be there because here's the alternative to know what else is going to do it. there's going to be resistance because it's the nature of bureaucracy both public and private to resist change. the good news is we can make

changes. clay hunt was a step in the right direction but is a good else said this is about mental health parity into the of the public sector to do that because that's what it's going to start. we can change behavior. we can change a people think about it. i want to come to a grander vision on this because i think we can't lose sight of this. there are things we can start fixing today and make differences in people's lives on that. mr. rowan i wonder if you could tell me, could you explain quickly what's the relationship with iom and the va? what do they do together and what's going on? >> the institute of medicine was brought into play back into 91 act of the agent orange act in 91 for basically the institute of medicine was asked on a biannual basis to report out of research that they would look at of agent orange related research and any diseases that they felt were identified as a result of that that would then eventually end up on the presumptive list

which unfortunately now is rather substantial for vietnam veterans. that's benefiting. the problem is one of the reasons why we talk about doing research is, in fact that there is no research. the va has never done research on agent orange. so iom were scratching around wherever they could find stuff instead of having original research review. it was a shame and the iom induced toxic research act we're talking about we also talk about -- which would basically extend the 91 act to include persian gulf and more recent veterans with the institute of medicine would start studying them now. the one thing about the iom was they were considered off to the side. it's interesting once again we see the va just recently put up barriers. so when the iom basically told the va you guys really screwed up when it came to the sea 123 crew members and pilots and

crew, that they agreed those planes were toxic even despite the va basically disavowing all knowledge spent this is the point i want to bring up that is why say this to my colleagues. while it may be a granular issue it is a broad one because this is about research, best practices and cutting up problems before they become as big as they are. we know we're going to see these things from burn pits to depleted uranium. they're coming. the research needs to be done. at treatment plants need to be done now. i bring this up because i think it shows and secretary ushers ashes is unhealthy continued to push on this this insular nature of the va cannot take outside experts on this in partnerships. it's a waste of resources. it ended up setting us up for another situation with agent orange claims that will come later and this is what i'm talking about. we can prevent those now if we choose to do so. so thank you. keep pushing spend spent fmi continued

that. the other thing was the dod the recorded research that showed that these were toxic but the va wouldn't talk about it, wouldn't acknowledge it. that is just a mindset somewhere in there that people don't think these kinds of illnesses count. >> we are going to come back at it and somebody will be hearing it. we will push that some. >> thank you mr. chairman. it's great to be your fantasy all of you who have served them like senator boozman said, in so many years, i appreciate that. the issue of a denver hospital has. i'm from southern colorado and although it's not in my district, lots of my 100000 veterans do need the hospital to be finished. existing facilities just not up to par. i know it's a mess financial and i don't know the final solution but we have to find a way to bring all or part of the

hospital to completion so it can be used. but for anyone of you i'd like to ask this question. i also ask visit secretary mcdonald when he was here earlier this year. and that is, how can we find a better way to have a seamless transition for our active duty men and women leaving the department of defense going into the va? i know just months ago we talked about matching formularies. that's probably one step in the right direction. but what are some of the ways that you would like to propose that we can work on for a better and more seamless transition? >> congressman if i may. the one issue i can see is at this time the department of veterans affairs is only employed by 33% veterans. it's supposed to be veterans taking care of veterans. so if you take the 66% that are

not veterans once they transition, those folks don't understand the military health care system for even the military way of life. so i think one of the best ways to do it is to actually hire more veterans within the va health care system or even vba as well. >> excellent. >> that's one approach. >> thank you. we have five specific recommendations. provide oversight by moderating. remember that? will stood up with the president i think five is ago and talked about the initiation of the plane. that plan is still somewhat ongoing. automatically and will all troops in the health care with an option to opt out. gifted in when they are still in and have that be more seamless. fold and put a duty planted

develop an automated system to transfer the service paper records to the va electronically. fully government a comprehensive exit physical before servicemember leaves. those are five suggestions we have been happy to follow up with you step on more detail. >> please do. >> we've had that for like the last five years. we had a plan but we have to execute the point at a don't think the plan will be executed until you sit down with people from the leadership, i'm dod and va and say okay, what's the malfunction? this is where we are going. how are you going to implement it? until summit has oversight on that and direction it's going to happen. >> would anybody else like it answers because we would suggest more needs be done in terms of recruitment of physicians, nurses and other medical professionals from dod went either to complete their term of service or when they retire. things like fellowships postdoctoral opportunities,

research, even recruitment stipends to attractive entity a service. that gets back to the ranking member brown's point about the long lace in the va process. if some is certified as a physician in the department of defense, and got to be quick easy and seamless to move over into the va and provide opportunities for them including reasonable incentives for them to want to affiliate as a va medical professionals. >> once again, at this time there between 40 and 50000 navy corbin army medics and air force technician put the department of veterans affairs will not-based author military dod education. an individual could be an x-ray tech in the army for 10 years come want to go to work for that the and visas we will not how you because you are not

credentialed. there is part of the problem. dod needs to credential they enlisted military personnel so they can have the opportunity to go to work for the va. there's a disconnect right there. if you can take care of an individual while there in uniform, why can't you take care of them when they are a veteran? >> i'm going to speak -- his son as a major in the air force and under all just. but the bottom line is this. is looking around to get out, quite honestly, and the bottom line is the headhunters are telling him don't even think about the va. they are not looking. they are just not looking. despite the sector having told my secretary is going to go after his son he never did spent thank you again for your answers and for the service you provide. thank you, mr. chairman.

i yield back. >> again i want to thank all of you for being a today and to thank all of you and your organizations are what you do for our veterans and their families. i would take this opportunity to yield to ranking member brown for any closing comments. >> i just want to thank you all for your service, for your comments. clearly we've got a lot of work to do but as we go into the memorial day thanking all of the veterans for their service and the women veterans. you know the first president george washington said was a young people want to join the military will depend on how we treat the veterans. and i'm committed that we will continue to work to give them the service and the quality care that they need. i mentioned earlier about denver. on the 24th if we in congress have not come up with a plan to

authorize additional, so they can spend money, that project is going to close. that will cost $20 million. and it will cost $2 million a month. that is a waste of taxpayers dollars. you know, we can blame the a. i say we can blame the congress because we are not authorized hospitals in 15 years. blame whoever you want to but veterans will not get the service they need. what happens when failure is not an option? we've got to get it done. thank you. >> i want to take this opportunity once again to thank all the people who are here all the organizations. one of the things i think you are seeing with this committee i've been your six and a half years and ms. brown has been there for over 20. >> twenty-three. >> twenty-three, correction. one of the things that i've

noticed in these hearings is the attendance of the members. there's much more interest in the last year. it's a doubled or tripled. they are very meaningful. i've learned a lot of things today and things are going to be fairly simple. things are not going to be hard to fix. and it is a bipartisan effort i might add i think you're seeing input from both. i think the fact choice card, veterans choice act i mean is nothing intimate as congress intended. we will have to do oversight on that. i can also tell you being a vietnam era veteran i served in korea in 1973 and 1974. i see a lot more emphasis towards helping veterans that i saw when i cut out of the army in 1974, i contributed a. basically they gave did not know the backend going out and that was about it. that was the only connection i got. i mean there was no t.a.p. program, there wasn't anything. we're doing much better.

post-post 9/11 g.i. bill is a phenomenal benefit and 1 million young people have access to that our country is better off. we will get the money back in space. no question about that. we will benefit mightily from that. on the veterans hospital in denver, you know, i mentioned this anything but they built the coliseum in rome and eight years and it looks like we're going to exceed that would be a. they had different labor issues realize that an they didn't have the epa on them but it looks like you could go the hospital for less than $1700 a square foot. i think about how much care mr. kovach mentioned that we could be giving our veterans. and it takes away from other veterans construction projects that could be done. i didn't sign on to be the project manager for feba hospital but they can do better and able to but i think the oversight from our committee

will do that. it's a privilege as i said to start my comments to serve on this committee to serve those now who serve us. and i will come this is just my view. i've been to afghanistan twice hope to go again. we have the most courageous volunteer and highly trained military in the history of this country. it is amazing the professionalism of these young people. i say this every time i speak. i fiscal conservative. there are three things i will never ever ever apologized for spending money on. what is if you're a soldier in a in the field i want you to would've you need to protect you and your comrades, period. would have any. number two when you made that service and you come home i want this country to serve again as you served it. dark alley i'm going to also support for agriculture community because i like to eat. so i want to make sure my farmers are taking care. i appreciate you all being here

and closing up asking in his consent all members have five legislative days to extend remarks including extraneous that you. without objections ordered. with that the hearing is adjourned. [applause] [inaudible conversations] [inaudible conversations]

[inaudible conversations] [inaudible conversations] >> for he today that sheds his blood with me shall be my brother. be he never so while. this day shall gentle his condition. and gentlemen in england shall

think themselves accursed they were not here. >> one drop of blood drawn from nine countries but some should be the more than streams of foreign court. >> director of the shakespeare labor talks are shakespeare and how politicians use quotes from famous playwright in their speeches. >> sometimes you have to just go with the music of the words, the poetic images, the sound of the rhymes and also the way in which that senator burr did commit able to pause and linger over a long phrase and then stop and keep going. i think he's really using the language which is something that shakespeare did so brilliantly. so that he can take english and they can put it into high gear at one moment and then he can slow down.

that's something shakespeare let you do if you're a politician. >> sunday night at eight eastern and pacific on c-span skua date. >> goodnight, goodnight i'm parting is such sweet sorrow and it really does. >> next committee hearing on rural health care. the senate appropriations subcommittee on labor health and human services heard from officials from medicare and medicaid services as well as medical specialist. the hearing is an hour and 45 minutes. onspent the appropriate subcommittee on labor health and human services, education and related services will come to order. glad to have all of you this morning but i want to thank the witnesses for appearing before the subcommittee today to discuss technique health care needs that face rural communities. we have two panels this morning.

members should not expect to call up the second panel around 11 a.m. so we have adequate time to hear from both big and, of course if for some reason we get done with this panel earlier will go to the second panel quicker but will try to go to the second panel noted at 11:00. riptide everybody has come today to help us talk about this issue. certainly one of the priorities of the committee and one of my priorities in congress has been to ensure that all americans have access to quality and affordable health care in their local communities, regardless of where they live. the obstacles faced by rural health care patients and providers in rural communities are unique and often significantly different than those in urban areas. albeit -- i will be at the truman medical center to more than a whole different set of problems but they have some unique problems, both our inner-city hospitals and our rural hospitals have the challenges that are unique to

them. in rural health care issues can range of a lack of access to simple primary care physicians to difficulty finding a specialist as result of communications have to drive long distances to receive care or simply just may not seek care until it's too late. this creates unnecessary disparities in health care not found in other parts of the country and ultimately costs taxpayers more in medicare expenditures and if we have provided access in a better way. i think it's critically important that washington recognize the health care access is essential to the survival and success of rural communities across the country. i'm concerned that some of the proposals within the department's budget and recent regulations that have been issued that would disproportionately affect rural health care and jeopardize health care access and, in fact, when you do that you threatened the survival of small towns.

the medicare payment system often fails to recognize the unique circumstances of rural or small hospitals. this administration has appeared in my view, to target rural hospitals in particular. for example the department once again has proposed to decrease the reimbursement rate for critical access hospitals and eliminate critical access hospitals within 10 miles of any other hospital. the department has proposed that change for years, yet recently been able to provide detailed to the congress about which hospitals would be eliminated if we look at that new mileage standards. the department has continuously issued regulations that would affect small and rural hospitals more than their larger urban counterparts. seem as abrupt enforcement of the 96 hour condition abatement for critical access hospitals and the direct physician supervision roles -- cms --

audit contract august the only hitter care patients but consume significant amounts of medical staff time and resources to comply with those rules. finally given the fact that the department requested $4.1 million increase for the coming fiscal year it's even more surprising, or maybe not so surprising, that the office of rural health received a $20 million cut in the proposal that the administration issued. the administration in fact has never once asked for an increase in rural health programs. more than 46 million americans live in rural areas ever life on rural hospitals and other providers as a lifeline to care. they face ongoing challenges in assessing the proper medical treatment while rural health care providers are overwhelmed with federal rules. senator murray and i both have an interest in this.

i look forward to working with her and the rest of the committee to ensure that all americans, regardless of where they live, have access to affordable health care. and senator murray? >> well, thank you mr. chairman, for going fishing on such an important topic. i am very pleased to welcome all of our witnesses who are here today but i'm excited to welcome julie peterson. julie is the chief executive officer of the medical center in prosser, washington and to work at the may general leadership across our state julie is helping make sure rural communities get health care they need so julie thank you for coming all the way out here on this link today to difficult the last few years we've had taken historic steps forward when it comes to making our health care system work better for our families i believe stronger there's much more we can do to continue to improve affordability, access and quality amid to keep building a health care system that works

for women, families and seniors come and put their needs first. in my home state of washington where about one out of every five residents live in a rural area, a critical part of this work is making sure that families can find a doctor's they need right in their own communities regardless of whether they live in prosser or in seattle. this is true in many other parts of the country as well. this is a star's challenge. i can focus on long time and i'm proud washington state utility so much to tackle it head-on. washington state received a federal grant to explore the role of community paramedics in providing home follow-up care. this approach could reduce emergency room visits and help patients avoid the cost and inconvenience of leaving home to get care. i also you repeatedly about the number of new patients getting coverage through the affordable care act across my state. for example, a network of for rural health clinics reported a 43% increase in patients last year.

that's a great news but it also means we need to think about how to make sure the are in a doctors and other health care providers to treat all of the patients. i'm glad you the opportunity today to talk about the investments we need to make so we can build on that progress. the agreement of the president recently signed into law to fix the broken sgr system took important steps to support access to health in rural areas. and included funding for health centers and the national health service corps, each of which played a critical role in expanding access to primary care for struggling families, especially in our rural areas. the sgr legislation extended hunting for teaching health center residencies. my home state was the leader in setting up these training programs, not primary care providers are being trained in communities with a shortage of health care providers from spokane to yak to our tribes. we know that training and rural areas is critical to keeping

providers with an interest in rural practice in our high need communities. i please were able to agree and a bipartisan way to sustain those investments and i hope we will be able to do even more moving forward. i'm also pleased the president's budget maintains investments in other key programs that do support rural health. 340 b. drug pricing program for example, provides outpatient drugs to a little health care providers at a lower cost. 26th out of my state's 39 critical access hospitals which provide crucial support to rural communities purchase put in that program. similarly the budget continue to support enhanced payment for rural health clinics and community health centers. in my home state and many others these facilities help make sure that when for example a parent needs take a sick child to the doctor our senior needs follow-up care come it's easier to get the treatment they need in their own community. we really need to make sure they have the resources that they

need. i do also want to express concern that the budget proposes to cut the rural hospital flexibility program. that program helps sustain and improve hospitals and the most difficult to reach communities including 10 hospitals in my home state. i believe we need to seek continued strong support for this investment in health and safety of families in rural communities. finally, i know rural health access is a priority. allall of this year to about of this year to about some want to note the president's budget is able to sustain those investments along with supporting other keep arteries from education to infrastructure to defense because it responsibly replaced the harmful cuts from sequestration that are now set to kick back and i'm proud less congress republicans and democrats were able to come together to reach an agreement that rolls back sequestration for fiscal years 2014-15. with our deal set to expire a hope we can build on that bipartisan foundation and

prevent these harmful cuts to investments in families jobs and our economy including critical support for our rural health care. i look for to work with all of our colleagues on this in the coming weeks and months, and again am what you think all of witnesses for being here mr. chairman again thank you for holding this was at fort hood. this is a topic that means a lot to the people in my state. >> we have to win is on the first panel sean cavanaugh deputy administrator of the center for medicare centers for medicare and medicaid services, and tom morris, associate administrator for the federal office of rural health policy, health resources and services administration. we are pleased you're both here and we will listen to your opening statements. >> mr. chairman, and members of the committee i want to thank you for the opportunity to testify today on behalf of the old resources and services administration into federal office of robot on the topic of rural health. i'm pleased to discuss that only

the challenges that you outline but also some of the accomplishments of our programs. across the department of health and human services is a range of programs and resources that support rural communities. in 2014 this include $11 billion in grant funding that went to rural communities. my office serves as the focal point with a continued focus on improving access to care. they are nearly 50 the many people living in rural areas about 15% of the population spread across 80% of the landmass of the united states. individuals in rural communities often have to travel further for their care and this can have an impact on their health care outcomes. new research shows over the past 20 years life expectancy in rural areas is lower than urban and that gap is widening. this includes supporting role health facility come investing in committee health centers to build a strong health care workforce and expanding the use of telehealth. the federal office of rural

health policy has several initiatives that focus on compatibility and rural communities. hrsa supports the rural health outreach program which provides a starting point for pilot projects. kinard health centers are an essential part of the rural health care delivery system because they provide accessible, affordable and efficient care in underserved communities. hrsa history 1300 health centers supported nationally with 9000 health centers service sites and about 50% server rural communities. hrsa announced 164 new access point grants for new community health centers, 74 in rural communities totaling $45 million

in investments will go to improve access to care in rural communities. hrsa pastoring programs to work to increase access to healthy by ensuring that our providers in underserved areas. and national health service corps support loan repayment a scholarship for primary care providers, almost half we support are located in rural communities. in fy 2014 health professional students supported by hrsa went to 11,000 training sites in rural communities. we invest in community-based rural residency training and work with the 30 for rural training tracks around the country. telehealth plays an important role in enhancing and extending its reach. hrsa is something telehealth projects in 230 rural and underserved communities in 48 different clinical areas and this includes mental health. we've seen for pilot initiatives such as the emergency care and other service. we have 14 telehealth resource centers around the country to provide free technical assistance to communities either

that start in telehealth or enhanced what they are doing in telehealth. rural communities have benefited from the collaborative work of the white house world council which was great in july 2011. the councils focused on getting federal agencies and departments to work together to coordinate and server rural communities better. i know in our case basis lead to ongoing partnership between my office, the u.s. department of agriculture and veterans affairs on enough of health projects. one example is with expanded the national service corps to critical access hospital. want to thank you for the opportunity to be here today to talk a row health issues and thank you for support of hrsa programs. i look forward to answering any questions you might have. >> chairman blunt ranking member murray and members of the subcommittee, thank you for the invitation to discuss our efforts to preserve access to quality health care for medicare beneficiaries in rural areas. provide high quality care to a quarter of all americans

presents unique challenge of the rural areas often have fewer physicians and hospitals and medicare beneficiaries in rural areas often recite a significant distance away. beneficiaries rugged inhabitants of the total patients are by rural providers than in urban provided making these organizations particularly sensitive to changes in medicare payment policy. at cms were taken a number of steps to improve services. first we create numerous opportunities for rural stakeholders to engage with cms jimmy choo we understand their concerns and challenges. cms has rural health coordinators at each of our regional offices who meet monthly with central office staff and with representatives from the hrsa office to discuss emerging issues. cms offers regular rural health open-door forums to provide current information on cms programs, answer questions on guard about the emerging rural health issues. we are trying to remove regulatory barriers for rural health providers. last year seen as reform medicare medic regulation that

we didn't fight as an acidic obsolete or excessively burdensome which was a providers nearly $3.3.2 billion over the next five years. this include specific provisions target of reducing burdens on rural health care providers. for example, a key provision reduces the burden on critical access hospital world health clinics by limiting requirement that this issue be held to a prescriptive scheduled for being on psychic this provision recognizes the taliban improvements to allow physicians to provide care at lower cost while maintaining high quality care. medicare's telehealth benefit allows services that would not require a patient and practitioner to be in the same location to be delivered via interactive telecommunications system to a variety of practitioners are authorized past telehealth provided that the statute requires medicare pay for professional consultations office visits and psychiatry services.

each year cms solicits public comment on additional services that should be illegal under the telehealth benefit. in 2015 we've added to the annual wellness visit psychoanalysis, family psychotherapy and prolonged services. we are exposed we can improve the current telehealth benefit to the centers for medicare and medicaid innovation is testing pilot project to use telemedicine to bring additional services to rural communities. the health innovation awards initiative has awarded a grant to a link now and the apparent aspects of telemedicine and telepsychiatry with a virtual care navigators and health specialist usurpations with behavioral health conditions in frontier and road conditions and wyoming, montana and washington state. this year we announced the next generation a single model that is currently sucking applications to begin next year and that model will be testing expenditures of telehealth

services as well. as you know critical access hospitals are small role this and that serve communities that otherwise might like access to inpatient care. .com and more than 1300 in the united states and here i would pause and think congress also for extending the medicare dependent hospital program which was in the sgr repeal legislation that she recently passed. ..