in cyberspace which is to influence the u.s. political process. there is a system in place where the state department receives requests like the one that was put forward a neighbor for those request to state officials and state officials are responsible for administering -- so it's up to the state officials to render that judgment. there is a process that is organized by the osce the office of security corporation in europe that does observe u.s. elections and we have been able in the past to coordinate effectively with them. russia has had an opportunity to send essentially individuals to be members of the delegation to observe u.s. elections. russia has declined to participate in that way.

you would have to ask them why they can take advantage of that opportunity if they were so interested in understanding more about the conduct of a free and fair election. it's a concept that may not be as familiar to russian officials. tonight the state department called. >> i wouldn't quibble with that but it is unclear what the russians were intending to do in this case. i think it's appropriate that people might be suspicious of their motives or at least their motives might be different than what they have publicly stated given the nefarious activities they have engaged in in cyberspace. >> and i wanted to speak to the supreme court. [inaudible] i'm wondering if you have heard that and had there have been a new conversations.

>> this is largely the case we have been making for more than 200 days now which is that republicans in the senate do have an obligation to do their job and to fulfill their responsibility to treat chief judge carolyn fairley come and meet with and give them a hearing and a timely yes or no vote and we obtusely welcome the comments of senator flake that he believes that's what should happen. he is somebody who has a special influence here because he serves on the senate judiciary committee. this is the committee that would be responsible for organizing these kinds of hearings as they have for generations. i did take note yesterday that the chairman of this committee, senator grassley from iowa, had a discussion with some members of "the des moines register" editorial board about this process and in the context of

that discussion chairman grassley indicated that taxpayers couldn't afford for him to hold those hearings. it would require hiring additional staff in order to do so. the american people have actually hired, already, senators to fulfill their basic responsibility. and that asic responsibility is to give a fair hearing to the president's nominee to the supreme court. so, senator grassley is wrong when he says that the american people can afford to hold those hearings. the truth is the american people and the people of iowa can afford to be paying the salary of a senator who is not doing his job and chairman grassley has not been doing his job. and that is unfortunately rather significant departure from the

rest of his senate career. he is somebody who has righted himself and acting in a month partisan fashion and putting the best interest of the people of iowa and the people of this country above his party. in this regard he has failed to do that and in a situation i think as is evident from his rather lame explanation for why he hasn't been doing his job. that's different than senator mcconnell bragging about not doing his job but it's concerning nonetheless. and i think in some ways the comments of senator flake underscores just how indefensible the position is that's been adopted by chairman grassley. >> and just one more. i'm sure you noticed then that secretary clinton dimension garland by name when she was asked about the court in the

debate the other night and i'm wondering if you take that as a sign that she doesn't intend to renominate him. >> well i think what she stated. candidly is her view that the united states senate has a responsibility to consider the nominees that a president puts forward and she indicated her strong support for that principle. she also has indicated her strong support for the president's decision to nominate chief judge garland. she did that on the very day the chief judge garland name was put forward. so i don't know who president clinton would nominate to fill a vacancy on the supreme court if she is elected president. at this point i don't know if there will be a vacancy on the supreme court today that she takes office. we continue to make a case that congress should act. either way if she's present of an estate and there's a vacancy

on the supreme court she will decide who she believes is the person that should fill that they can see in the senate would have a responsibility to give that person a hearing and a timely yes or no vote. jeff. >> josh, can you confirm a report by some of my colleagues today that a u.s. navy warship has carried out a freedom of navigation operation in the south china sea lacks and if so can you explain what the u.s. hopes to achieve with that type of operation? >> jeff i can confirm that last night the uss decatur conducted a freedom of navigation operation the south china sea specific way in the vicinity of the parasol islands. the purpose of this mission was to uphold the rights and freedoms of all states under international law as reflected in the law of the sea convention. this operation demonstrated that coastal states may not unlawfully restrict the navigation rights freedoms and lawful uses of the sea that the united states and all states are

entitled to exercise under international law. as we have discussed at some length in here, the united states is not a claimant to play and features in the south china sea. it you of the united states is that this dispute about claims to those features should not be resolved through -- through coercion or military force or intimidation but rather through negotiation. and that's a principle that we believe strongly in. our interest interests in the region again are not rooted in particular claims gore supporting particular claims that are made by countries with overlapping disputes but rather our view that international order is best maintained that these kinds of disputes are resolved through negotiation.

and are interested is that this is a region of the world through which a lot of commerce passes and the disruption of some of these commercial shipping lanes could have a negative impact on the global economy and the negative impact on the u.s. economy. so that's what our interest is and that is an interest that we will look for opportunities to convey. and that essentially is the message that was sent by the operation that was carried out at the uss decatur last night paid. >> free concert at all about china will view this as a provocative act? >> they shouldn't. i guess you'd have to ask them for a response. they shouldn't because this is a principle that reflects what we believe is the broad interests of the international community. we believe that it's in china's

interest to ensure that international norms are not violated or international order is not disrupted in this region of the world. the united states and china have they in economic interests as well as the united states does as well. the kind of, or the principle of freedom of navigation in international waters is one that we assert not just on behalf of united states and the united states military but one that we assert on behalf of states all around the world including china so you will have to ask the chinese were a response to this particular action but we would not intend for this to be viewed as some sort of controversial or confrontational action on the part of united states but rather an illustration of our firm

commitment to an important principle that serves the interests of countries around the world. mitchell. >> we have heard some interesting statements from the president of the philippines in the last couple of days. his office today is seeming like they want to walk some of it back and saying that he wasn't fully saying that he wants to completely -- i think you know what i'm saying. >> i do. i've dubbed that person the filipino mike pence. [laughter] >> what do you make of the impact of his words? i mean there's a point, often we say let's look at actions, this rhetoric but is there a point now if to tear today said it's gone beyond rhetoric and what he is saying is actually damaging or dangerous to the region? >> michelle weise certainly have seen a lot of this troubling rhetoric recently. the rhetoric is inexplicably at

odds with the warm relationship that exists between the filipino and the american people and the importance of cooperation that has existed between the u.s. and the philippines have a government and military level for decades. we haven't heard any specifics from the filipino government about what precisely president to tear it means when he refers to a separation that those comments are creating unnecessary uncertainty in our relationship. daniel russell who is a senior state department official as traveling to the philippines on a previously scheduled trip to have a discussion about the

scope of the relationship between the united states and the philippines and i'm confident that these recent comments from president duterte will be on the agenda as we seek some clarity from the filipino government. for the united states i can tell you that we will continue to do what we have been doing for a long time which is we are going to honor our alliance commitments and our treaty obligations and their expectations that the philippines will do the same thing. the united states in the philippines have been allies for 70 years and we value the relationship that we have that the philippines. the feel of pino -- filipino government have benefited tremendously from the warm relationship that they have at the united states. we can have a weight that in terms of the deep economic ties between the countries in the cultural ties between our two

countries including a vibrant and active filipino american population that's concerned about the relationship, or the uncertainty that's been added to the relationship. >> this is somebody obviously who is now known around the world for his rhetoric rate that's probably why he was elected. so at this point do you take these words seriously? i mean does it reach a certain point where you do or you generally just see this as more rhetoric that is designed to make a statement or get some rise out of united states? >> was in when you are the leader of a nation that has a seven decades long alliance with the united states, it comes with it a set of important responsibilities including understanding the consequences for your public statements and

we have seen too many troubling public statements from president duterte and the frequency of that rhetoric has added an element of an -- and frankly it is at odds with the warm relationship between the citizens of our two countries and it is certainly at odds with the benefits that the philippines have enjoyed as a result of our alliance between our countries. >> are you seeing within some of this statements of real intent to back away from the agreement and the relationship of united states? >> again the bottom-line michelle is that there is some uncertainty about what exactly his intent is. you have successfully covered the rhetoric he has used some of the personal and some of it offensive, some of the confusing all of it walked back by senior

officials in his government. so that is the source of the uncertainty. that will certainly be part of discussions the discussions that the assistant secretary of state mr. russell will convene in the philippines when he runs there. >> we just heard from me italian prime minister talking about the potential for further sanctions on russia over syria, saying that he doesn't think that works and that doesn't change the behavior that there's no point to it. what do you think are his thoughts on that? >> well the u.s. approach has been to leave the option of sanctions on the table. and in discussing publicly these

options we have made clear that her concerns about russian behavior in syria are significant and we have made clear that the use of this particular option financial sanctions as most of the good when implemented and careful coordination with our allies and partners around the world. we have also been reluctant speak in much detail in advance about what a potential sanctions architecture could look like because frankly we don't want to tip off individuals or entities that could be targeting those sanctions so they can begin to take steps to evade them before they have even the put in place. ..

>> >> using the financial sanctions in the context of ukraine has imposed those costs on russia. >> it sounds like the behavior has not changed but it seems like you're saying there is potential? >> there is the potential adding the additional

sanctions to those additional cost on russia russia, we know what impact and a negative impact on the russian economy. and ford trying to reduce the violence in syria for far too long. oh as reduce dust some like there is a fundamental contradiction from president putin has pursued and he has intervened militarily and conflict against deicide receive even though he says it will negotiate a political transition. if we can mobilize the international community to apply pressure to russia to resolve that flood the mental-health contradiction in their tactics that could potentially lead to the

reduction of violence. >> and with the insurgency we have heard about the preparations from those all but you have not heard about anything from iraq. with the possibility of terror attacks of the concern has spread to the usa and europe. >> with the first part of your question, if you will recall the race series of bombings in baghdad.

they did grab but that assistance to help them better protect their homeland of those personnel to the major urban areas. so that exist with the equipment or expertise or advice to the latest breach for their compliments. with the ability of isis to focus its efforts out word and to expand people around the world to carry out acts of violence this is the one this refocused on mitigating with those military operations to take them off

the battlefield. then those military operations to have an impact on the ability to organize and plot the overseas attacks. but we remain vigilant. this is the principal concern from the very beginning to try to establish a safe haven in this part of the world to apply and organize attacks. this is the most direct threat that we are very focused on and continue to be. and then makes the harder for them. bidault to apply pressure to the leadership in general of isil makes them harder for them to plot if they are focused on their own safety.

>> another key aspect has to try to send a message to people around the world that added a lot of credibility to the argument that is why we are steadily focused to undermine that message. and this is what isil previously controlled and iraq. and with the iraqi capital of isil in the cross hairs. that has undermined their ability to deliver a potent propaganda message as they inspire others of backs of violence in their name but

to grant your question is he continues to be very focused on protecting the american people and our allies from the threat that emanates from iraq and syria. >> [inaudible] >> so i will let them read out the specifics that secretary carter has but uh message made have delivered publicly is the same as privately that the account 35 coalition is operating in

iraq at the request of the iraqi central government to support iraqi security forces. that assayed principle we have insisted on from the very beginning. turkey has had a military presence in iraq because of the concern of the extremist kurdish elements in iraq. but we have made clear that any effort or operation that is undertaken in support of the counter isil operation must be credited it - - coordinated and support of the iraqi central government. and with regard to that turkish presence outside of

mosul we have not seen the turks violate the this is a situation we will continue to monitor is secretary will stay with the turkish counterparts. to remind the house strongly we feel about that principle. >> there is as many as 550 families? and then to do anything to redirect. >> i cannot independently confirm that report but obviously as they try to get to the fact of the matter. >> but the truth is more

than 1 million people there all at risk. with a deep concern expressed by some of about a potential humanitarian but there was already serious humanitarian situation. we note that they have carried out heinous acts of violence to subdue the population. they have flagrantly violated and if it is likely to use them as a human shield in the context of this operation to be deeply concerned and while i cannot confirm that report that you cited, if true it literally

add to those concerns we already have of that current situation of the iraqi and kurdish forces entering the city. >> but then delivering a denial of service? >> >> i do know that the department of romance security and u.s. government agency is irresponsible for monitoring the security in cyberspace to court nate but to monitor the situation but that this point i don't have any information to share of who is responsible of this

activity. >> talk about south africa would interview with negative what is your view of the role in the region? >> i have not seen that report but we will look at at and get you able response. >> the president just click declared victory in november but what is the assessment that is necessary not just the candidate but the idea? >> the president has spoken and asked bank about the stakes in this election. he certainly is not taking any votes for granted. that is why you have seen them make a bigger case for

secretary clinton and democrats of the campaign trail. with his activity in the two 1/2 weeks before election day below the increase. said he isn't just guarding against a warning against it all recognize that could be confused the president understands the stakes of this election. if they lose this election then they will not show up at the polls the risk public evidence to indicate most americans are supportive of the idea of the democrats have put forward. the challenge now is to insure that those voters express that view at the

polling place. if that includes a clear and unambiguous of the divisive rhetoric used by republicans , that is able to malcolm as well. -- will come out, as well. >> with the general election >> again, the president expresses deep concern about the rhetoric and tactics deployed by republicans. as concerned as they are inconsistent with american values and the democratic traditions that previous

generations fought and died for. so he is cognizant of the stakes in this election and believes the people should not be complacent and a strong outcome to repudiate that of rhetoric and pessimistic fission put forth by the other side, would be a good outcome. it is not to end the debate because ultimately there will have to be a decision made by republicans. to decide if they are prepared of that governing agenda again. >> for the last several years we have seen republicans focus all of

their efforts to opposing any progress that the president advocates. so much so that they end up opposing those policies just because president obama puts them on the table. that has led to a situation where even republicans are wondering what they stand for. i think that is why there is such intense dissatisfaction not just across the american electorate but among the of voting republicans. so for those who will take office as a result of this election but also to recognize this debate and questions about the health

and vitality and functionality will extend beyond election day. with the soul-searching of republicans. this is not just a few the president has expressed by leading republicans in washington d.c. have expressed. this is part of what senator flake is referring to. to express his concern the way the senate is treating chief carl led the last 200 days some republicans has described as a convincing nominees some of those say republicans are refusing to even hold a hearing to consider his nomination. that is exhibit a to illustrate how republicans have abandoned any sort of principle or dancing a

common sense governing ideology so they can prioritize to throw the say and into the gears of government. it allows them to make some political gains. it is a political tactic but not a strategy for running the country to enhance the american people that republicans have a clue for the future of the country. that is a logger answer that i intended to give one started but it is an illustration of how the question tarascan are not just for the next 80 days but who these are the kinds of questions that they have to answer into the next demonstration how. >> and that we won't sever

ties with the u.s. >> i think based on his extensive comments there is greater clarity we would like to get him with the intent are but based on what you have read that seems to be a change in intoned bomb - - in tone that is more consistent of the seven decade-long alliance. >> day deny the white house is so confident that secretary clinton will win the election that the president can expend capital is easy puts a lot of energy into that.

not just the president also keys surrogates like the vice president and the first lady. >> a good news you saw obama deliver a speech in support of the democratic candidates. i would suspect to cns they travel not just for secretary clinton with the support up and down the ballot. but his ability to try to persuade voters is not just limited to the geographical locations. president obama with the wide range not just for

secretary clinton but this is a testament to did deep reservoir of the political will and support the president has and they're prepared to use that capital to benefit in this election because they are committed to building on the progress that we have made. that doesn't mean we agree with every democrat on every issue but it does mean that he has confidence that democratic candidates are committed to pursuing the economic strategy that benefits the middle-class

with the national security strategy. >> on the one hand it seems the president pretty pointed a talks to the g.o.p. base how can you support a guide who does xyz but then at the same time the woman who is supposed to be his successor claims the same base to save hoped-for me. why the distance? >> you may be understated the message she is making a broad appeal to democrats and republicans and independents. that frankly they should be asking tough questions of republican candidates who continue to support the republican presidential nominee based on all the controversial rhetoric and all of the comments that syndicate abject opposition

to the kinds of values that we hold dear? that raises some serious questions about the judgment and character of many republican candidates for office. that is what the president believes democratic independent republican voters should consider as they evaluate the candidates below the top line of the ticket. >> with the latest round to comment specifically with the veracity is in question but it seems to be a cascade of more inside information that bernie sanders and others dwell treated equally

by the democratic party have adieu reach out to those voters so strongly to make the case to them that secretary clinton when this seems to me throughout the process? >> each voter will have to make up their own mind and maybe those across the country who has chosen to be active in support of the campaign for president did so because they are animated by a core set of values and the idea to see where they want the country to go. looking for a candidate who was a more just america of middle-class families and college students to try to

prepare themselves for 20th-century economy. they got involved in the campaign they want to make sure somebody acknowledges the climate change and supported the campaign there was someone to responsibly advance the interest of the dead is states with the international community. and i need to continue to be motivated by those values and that vision to determine who they support in the upcoming election. that is what senator sanders has urged them to do and to take his advice basically all of them will be supportive of democrats. >> but that won't be the case. >> we will not take anything for granted you heard the president make direct appeals to people who supported the campaign with the same kinds of values and priorities that prompted

them to be engaged those of the values of priorities that should be done to support the. >> leslie, now is it the demonstrations perspective that the clinton foundation and the relationships that secretary clinton had with leaders and others from different countries around the globe but that was by secretary of state but. >> is about messaging but putting debt interest of united states and first with her professional responsibilities to representing the interest of very high level. idol think there is any evidence she did anything in

fact, we saw she acted and conducted herself very effectively to the advance interest around the world. >> i want to follow-up u.s. in the speech from patrick murphy and marco rubio that almost sounded like that he is building hard at him and that everything day mission why would we have not seen him go the hard with other republican senators quick spin mckyer made a very vigorous case and he raised sharp questions about the judgment of senator rubio and others who would pursue

a strategy to prioritize instruction over everything else. there is a great example from that senator rubio 1.claimed a constructive role to broker a bipartisan compromise for immigration reform. he did so because he recognized that would benefit the country and it is consistent with our values and reflects his own personal story. deterrence is back on all of that. let the president believes that says something about his character ament -- and to give priorities that he pursued when he was in office demanded sounds like

and it appears from that episode that those priorities are a much more centered on his political ambition, a desire to be loyal to his party, his desire to raise money from republican donors, and not the best interest of the economy or securing the border. were to fight for the kinds of values that he occasionally speaks rather eloquently about on the campaign trail. again, i know it may seem like senator rubio a pretty direct or personal criticism , but this is a concern the president has about a wide variety of republicans he has dealt with over the last eight years.

the republicans in congress time and time again prioritize political tactics that obstruct the president's agenda over the national interest. over investments of the middle-class and of the safety of the national security. that is unfortunate and it is an indication of the state of the republican party. . .

you doesn't mean folding on all of their principles and infected me standing up to those principles am looking for opportunities to work with democrats to advance them. it was opportunity to do that in the context of immigration reform until senator rubio walked away. and the president is hopeful that the next president of the united states will have a different set of partners in congress to work with. >> hey josh. has the white house been assured by judge garland that of hillary clinton is elected president he will not remove his name from consideration? >> well that is not how it works. his name is in consideration until the congress adjourns at the end of the year and then

there will have to be a reevaluation by the white house about whether or not to put them forward. secretary clinton at the vacancy is still there will have to decide if she wants to nominate him or somebody else to fill that vacancy. but i can tell you president obama certainly is committed to his candidacy and believes he should serve on the supreme court. and i certainly know that somebody with the credentials of chief judge garland to conserve the country so well on the court is still very interested in using those skills to benefit the american people on the supreme court. >> but there will be a period of reevaluation as you mentioned after the election as to whether or not, let me say it this way. republicans have said that they will consider judge garland's nomination if secretary clinton is elected president. we have been wondering if that's going to happen and can we be assured that judge garland is

not going to say now that a democrat has been elected he no longer wants to be considered? >> i've seen no evidence to indicate the chief judge garland is somehow going to withdraw his name from process and president obama is committed to do it everything he can to see chief judge garland be confirmed to the supreme court. >> but what's is the white house asked him about that specifically since it's something that the republicans are discussing. publicly? >> i'm not aware of any -- i don't know why he would wait around for 200 days and then pull out at the very moment that it seems like he's going to be confirmed. so i think that's not likely to happen. >> wikileaks. her statement last night was, or your office a statement last night is that you wouldn't comment on packed e-mails of a private citizen and at that point mr. obama was a sitting senator. he was president-elect. why make the distinction about a public citizen and certainly can't claim that for mr. obama that point.

>> they were the e-mails of mr. podesta who is was a senior official in the clinton campaign. again you can make your own journalistic determination about whether or not it's appropriate to report on the kind of stole a material but i'm not going to comment on material that was stolen from a private citizen just because it's been thrust into the public sphere in part because there has been a determination that's been made by the intelligence community that the kinds of tactics that were used to plunder mr. podesta's e-mails are the same tactics that we know the russians have used another settings to get access to material and make it public in an effort to undermine our political system. so i guess i have lots of good reasons lots of principled reasons for not commenting on it.

>> and finally one more question about the election. how is the white house feeling about the down ballot effects of donald trump and hillary clinton? >> well again i will let you guys play sort of a political analyst and i think there's lots of spinning going on by both sides. i haven't heard a lot of people spinning at the republican nominee is helping republicans down the ballot but maybe there are some people out there who can make that case and it's a free country so they are welcome to do so. but the president is focused on is making sure americans understand the stakes of this election and it matters deeply to succeed president obama in the oval office but it's also. important who will represent communities across the country in the united states senate and who is going to represent communities across the country and state legislatures. the stakes in this election are high not just at the presidential level but at the legislative level as well both

for federal government and also for state government. the president is going to make his voice heard and in these going to make a forceful case for democrats up and down the ballot. he's in a position where we expect a lot of americans to be persuaded by his advocacy. >> any other candidates that the president will really be pushing for in these final days? >> yes, many. stay tuned. >> of course the first lady is on the campaign trail too. they have both been making a lot of noise lately and a lot of pundits and writers have been saying that the first lady is hillary clinton's most potent surrogate. with the president agree that she has more power to move the needle in this election than he does? >> i think the president would agree that there are just basic facts about the first lady and the first is, she is somebody who enjoys the deep respect of a large majority of americans. >> but does she have more power

than he has in the selection to change peoples minds? >> she is somebody who is very persuasive than she is somebody who's been able to make a forceful personal case about why she is involved in this election and yes i think the president would admit that his wife is an enormously influential and powerful surrogate in support of hillary clinton. >> more than he? >> yeah for all the reasons i just cited based on the strong support in the deep respect the people across the country have for her based on the compelling personal argument that she has been making in support of secretary clinton. and she's also quite talented in her own right when it comes to the delivering of the speech. those things i do think combined to make for a very powerful at the ticket -- advocate for secretary clinton and probably the most powerful advocate that secretary clinton has. >> and.

>> could. >> and we were right to tape tape for second-year go back to your conversation with michelle when you said, you compared president duterte the philippines to mike pence. can you repeat what you said it explained alike a little bit? >> i'm glad you asked. because michelle was actually making reference to the significant number of senior filipino officials who have tried to walk that certain things that president duterte has said. in some cases they have gone to the extraordinary link that denying that he's even said that when the videotape would suggest otherwise. i think many of you have observed you found yourself in a similar position a couple of weeks ago. >> back to mosul. do you have any more on the american servicemember who was killed in the operation? >> let me start by saying that the department of defense did amounts yesterday that an american had been killed in support of -- while he was supporting a peshmerga operation in iraq.

and the thoughts and prayers of everybody at the white house or with the family of that u.s. servicemember who was killed in action yesterday. as you've heard me say on a number of occasions, those american servicemembers who are serving our country in iraq are doing very dangerous work and they are putting their lives on the line to protect our national security. there is a clear threat that emanates from isil and they are operating in a dangerous part of the world to try to mitigate that threat. now the role that they are playing is to offer their advisers and assistance to iraqi security forces and kurdish forces that are taking the fight to isil on the ground in their own country. that means that they don't have a combat role but the work that they are doing is very dangerous and they are equipped for combat because in some cases they find themselves in situations where they need to force to defend

themselves. >> was this individual on the front-line? >> i don't have the details about the incident self reader notes that the department of defense is investigating the situation about what exactly happened and updates on the situation will come from them. >> but it's still the white house assuring the american people that and maybe i'm wrong that there are not americans on the front lines in this fight to. >> i think what we see in these situations is and this goes to enders question, kirkuk for example has not been on the frontlines of the conflict but it was the site of very serious violence yesterday in iraq. and there were significant casualties as a result of isil's activity in that location that was not on the front lines. so i can't speak to exactly where the servicemember was the ace on the fact that they were serving our country in iraq acting in support of the

peshmerga advance on mosul is an indication that they were in a very dangerous situation and that they were in that dangerous situation because they were trying to protect the united states of america and we owe that servicemember in their family a deep, deep debt of rectitude. >> is the president willing to do -- to win this battle is offensive, the president willing to do anything of it takes to win this particular battle including increasing the american military role there? >> ron, the president has made the case that the success of this operation over the long term depends on a couple of things. the first is the ability of iraqi security forces and peshmerga forces to effectively coordinating this effort and that's what we have seen. they abari undertaken some very logistically challenging operations as they begin their advanced toward mosul. we certainly would complement them on their ability to coordinate their efforts.

but ultimately ron, in order for us to see the kind of sustained success in resolving the security situation inside of mosul, we know that it has to be iraqi's fighting for their own country. they had to be operating under the command and control of the iraqi government. there's an important role the united united states military can play to advance their efforts on the military battlefield. we can provide them equipment and expertise that can be used on the battlefield to make them more successful against isil targets. but ultimately they have to be the ones on the front lines fighting for their own country because they also need to be the ones who are responsible for rebuilding that community once isil has been dislodged. >> at some 5000 troops. that's the top, that's the? that's a number that the american public can expect in iraq. for how long? >> certainly for as long as

president obama's commander-in-chief. the role that will be given to our men and women and their servicemembers serving in iraq will be to, in some cases, provide training to iraqi security forces and other cases provided i said this is to iraqi security forces that are take responsibility for the security situation in their own country. we do maintain special operation forces and they have the unique counterterrorism capability that in some cases they may be called on to undertake raids to after high-value targets were to go after caches of information that could have significant intelligence value. there are obviously u.s. military fighter pilots who are carrying out operations, dropping bombs on isil targets. all of that work is very dangerous and all of that work is a testament to the bravery and the skill of the american military but it's also a testament to the strategy that president obama believes is critical to our long-term

success which is that we need to build the capacity of security forces to fulfill the responsibility of fighting for their own country. >> just one all up o.. there's talk of another humanitarian pause and i can anticipate your skepticism about that. at the debate the other night secretary clinton said she supports the idea of safe havens in that area. in terms of the transition that's going on in the talks that are going on is there ever any discussion between secretary clinton's people in the white house at that level about her views about something like that, a safe haven in syria verses the current white house position of no safe haven? i know you are talking about a lot of things but is there ever that kind of level of discussion about those kinds of matters? >> no, there is not. the fact is the president is national security team are working to formulate the kind strategy that advances their interests against isil in iraq

and in syria. and if secretary clinton is selected to be the next president of the united states and she will have an opportunity to participate in the transition process in which there will be extensive conversations about what our strategy has been an and then on january 20 secretary into multics office as president of the estates as president and his states in chic and former national security team and implement a strategy that she believes best dances are interests. all that is obviously contingent on the outcome of the election but before the election i would not anticipate that kind of consultation that you are asking about. >> and is still the president's position that this is not in america's national security interest to create the sort of safe haven as it's been generally described? >> i'll also point out that it's also the conclusion of the nicest military that imposing a safe haven like this is not the most effective way to advance our interest in united region. the president has routinely

pushed his national security team to evaluate different options and consider the likelihood that different strategies could be more successful to look or ways to reinforce a ramp up our investment in some tactics that are yielding progress. that's the kind of rigorous process that the president has been focused on that has allowed us to make a lot of important progress in against isil both in iraq and syria. but thus far the conclusion of the president's national security team has been that the approach that we are pursuing now in trying to reduce violence in aleppo through diplomacy and using our military might to focus on isil has advanced the security interest of the united states has made the american people safer, has degraded isil. but we haven't yet seen the kind of reduction in violence in syria that we'd like to see because there continues to be too many innocent people in harm's way. >> so the strategy is working. >> well there's not denying we

have made important progress. >> but you just said that you haven't seen a reduction in violence that you want to see so that aspect of that's not come the strategy is not working. >> we have anic on the struggle yet. we have made important progress in driving isil out of 50% of the previously populated territory and previously controlled in iraq. we been able to drive them out of 25% of the territory in syria. there have been important gains in dislodging isil from certain territories and reducing the violence in certain territories that there are some populated areas including aleppo where we haven't seen the reduction of violence a bit like to see. scott. >> josh a minute ago you talked about made a comparison of the tactics used in the podesta hack and tactics that have been blamed on the russian government i just want to make sure i'm clear that the homeland security secretary and the dmi talked about the attacks on the

democratic national committee and others. do you know something about whose response will or the podesta of tax? >> united states is not reached a formal determination about that but i believe what the intelligence community and barb bauman security is said is that the kinds kind of tactics that we saw with regard to the malicious activity on mr. podesta's e-mail account are similar to the kinds of tactics that we have seen used in other places. obviously the outlet is the same but i'm not aware of any sort of formal determination that ascribes responsibility to one country or one at your with regard to the malicious activity and mr. podesta's e-mail account gene. >> thank you josh. on north korea, north korea's continuing to threaten to launch ballistic missiles and that would also devastate the white house.

how do you address that? >> i'm sorry, can you repeat the question one more time? >> north korea threatening with their ballistic missiles. it would also devastate the united states and the white house. >> well as we have discussed here before the president of the last several years has increased the u.s. military presence in the asia-pacific to counter the ballistic missile threat from north korea and that includes the deployment of anti-ballistic missile capabilities in places like japan and alaska and guam. their aegis equipped u.s. naval vessels and the pacific that they can use to protect the united states. the president and his national security team and military leaders believe that the sufficient resources have been deployed to protect the united states. we are looking to enhance the kind of cooperation that we are

to have with south korea to locate an anti-ballistic missile battery in south korea that would better protect the south korean people, our allies in south korea from a ballistic missile threat in north korea. but we continue to be confident that the president's decision to deploy the those military assets adequately protects the united states from that threat in north korea. but i will say is those repeated threats and provocations from north korea to have the destabilizing impact on the region. our goal is to work with the rest of the international community to apply sufficient pressure to the north korean regime so that they will abandon those destabilizing provocative tactics and actually pursue an approach that's more consistent with their international obligations. >> yesterday secretary kerry mentioned that u.s. and south korea to plus two ministerial

meeting. he said that the united states has the ability to devastate north korea any time. do you agree? >> i certainly would not contradict secretary kerry. united states maintain significant capabilities but what we would like to see is a de-escalation in northeast asia and an end to the provocative rhetoric in the destabilizing actions like a clear test and missile test that violate u.n. security council resolutions. that's the constructive path we would like to see north korea pursue and when i say we i don't need just the united states. i mean the united states, south korea, japan, russia and china all agree that that's what the north korean government should do. jc. >> i like to follow up on my colleague chips line of thought regarding an individual who was in the middle of all this is

divisiveness and as you call her rhetoric has come out very favorably and very powerfully and that's the first lady. her very speeches, her surrogate opportunities for secretary clinton. would she ever consider coming back to this white house on a future date not as first lady but perhaps as the president? >> no. [laughter] >> that's it. >> pam i will give you the last one. >> the presidency now was hacked last year on the unclassified server. is there any concern that any of those e-mails could find their way onto wikileaks and was the perpetrator ever identified there? and if so is that the kind of thing that would provoke a proportionate response from the u.s.? >> pam come i've never discuss the president's e-mail system and so i have never been in a position of suggesting that

somehow the integrity of the president's e-mail system has been violated. what we have acknowledges that there is -- that there was an intrusion on the white house e-mail networks a year or or two ago. i am not aware that any public attribution for that malicious activity has been revealed by the intelligence community but that is something that was obviously closely investigated by the intelligence community and by the department of homeland security and other agencies. the white house to take steps to enhance the safety and the security of the e-mail system here but i don't have any response to discuss publicly. >> and just on that opium hacked , was that ever determined publicly who was the perpetrator

and whether that would require a proportionate response? >> with regard to the breach of the opm systems i'm not aware that any public announcement was made about who was responsible for that intrusion, but we did talk at some length in the context of that intrusion about the kinds of capabilities and potential responses that the president could use with regard to that intrusion. but i don't have any insight to share about what public response , or what sort of response was mobilized. >> is it that you haven't figured out who did a? because you are pretty clear about north korea did the sunni hack and russia hacking to influence the elections but we still don't know who officially did that opium hacked. >> when these breaches are reported there is a careful investigation that's conducted by experts at ths and other

investigative agencies like the department of justice and the fbi. in the context of those investigations what they do is they try to learn as much as possible about the individuals or organizations or country that perpetrated the attack. they try to get inside into what vulnerabilities they were able to exploit and try to determine what information was put at risk. what they also do is they also evaluating whether or not naming the malicious act or would advance the investigation or dance the interests of the united states. that's why on a case-by-case basis, the intelligence community and the department of homeland security and law enforcement carefully evaluating

whether or not naming a country or a criminal organization would be helpful. for what decision they have reached, or why they have reached that decision, i would refer you to those investigative agencies. but what the president has tried to do is to prioritize the resources that are used by the united states government to protect the american people and to protect their interests in cyberspace. there is a lot of work to be done because the united states is in a position where we are quite vulnerable. so much of the work that we do a daily basis, not just in government but also the private sector and the lives of our daily citizens, involves connectivity to the internet and that includes risks. and so that's why the united states government has been working aggressively and his wife frankly we retain better defensive and offensive capabilities than any other

country in the world. we need them given how much our country and our economy and our national security relies on the internet and their abilities to use the internet in the context of our daily lives. >> anything on the mass outing today on line? >> i'm sorry. >> is the white house where the mass internet outage today? >> yeah justin asked me about it. so the dh is tracking it. why do we do the week ahead. on sunday the president will travel to las vegas nevada to deliver remarks for hillary clinton and candidate catherine cortes masto. in the evening the president will travel to san diego california where he will deliver remarks at the questions added dccc event item under the present will deliver remarks at a hillary victory fund reception and in the afternoon the president will travel to los angeles where he will participate in a taping of "jimmy kimmel live". leaving the present will participate in the dnc and

hillary victory fund roundtable. on tuesday the present will participate in the dscc roundtable and an afternoon he will come back to the white house. on -- that's on tuesday tuesday. and when tuesday. on wednesday and thursday to present will attend meetings at the white house on friday the present will travel to orlando florida where he will participate in a hillary for america event down there. all right? have a good weekend, everybody. >> is in there feature of booktv and c-span2 is her coverage of book festivals from around the country. saturday we are live at the wisconsin book festival in madison beginning at 11:30 eastern.

>> it was part of this debate designed to prove to the public that the danger was real and that therefore the military trial was helped by it.

and as we know it worked. lincoln won the election. >> the liberation front is playing on and building on all of the lessons that the whole other array of social and cultural movements from this period are developing, the antiwar movement, the civil rights and black power movement, women's liberation movement. they are taking the best aspect of those in building upon them. >> sunday the answers to lock on american artifacts we take a tour of the woodrow wilson house in washington d.c. with the second of director where the 20th president retired in 1921 and died three years later. >> he responded to that crisis by sending food aid to armenia. the armenian people were very grateful and a group of armenian women touring the united states

raising money for armenian charities were here in 1917 just after we declared war. .. >> after that james clapper talks about alleged hacking.

now, a briefing on veterans access to va-owned health care facilities and suggested changes to the veterans choice act which is set to expire in august of 2017. this is just over an hour and a ha half. >> hello, everyone, we're going to go ahead and get started. i'm marilyn serafini, and on behalf of blunt and carden, i'd like to welcome you to the veterans briefing on health care. the veterans choice act became law in 2014 creating a pathway for some veterans to receive some of their health care through the private sec torre. there's been a debate how best to deliver health care to veterans for quite some time and the last two years have some experience to consider as policy makers here in washington decide how to

proceed going forward. today our speakers are going to help us understand the complex system through which veterans receive their care and how it's changing given the unique needs of veterans. i'd like to thank our sponsor for today's event, ascension health, and i'm going to turn over the mic now to mark hayes for a few words. >> well, welcome. i'm going to be very brief. i just want to thank you all so much for coming to this important briefing on a very important issue. ascension is very pleased to be a sponsor of this briefing because the care for our nation's veterans is so important and it's the issue that combines both veterans issues and health care issues and so it's a great issue for the l.a. and different offices to meet each other that we don't always interact, but it's a great opportunity.

we have a great panel this morning, ascension is the largest nonprofit health system in the united states and the largest catholic system in the world and we participate in the veterans choice program because we see caring for our nation's veterans, those who have served alongside the va, as something that is very central to our mission. and so, we are very pleased to participate in the program and are looking forward to what we will learn this morning. thank you all for being here. >> thank you, mark. so if you are following at home on c-span, you are welcome also to follow and those in the room are welcome to follow and participate in the twitter conversation, the #veteranshealth.

you can also use twitter to post questions to the panelists after each speaks and after we go through the line, we'll turn to your questions and you can ask several different ways, pose your question via twitter #veteranshealth. we have two microphones in the room and also in your pacts, you have a green card and you're welcome to write your questions on the green card and our staff will pick them up and i will present those questions to the panelists. also, if you are not with us here in the room today, you can find the speakers presentations and also other resources at our website, allhealth.org. so, now i'm going to introduce our panelists today. first, we have sherman gillum, jr., the director of paralyzed

veterans of america and served our country in the marine for over a decade. after 9/11 as he was preparing to deploy for afghanistan, sherman sustained a cervical spine injury that ended his military career. since then he's served his fellow veterans with work at the paralyzed veterans of america. thank you, sherman for your service to our country. and next we have the deputy undersecretary for health for community care at the veterans health administration. before joining the va he was a leader in hiv medicine in pennsylvania. and from tri-west, and carry farmer for the behavioral and policy, social science-- excuse me sciences for the rand

corporation and access to and quality of behavioral health care for military service members and veterans, as well as treatment and recovery from traumatic brain injuries. and finally, we have john kerndell. senior vice-president for lifepoint health and oversees operation support and planning departments that provide direct assistance to life points hospitals and providers. so, we're to start off first with sherman. so, i turn it over to you. >> thank you, marilyn. good afternoon, everyone. these pictures show me the book ends of my military career, 17-year-old private first class that became the 29-year-old commission officer that you see on the slide.

and at that time, i didn't know much about what being a veteran meant, nor did i really care. i never set foot in a va medical center much must less receive care from the va system. anything i had would have been secondhand knowledge at best and ignorance at worse and we have too many in media and government that share the same lack of ip sight and since they know what's best for veterans. and hopefully we can change that in this forum today. and here is why. because this happens. car accidents, mishaps, illnesses, and inflictions inherit to the hazard of military service. this was my car after i was extricated.

following spine surgery and intubation while i was unconscious, 11 days of intensive care until i stabilized and my very first contact with the va medical center, where i'd start my rehabilitation journey. there was virtually no decision that was my own. my life was literally in the hands of others. the same with service member who suffer the fate in the future and those veterans who had seen war and profound mental and physical hardship. so here are the questions, what will the va of the future look like for them? what will change? will it be better or worse? more importantly, who will decide? will that decision only be on public outrage for isolated incidents? or will decision makers at least have set foot in several va hospitals and spoken with

numerous veterans to inform their thinking? so this is me now. byproduct of va health care. one of many who have filtered through the system, seen firsthand what needs to improve and there are things that need to improve. and no experience that makes it unique. a veterans system of health care that cannot easily be replicated as they're currently constructed. there's more work to do. this version of me has coverage through tri care and i've accessed emergency rooms when the va wasn't readily available. providers were competent and compassionate to my needs, but there was a disconnect that was stark. as i recall much of my relevant history while fighting a debilitating favor because my records weren't available.

i'd be left sitting in a waiting room behind the line of cast of characters as just another guy in a wheelchair who needed medical care. after dealing with what ailed me, i'd have to drive myself to the nearest drug store hoping to carry my prescription. i'd have to bounce around to several drug stores or simply wait for medication because it was out of stock. >> and this is what fragmented health care looks like when taken out of the abstract for veterans who would be impacted. let's take a look who will be impacted today and in the future as va health care evolves. for most, getting dental care, eyeglasses, hearing aids, x-rays, urgent and emergency care in a timely manner is a good thing. but let's not underestimate what that means for the men and women in my circumstances or worse. you see the numbers on the slide.

to me, they're not just statistics. these are veterans whose quality of life is a matter of life and death in many cases for the rest of their lives. here is a problem for those who advocate for complete privatization, yet agree that va should provide the function for specialized services and i keep hearing, they can do what they can and privatize the rest. that doesn't work, having the spine doesn't mean i won't have cancer, develop diabetes or need what is referred to as tertiary care. and the veterans access those other services such as oncology, surgery, cardiology, neurology and because of the interdisciplinary frame work unique to va. that's why you cannot separate

them. in kt fa-- in fact, specialized services should demand that tertiary services be driven completely to the private center. so with this busy slide in front of you, we'll turn to the discussion of the attributes that make va unique during my 14 years of using that. and the tertiary and specialized care that most who opine on the topic likely do not know. here is a bit of education. i'd like to draw your attention to a few starting with ones in the red boxes. did you know, a veteran seeking care in the private sector do not have to pay for the expenses for them providing a request to cover unauthorized medical expenses is timely provided. that's not so in the private sector. eligible veterans who have medical appointments are reimbursed for their mileage

and travel provided-- unless provided by the va or contractor. that's not so in the private sector. a veterans receive access to prosthetics, va benefit assistance and peer support durling appointments, making it a more veteran centric experience than they'd receive anywhere else. that's not so in the private sector. now eligible veterans do have a choice, they have a choice and that's a good thing because they can seek care from alternate provider of timely va care, is not available, which is great as a component of va health care, but not as a replacement. >> finally, i'd like to close with comments on the most overlooked aspect of collaboration between the va and the private sector when discussing health care for veterans. title 38 of the united states code, the authority that

governs the delivery of health care, products veterans through due process provisions, medical, and title 38 afforded protection do not follow the veteran who opts for care under the choice act. congress will not have the jurisdiction to compel testimony from private sector ceo's whose health care systems, gained the numbers or have hidden -- maybe we're wrongly assuming it never happened. moreover, veterans rely on the courts if health care goes awry if they can afford it. it's effective and sustainable collaboration is to happen this absolutely must be addressed. as long as these veterans know that, that's the reality, then we've given them not just a choice, but an informed choice. beyond simply hoping for the

best. if they chose va for their health care, it needs to be a viable choice. thank you. >>. [applause] >> thank you, sherman. now we will turn to the doctor. >> thank you very much. that was just an amazing experience of some of the care that's provided in va. just a little about myself. i'm a practicing physician within the va. when i'm not seeing patients, as often as i would like these days, i'm in d.c. leading the va office of community care. one of the other key pieces about kind of my journey with va is i trained in va. i was a medical student down in gainsville, florida and then a fellow at university of pennsylvania, the philadelphia va, as many of you may know,

70% of all of america's doctors at some point interact with the va. that's another key feature of the system not only taking care of our veterans, but also training the next generation of nurses, doctors, and other health care professionals that will take care of all americans. to sherman's point, at the end of the day, what we want to see as a vision for va, and va health care, is what we call an integrated health care system. it's a system that includes va health care providers and clinics, as well as leverages, expertise from the private sector. unlike many other health care entities in the united states that are limited by their geographic markets, so if you're starting a clinic, it's-- what you actually do is patients come to you. va is completely opposite. we go to where the patients are. where the veterans live. and our veterans live in every corner of the united states.

some highly rural and some highly rural places and urban places and they span the entire geography of america. and in those circumstances, we cannot have a brick and mortar facility in every one of those individual locations. and so, we have to leverage community partnerships and they really are about partnerships, not just the care. partnerships that allow us to provide health care to veterans in those areas. so at the end. day, what we want to do is build an integrated health care network and i know that the alliance puts on a lot of these various programs and they focus on medicare, and so, medicare correlary would be an accountable care organization. this is really where we're looking to build, which is a network that is highly coordinated, integrated and includes va and community providers, really, we need both aspects to meet the full spectrum of needs for our veterans population.

how do we get there? we start with the veteran in the middle. so va and va community care has been ongoing transformation since the care came out and a year ago we presented a plan to congress, called the plan to consolidate care and right now we have multiple ways of purchasing care in the community and it's important to note that va has been partnering with community providers for decades upon decades. >> the choice act might have been a spotlight on our ability to purchase care, we purchase way more care outside of the choice act than within the choice act and we've been doing that for years and years and years. and a perfect example, the partnership we have with economic medical centers we started out 70 years ago. we're able not only to share clinical knowledge, but also research and training expertise. so, this is not new to va, this ability as a partner with different providers across the country.

and like i said, they span the spectrum from academic, community providers and federal institutions like dod or in the health service to fqac's to regular mom and pop shops across the country. so, how do we get to this integrated healthcare? we look at the community providers and we map the veterans journey through community care. it starts well -- with eligibility. right now base of the various programs, it creates confusion. the benefits that veterans earned and deserve are not clear in the community. so we have to be very specific who is eligible and who is not and hopefully make it fair and he c

he can he can quitable system. and hour community partners don't know if the veteran will be covered by va or not and that creates problems with payments. if they take care of an individual that we are not by law able to take care of. second is a referral and authoritization process. how do we make sure that we get our veterans care, timely access to that. this is making sure that we're able to leverage electronics, exchanges of information so that the doctor knows clearly what veteran they're seeing and the reason for that and the veteran also knows why they're seeing that doctor and when they're supposed to see them. care coordination, i always kind of state is where the magic happens here, this is the golden nugget if we're able to get this right we'll serve a model not only for our health care system, but for all of

american medicine. and it's in the era of value-based payments and integrated networks and this is the thing that folks are trying to figure out because you cannot live in your own institutions anymore, you have to work with other community partners, whether they're for delivering health care or community resources, housing and transportation in order to actually take care of patients. at va, we're uniquely positioned to start to address this because of our ability of integrating care between the community and within our own health care system and we're hoping to leverage more electronic health information exchanges and portals to share medical records between va and the community. the next one is the community care network, which is who is this network of providers that we work with. and this really does get to the idea of informed choice. right now, we have a broad network of providers, more than 350,000 partners that we work with in va with the community

of veterans. we want to make sure that the veteran is empowered to make informed decisions about the providers that they want to see and this is the same movement that all of american medicine is getting to. how do we get our community network to report on quality, satisfaction, value, so that veterans are able to choose a provider that makes sense for them, that this is a health care is a very personal matter, how do you choose a provider that actually meets their needs? part of this is also identifying what we call at va is our preferred providers. we know our providers in the va by interacting with veterans understand military competency and unique circumstances and conditions that our veteran population has. when i was practicing in the private sector, there just really isn't enough volume or touch points that you have with veterans to really understand all the different nuances. so we want our preferred providers to know the only

deliver excellent quality, high levels of value and expertise in military cultural competency and be aware of veterans issues and i think that way we can start to help our veteran population understand and choose a provider that meets their needs. next, is provider payment. and this is critically important, especially it being a practicing physician, as we view our providers as partners. and in order to be good partners to our providers, we have to pay timely and accurately. and this is something that the va continues to work on because of the multiple ways that we have of buying care today, it creates a lot of confusion. and i'll give you one example. when the choice act was passed, va by law was required to send out about 9 million cards to individuals. these cards look like health insurance cards and we have encountered many veterans that have taken that card to a community provider. the provider worked on the assumption that this veteran

was eligible and delivered care and on the back end, we got plans and not able to pay those clinicians because they did not meet those cry criteria. so we have to have eligible criteria that's simple, no red tape, make it easy for folks to understand so that the community and the veteran know exactly what is eligible and what isn't. and then us at the va can do our part that we pay timely and accurately and wrapped throughout all of that is a focus on the customer and customer service on our veterans and that makes sure they're able to get information to them in a quick and timely manner. so that's really our journey at va right now, on how we're tackle to improve community care. it's focused on the veterans and the touch points important to them and then spooling up projects to be able to move the needle in each of the areas. for almost every one of those areas we need to partner with congress to make sure that we make the system less complicated than it is.

when you're trying to run a program and keeping the veteran in the middle, it makes it hard when actually there's not one program, but seven or eight and we have to get to one program that makes sense for our population. >> i wanted to mention a little about how we can move towards a high performing network and this is a concept of this network that i described as internal va and external va partners and this graphic depicts that a little bit. you can see veterans moving from one location to another and including the va and our various community partners. and we want to-- we want to state where the puck is, where is health care in the future and what can we do with va to make sure we're meeting the needs of veterans not only today, but also tomorrow. and that means evolving from the fee for service model to a value based reimbursement model with preferred providers. with cms's and all the various

demonstration projects, they're testing out various model that makes sense from a value-based perspective. we want to participate in those as well. we want to make sure that we are not-- our community providers are not driven by volume, but more towards value. we do need some legislative help in order to do that. we also want to leverage better monitoring of quality of patient satisfaction and value. we want to be transparent about the care we're delivering in the va. the va reports publicly in a lot of various markers related to access as well as quality and satisfaction. we want to be able to get that same level from our providers that are veterans and are participating in. >> third, we want to transform from a care model that-- to a care model that's personalized and coordinated. inside va we have a central medical model we have teams

that take care of veterans and we need to leverage that personalized care as veterans that go in and out of the va. that's a unique challenge for us, that, as i said, also by many health care institutions across the country that being able to match a veteran with the right level of need and some veterans might just need a navigator to let them know where to go, what to bring and others need multiple point men and make sure they have transportation. how do we match them with the right resources and follow through the trajectory as they go in and out of the va? lastly, we need to leverage better exchange of information. right now in american medicine, there are a number of different health care providers that all use different electronic health records. and va has been in the business for decades and we need to communicate between those different entities and he think we have some innovative ways of doing that by really leveraging some of the community health

exchanges that are in existence today and moving more towards the portals of information. that's a little about the future of va and where we hope to get to and some of the challenges that we face from a legislative standpoint, but also, i think opportunities for us to be able to really lead the way in some ways for areas of american medicine. thank you. >> thank you, dr. yehia. [applause] >> now to david mcintyre of tri west. >> marilyn, thank you, and good afternoon, everybody. thanks for being here and those of you that represent members of copingress, it's a privilege to serve your constituents, because every one of your bosses have constituents, and part of why you're here. it's great to follow sherman who did a great job of weighing out the population, the individual responsible for being served by the system.

and dr. yehia who did a great job laying out where the system is today and where it needs to be going going forward. my-- they asked for me to layout how did we get to where we are from a choice perspective. what did that look like and what does the system currently do from a private sector perspective? so i'm going to spend a little time talking about the scaling that was involved to make this happen and where we sit when we look through my end of this lens. and this is responsible for one half of the country to build the integrated delivery system that makes up next to the va delivery system. obviously, as sherman represents, we have the privilege of serving the best of the best in this country. they're the people who serve this country. so, the choice act was born out of a crisis. i live in phoenix, arizona. in april of 2014, we all know what was disclosed in phoenix and quickly congress passed legislation and actually funded

it at the same time to give va money to be able to scale internally and also to buy more care downtown. they gave the private sector and va 90 days to stand this up. by the time the rules were actually figured out for what was going to be done, we had 33 days to go from a blank sheet of paper to full start-up. that's a very, very short period of time. but when we started, there were no four-hour waits on the phone and we were on our way headed down the track of what needed to be done and we spent a lot of time together trying to figure out where the gaps are between congress, the va, and the private sector and how do we close those things. many adjustments had to be made, policy and operationally and we'd probably gone about 75% down the track of closing those gaps, but there's a lot of refinement that still remains to be done as one would expect. massive scale had to be built and placement was key, but you had the greatest challenge was

to get people to understand what was actually enacted by congress. both within the va, within congress, itself and among the beneficiary population as well as by the health care provider community because this was launched very, very quickly. but we sit here today. a little past november 5th of 2014 when this needed to start and over five million appointments have now occurred through this program. our company and the network that we built is responsible for 3.2 million of those. how do you go about building out network. you've got to understand the demand curve. so we spent time working with the individual va medical centers understanding what demand looked like. if you had never filled out demand, you didn't understand that. we tried to map that. when you look at 2014, the blue area is our area of responsibility because we really didn't have a good sight line as to what the demand

picture look like for what needed to be purchased in the community and matched up next to va to give it the elasticity that it needed. this is what it looks like now. if you go backwards, that is what it would in 2014 of january, and this is what it is now, tailored to demand. and the bottom line of it is, very few cases are now returned to va in our area of responsibility because there's not a provider available to see that person, when the va itself is unable to deliver that care directly. i'd like to thank ascension for being a part of that network and thank lifepoint for also being a part of that network and the 185 to 190,000 providers spread across 28 states, they're delivering care today at the site of va to give them the elasticity that they need. in the first month, we served 2000 people and you can see what the demand curve has looked like. as dr. yehia said, the va's

been buying care in the private sector for a very long time. we're owned by two university systems which gives us a lens into the delivery system and by those that buy care and coordinate care and that's the core of what they do. you look at the demand curve and we're not at the top of it. yet, 6,000 units of care are placed from 2000 a month that was done previously. this is what's happened on the spend side. so, at the beginning of choice, as you start slowly into something like this, it's chiropractic care, podiatry, the lower cost, low acuity things. now it's brain, it's heart, it's digestive systems, it's brain injury, it's cancers. those things are placed in the community as opposed to va. what are the challenges that

remain? i don't believe that we've entirely solved the access equation. the issue at the end of the day is make sure we properly map the demand curve. make sure we're operating in an integrated way to make sure that people have the confidence that the provider in the community are the right ones to place care with. the second one is continued refinement and dr. yehia went through the various aspects of what's refined today. the biggest issue for us at the moment on our side, is to make sure that providers understand what it takes to file a claim properly. and then the process works in a streamlined fashion on our side, and then as the va reimburses us for the payment that we make to providers, that that full stream works. we still have works. and the doj stood up, and i was

in the same role then. it took three and a half years for the dod to engineer claims to get it right. what i'm going to tell you is the people in va are incredibly focused in the space and we're making a lot more progress than we made 20 years ago with dod. and in fact, if you go to a place like rio grande in texas, we just finished a triangulated project there to bring the va together with the hospitals in the community, together with our company to be able to look at how do we get claims right between all three of us. and we change the apiture dramatically in as short as five weeks and we plan to do that across the country. the third thing i would say, we have a very inhumane dialog going on in this country around this issue. this isn't about privatizing the va. it's not a good idea. we, as citizens have invested a

lot of money in the architecture and infrastructure of a great system. at the end of the day, this is about resetting a system. that's going to take 10 to 15 years to its end point. unfortunately, folks thought when you pass a bill, when you fund it, you're done. no, that was just the down payment on getting started. and some of us remember what happened with walter reed. it needed to be reset and reengineered. that took eight years. this is an entire system and it's about making sure that the people who served in combat the last ten years, they came from every zip code in this country, have the ability to go back to where they came from and live there and receive care. and if you're in a place like sherman is, you may need to go to a place that's right next to a va medical center, but the bottom line is, the system's not really set for that so this is partly a resetting exercise.

and then as they said, making sure eligibility works more streamline. the last thing i would say to those of you that are staffers here and i was a staffer a long time ago, back about 20 years ago, is when i left capitol hill, in the 60's when we passed medicare and medicaid, we created them as entitlements. >> the va is not an entitlement. the choice act makes it a virtual entitlement. that's a good thing. it's time to step back and figure out whether va should be the primary pair and whether we ought to think about, the notion that those that served our country, the way that veterans did, had the right, the first right to entitlement. because a lot of things would end up in a very different place were that the case and most of their care is financed by the federal government. >> so i said, that would be a challenge for former colleagues and those that followed me as a staffer.

lastly, i would say this is about teamwork. again, i come from the city of phoenix where the inferno started. on monday, this billboard was put up in phoenix. it replaced a billboard that was right outside the va that said the va is lying. for nine months, the staff that were driving to work saw that every day they went in. there are people that are dishonest. they happen to be in the private sector. they're also in the public sector, but not everybody's dishonest. and the fact of the matter, it was demoralizing. what this billboard shows that now replaces that one, as of monday, is that it takes a team to deliver for those who served this country. not to replace va, but to give it the elasticity it needs. 400 providers at the hospital in phoenix, surrounded by 800 providers in maricopa county,

of every specialty. to give them the elasticity to deliver our care. thank you very much. [applause] >> thank you, david, now to carrie farmer of the rand corporation. >> thanks, that was great. so i'm going to give a little bit of a different perspective from the research side. so, as something else that happened as part of the choice act was a requirement of an independent assessment of a veterans health care and rand participated in the independent assessment. i'm going to share some findings about the quality of va care, access to care and then also talk about what we know about quality of care and access to care in the private sector. so starting with quality of care, in our assessment, we looked at dr. yehia that va regularly reports many quality measures as does the private sector. when we compared va's performance on those quality measures compared to the private sector, in in case i

mean medicare, commercial hmo's and we compared in many ways. that va performed better than them on the-- >> and the wait time data when we think about timeliness of care. how long does it take to get an appointment. in this case va measured wait times, how long is it between the preferred date of care. >> that's the date that the veteran or provider would like the appointment to occur and the date when the appointment actually occurs. >> in our analysis, most veterans received care within two weeks of their preferred dates for care. of course, there's a lot of varabilities in these numbers. in phoenix it was not two weeks for an appointment, but in other parts of the country, the wait time nearly is much shorter. on average the wait time for a

primary care appointment was six days. another aspect of the access issue, where do veterans live. looking where they live relative to the va facilities, the vast majority live within 40 miles of some kind of va facility so this could include a va hospital or an outpatient clinic. when you start to look at more specialized needs for care a smaller proportion of the veterans population, live within miles of the facility that can give that care. and 46% of veterans live within 40 miles of a va hospital that provide the full spectrum of veterans care. >> so what does this mean about va turning to the community to help fill some of those gaps? what do we know about care in the community? >> what do we know about health care in the u.s.? overall, we know that the u.s. has a ways to go in improving the quality of care.

this study way from 2003, one of the landmark studies looking at quality of care across the united states. in this case, patients received 50% of all recommended care. the study examined chronic-- care for chronic conditions and for acute conditions. and since that time, there's been a lot of work understanding the quality of care, the institute of medicine had a number of studies, and examining the quality of care in the united states, and what we know about overall, is that the quality of care in the united states is variable. and there is room for improvement across all health care conditions. >> dr. yehia also mentioned military cultural competence. providers in the community serving veterans need to understand the particular needs of those veterans, with their experiences in the military are. in 2014 we did a survey of behavioral health providers in the united states, less than half regularly ask their patients whether they were

veterans or served in the military and even fewer reported knowing anything about military culture. >> and then what do we know about the timeliness of care in the private sector? >> we actually know little. it's difficult to prepare the timeliness of va care to timeliness of care in the private sector. everybody measures time limits of care different and there's not one standard how you measure this. in a couple of studies that we were able to find in the private sector, this measures the time between when the patient calls for an appointment and when the appointment occurred and we found that in these studies, that the times we-- the wait times were much longer. so 19 days for an appointment in one study and 39 in another study and these studies had a range. so when you compare that against six days on average in va, it does suggest that the timeliness might not be solved by the private sector.