to spend on independently on this kind of political speech, you know, they could crank that down to $500, to $100, to $5 and there is nothing that anyone could do to challenge it because they would have changed the first amendment to do that. now, the supporters of this amendment, all 41 of them and i have to tell you i find it absolutely shocking that almost half of the united states senate would for the first time in american history support something that would roll back part of the bill of rights, something unprecedented, has never happened in this country, they say that, well, you know, when you restrict the amount of money that individuals can spend, raise or spend, that's not the same as resouth africaing free speech. as the supreme court said in that decision 30 years ago virtually every means of communicating ideas in today's

mass society requires the expenditure of money from the humblest hand bill to leaflets to political ads run during prime time on tv, radio and other mass media to putting up billboards, putting up yard signs or in the modern internet age putting up a website all of that costs money. and, you know, the days when you could stand on a soap box in the boston common and speak politically to get people to accept your ideas or to vote for you as a candidate are long gone and, frankly, even then you want to be effective, it costs money and, again, those who say, well, the framers never imagined that the first amendment would protect money spent on political speech, political activity, well, excuse me, but one of the greatest works in america that helped spur our revolution, thomas payne's "common sense" it

cost money to write it, publish it, print it and distribute it and the federalist papers which helped get our constitution accepted by the states were printed in broad sheets which were the equivalent of newspapers at that time all of which cost money. so the idea that if you restrict money you're not restricting free speech is ridiculous, that's the same thing as saying that if you restrict the amount of money that a newspaper corporation like "the new york times" can spend buying news print you're not restricting their free speech. i mean that is just a ridiculous claim. now, this case as we have talked about wouldn't just overturn the citizens united decision and the mccutcheon case but as we said it would overturn the buckley decision, the case from 30 years ago, because it would also overturn what the supreme court said in that case about

expenditure limits. what a lot of people don't realize back in the 1970s, congress didn't just pass contribution limit, you know, that's what we've lived under now for 0 years. back then they limited the amount you could give to a congressional candidate to a thousand dollars. it stayed that way for 30 years. it was raised to $2,000 in 2002 and indexed to inflation but at the same time, back in the early 1970s, congress at that time also put in an expenditure limitation and said people running for congress and for president would be only be able to spend a certain amount of money to run for office. now, the supreme court threw that out because they said, look, that is a direct limitation on your first amendment rights. because when you limited amount of money that a candidate can spend, you are directly limiting their speech. you're limiting the amount of brochures they can send out, the amount of ads they can do, you're limping their ability to rent a hall and go speak live in

person to voters. so they threw that out. this amendment would get rid of that limitation that the supreme court came up with and once again congress could actually pass a law limping how much you spend. now, for those who think that's a good idea i'd remind you that once congress put the contribution limits in in the early 1970s, you can look at a graph of the incumbency rate of members of congress and that line will be like this, it just goes steadily up and why is that? it's because limits on contributions help incumbents, it's very tough for a challenger to take out a sitting member of congress. they don't have the name recognition, they don't have the contacts, costs a lot of money to knock out a challenger and when you put on limits on contributions, you're making it much easier for incumbents to stay in office and if you put in limits on expenditures which as

we've shown by history congress has already demonstrated it wanted to do, you would be making it an even tougher for challengers to come in and knock off members of congress and i will tell you that i don't think it's just a coincidence that in january 2010, remember, that's when the citizens united decision was decided, what happened in november of 2010? in november 2010 we had the most challenge i challenging congressional races since the 1930s. and that is because directly of the citizens united decision and the fact that suddenly there was independent political expend expenditu expenditures, the ban on that had come out. oral argue

don just mentioned this. if this amendment were passed the citizens united decision there was something usual and at the first i attended chief justice roberts asked a hypothetical question of the government. and the hypothetical question was, it concerned the electionary and communications provision, the provision that the congress had passed in 2002 that limited and banned the ability to run any kind of radio or tv ad 30 days before a primary and 60 days before a general election that named a candidate for federal office. now, the problem with that ban was that you could be running an ad, you could be the sierra club and you could be running a political ad about a bill that was going to be voted on by

congress on october 15th, had to do with the environment. and if you named a congressman who was running for office, if you simply told voters, look, this is an important bill coming up, please call congressman smith and tell them to vote against this bill you would be breaking the law if that congressman was up for election in november. even though your ad said nothing about the congressman from -- from terms of voting for or against in the upcoming election. that's one of the provisions the supreme court threw out but remember now that provision only extended to raid row and tv ads. the chief justice asked the government if we uphold this provision could it be extended to books by the government? he posed the hypothetical of a 500-page book that describes the political system and at the end

says vote for "x," could the government ban that and the answer given by the assistant solicitor general was, yes, we could prohibit the publication of a book. i just find it amazing that the solicitor general's office of the united states would give such an answer that they think there's nothing wrong with banning books and in the united states of america. some say there's too much money in politics. the intent is get it out of politics. very to laugh at that. i looked this up before i came down here, in 2013, american companies spent over $140 billion advertising their products and services across the united states. if you check several of the websites that total up political spending you'll find in the 2012 election cycle we spent about $6 billion total on elections, that's about the same as american companies spent

advertising fast food and candy in the united states last year. so this idea that we're spending too much money and then restricting it is the right way to go when we have such a great first amendment that believes in increasing debate in this country is i think just wrong. you know, the more political speech we have, the better and, again, i just have to say i'm shocked at the idea that congress, members of congress would be in favor of restricting the first amendment. these are all complicated legal issues, but i want to boil it down to this. this is what this amendment would allow if it was passed. many of you may know that the federal election commission where don and i both served does impose civil penalties on individuals who violate federal campaign finance laws. but if you knowingly and intentionally violate the law, you can be prosecuted criminally by the u.s. department of justice and you can go to prison

for up to five years. what a lot of people seem to forget was that david bossy who was the president of citizens united because of the fact that after the s.e.c. told citizens united it was not allowed to advertise for this documentary that it made about hillary clinton, because they -- if they had gone ahead with it after he had been advised he can't do it that would have been considered an intentional and knowing violation of the law and he could have gone to federal prison for five years if he had been prosecuted by the justice department. why? because he made a movie. now, i don't know about you, but i don't want to live in a country in which congress has the authority to pass a law that would put someone in jail for making a movie or political documentary writing a book sending out a voter guide publishing a pamphlet or taking out a political ad or because a

candidate spends $100 more than some artificial expenditure limit that the incumbents in congress put in to limit the amount of spending of anybody would wants to try to throw them out of office. i think this violates so the most basic tenets of freedom and liberty on which this country was founded and that the bill of rights was intended to protect. it's certainly not as i said the kind of country i want to live in. thanks. [ applause ] oh, and i should say -- one more thing. i almost forgot. i think there was an amendment at heritage would like to propose a new amendment that heritage would like to propose. you'll see that it's actually funny. it's exactly like the current first amendment that we have. [ laughter ] >> so we'll open it up for questions from the audience in just a minute, but first we have three ground rules. wait for the microphone, please

tate your name and your affiliation and ask a question, don't make a speech. so are there any questions? okay. down here. >> what do you think is the real motivation here for the left promoting this? it may be that this is popular or it will turn out to be a huge popular mistake. and do you see any way that given the fact that now 22 or 23 states have called for an article 5 convention for a balanced budget, that the left might be hoping that a convention occurs that they can then turn into a runaway convention that they can use to propose the amendment?

>> i guess i'll go first. ramon, i think it's being driven by two things. first is pure politic, second i think which is the more scary of the two, some of these guys actually believe that this is what we should do. as i mentioned in my comments, it is an election year, election years cause people to do things that they otherwise wouldn't do. and we certainly see a person drum beat being instigated by the democrats. to try to taint various messengers and messages and i think this fits hand in glove with that. i think it's also designed to intimidate and silence people criticizing them. this is nothing -- this is nothing new and to the extent governments do this throughout history we haven't seen our government do it at least in our recent history. notwithstanding efforts to limit and been struck by the supreme

court the idea of such targeted efforts. i think, are unpress dented. but, two, i think some of them believe it. you know, judge bork called it radical egalitarianism and equality for the sake of equality. i don't think anyone is against equality but what is the question of equality and when we see it play out equality seems to have an orwellian "animal farm" notion where some are more equal than others and i think that's part of what's happening here. i think long term it's bad -- it's bad for the people. its good for the incumbents. and ultimately it's probably best for those who actually get to make these decisions. when one looks at the text of the amendment, i'm struck by who gets to police limits on campaign spending. we know from the federal

taxpayer fund of presidential elections that the f.e.c. used to employ all sorts of people and do all sorts of mandatory audits. one can imagine an audit of every federal campaign in america. i was at the fec several years. most people there play it straight but some don't. recent think there was a person there who had to resign for rather blatant violation of the hatch act overtly campaigning for obama and against romney. this is someone in the fec enforcement division says the press. so the idea that you're going to have some neutral decision-maker over these things i think is fallacy. same with the freedom of the press. who gets to decide who is the press and not the press? a bun of elected bureaucrats at the fec. imagine going to the department of motor vehicle answer convince them you're really the media. do you want faceless bureaucrats doing that i understand the department of motor vehicles has come a long way in d.c. and

virginia and i don't want to cast aspersions there but it's convenient scapegoat. as far as the -- as far as a convention maybe but that takes a little bit long term thinking of sort we're not seeing right now. i think what we see is strategy between now and november. and i think what you see are incumbents desperately clinging to power. >> bobby, do you have anything you want to add? hans? >> i think we're deing with a well-established powerful and well-funded constituency that has for two or three decades advocated increasingly severe restrictions on campaign finance reform -- on campaign finances and interestingly one of their big issues is this so-called dark money issue. well, where do they get their money? none of these groups advocating for increasing disclosure and increasing restrictions on campaign finance disclose their donors. we think we know where the money is coming from, but they don't

disclose it. so there's a bit of hypocrisy there but there's also a strong constituency for increasingly severe restrictions on political speech. as for the constitutional convention i think it is a concern but i do not detect a great public groundswell for these sorts of restrictions and i think most people in this country understand that the purpose of the first amendment is to promote free and robust debate, the american public seems to like that and i would be -- i would be a little surprised to see if -- to a constitutional convention go down that track but it's a possibly. >> i'm sara stranahan. first of all, i think there's a perception that spending on campaigns both in direct contributions and in independent

expenditures have increased dramatically since buckley v. vallejo and i'm wondering if you can attest to the perception of that and i'm wondering whether you're aware of public opinion polls about citizens united and mccutcheon and what your sense is how the public feels about the current campaign finance rules. >> go ahead. >> i'll go first. taking them in reverse order, i'm not aware of any recent polls, i've venus coverage of polls and all universally say they don't like citizens united and when i read the poll i realize the question is skewed. i do primarily campaigns for a living so i think that i can read polls and when you ask it a certain way you'll get a certain answer and when you ask the question do you think megainternational corporations should be able to buy u.s. elections?

and the 80% say that's a bad idea. i wonder about the other 20%. but should the federal government be able to ban a movie that talks about a politician from pay-per-view so you can't view it in your home own, i think the polls should come out exactly of what the polls say so, you know, it really -- i always look for more of an informed question and not the superficial question that talks about, you know, the james bond guy buying the election kind of thing. there's no -- there's no -- in absolute dollars certainly spending has increased since buckley versus vallejo. spending on everything in america has increased. a brand-new ford mustang cost $3500 at the time. contribution limits imposed by buckley were a thousand dollars. if one were to convert that into today's dollars it's $4500.

state parties are limited to accepting $10,000 a contribution. if one were to index that to inflation you're up to $48,000. so spending, yes, has gone up but the way spending has changed, i think, is more the story. candidates have really lost their ability to be the central voice in american democracy in large part because of the reform law, party committees used to be the natural ally to echo candidate voices that's no longer the case. money has move add way from candidates and parties to groups that are not as transparent, not as accountable and not as long-term. so, yes, the total spending has gone up but when one compares to it other spending it's an interesting approach. when you compare it to what others spend on advertising for products it's still a drop in the bucket. i think ultimately it's not about the money, it's about what money buys, the cost of tv advertising has skyrocketed.

even over the past ten years. used to be you could get kind of a week of television in a house race for maybe 250 to 400 grand in a competitive race now it's 4 million and compliance costs have gone up to make political phone calls require an ever-changing set of review processes to comply not only with federal law but an ever shifting group of state laws so everything has gotten more expensive and the bottom line is even though spending has gone up unequivocally there's not enough money in politics to keep up with the information flow that voters deserve. ultimately the answer is more information for the voters, not less, it's unfortunate that takes money. but it does and advertising costs a lot of it. >> i agree with all of that. i would add to don's last point. this is -- this is the american

democracy, the american electoral system that we're speaking of, and to me more debate, more speech, more focus on the issues in television ad, in print ads, in public forums, that's a good thing. i do interthink it's a bad thing that people are airing a lot more commission ads and certainly are because of the restrictions because of the first amendment implications have rolled them back. the second thing i would say with regard to polling, it is true that these questions and i've been on panels specifically to discuss polling, the questions -- whether whatever the results that result -- whatever the results of the polls the questions are almost always slanted one way or the other. i haven't seen a question that fairly presents the issue in my view. they can be complex issues. they're difficult to phrase in a

o one-sentence poll question. but even if 85% of the american public wanted to impose tighter restrictions on campaign speech, that's what the first amendment prevents. the first amendment protects us from the tyranny of the majority. it protects the right of individual person to say unpopular things. and that's the spirit of american democracy. that's the tradition after american democracy and i frankly think that's also a very good thing. >> ken doyle, reporter with pna. i'm curious about how you see this playing out in the senate, the actual debate in the senate assuming senator rei dichlt brings up this amendment proposal. will there be alternative proposals debated or a straight up-or-down vote on this particular proposal and would you predict it'll end up just being a party line vote which

would obviously be far short of the two-thirds needed to pass it? >> well, let me take a first shot and just make a couple of comments. you know, i'm not sure how the politics of this play out actually. i think for democratic senators going on record to try to change the first amendment might not be such a popular vote. i could see -- i could see a real bolt from the majority leader on this issue. now, he may have enough votes to keep his -- he may have the power to keep his caucus in line on this. but to me it's not a foregone conclusion that you're going 0 have all the members stand up and vote party line on this. that changing the first amendment is a good thing. >> yeah, i would say and something that tells you, gives you kind of an indication of this, i think, is the fact that i think the administration really miscalculated recently

when it got the irs to propose new regulations for 501(c)4 organizations that are used, you know, the nra, sierra club, all 501(c)4s and the administration proposed these new regulations that would have severely restricted the political speech and activity of these organizations. the irs was overwhelmed with public comments in the negative. they got over 150,000 comments that's more comments for that one proposed regulation that all the other regulations, the treasury and irs proposed the last seven years and they were overwhelmingly against this change that i think they thought would be popular. and as a result the irs has backed off and said, oh, we're not going to put out these regulations this year. we have to take into account all these comments on it. but i think that's an indication of how they have miscalculated

on this issue. >> hi, my name is aerial giordano of the columbus school of law at catholic university and law clerk for the senate judiciary. according to citizens united laws that interfered with they political speech is subjected to strict scrutiny and the government needs to prove that the restriction furthers a compelling issue and it's narrowed. according to this amendment the wording is to advance the fundamental principle of political equality. bebides that specific wording has senator udall or any. the dems showed narrowly tailored compelling interest to justify this amendment? >> no. >> what they're trying to do is end run the idea of strict scrutiny with all respect to the court from years ago was made up

in the first instas, the amendment says what it says but congress will make no law actually means congress will make no law unless there's a government interest that's narrowly tailored. but you do raise a very interesting question that's sort of a sub seth of questions. political equality for all is a new principle being interjected in the world of speech and is that language that would empower congress in and of itself is a principle the court would use down the road to so-called level the playing field? who knows. what is clear is the senate, udall and others have not presented anything in the lines of analysis on this. this seems to be completely developed for the newspapers and the sound bites and maybe there's some white paper i haven't seen but i doubt it exists. and i think that notion of political equality goes back to the point i made when i was speaking were this motion there are democratic process limits on the first amendment and in some

instances the first amendment should be used to suppress speech rather than promote speech. that's a troubling concept and you see some notions of that work their way into justice breyer's dissent in the mccutcheon case. >> we have time for one more. >> mr. mcgahn, it it rides now, it limbs communication. could you say more about that. can i see that? >> under current law and even prior to citizens united when corporations were banned from sponsoring certain political communications, both corporations and labor unions were exempted to varying degrees when came to those identical communications if they were sent to what's known as the restricted class. so if i were to -- if i were a

corporation ax or union ax and decided to run an ad that said vote against senator so-and-so, if i published that publicly prior to citizens united that would have been illegal but if i sent that message to the restricted class which in the case aif union is its member and case of corporation is its administrative and executive personnel, their families and stockholders that was exempted. and i think that was driven by not just the speech concern by the associational concern that's also guaranteed by the first amendment. so when one empowers congress to in the name of political equality for all and protect the integrity of the processes and not just electoral this, is also legislative advocacy and it expressly empower congress to regulate the raising and spending money and in kind equivalence of federal elections i don't see how you can read it any way other than to say congress would have the power to limit the ability of a labor union to talk to its members

about politics. or -- >> can you watch the last few minutes of this discussion online and the entire discussion in its entirety at c-span.org. we leave it now to take you live to capitol hill for a house veterans affair on delayed medical treatment of veterans and reports of data manipulation at some v.a. facilities. >> with a subpoena on that particular issue, so we will not be having the business meeting that we originally had noticed and talked to everybody on the committee and i appreciate it. good evening. iowa tonight welcome you again to tonight 's hearing, oversigh hearing on data manipulation and actos to v.a. health care, testimony from gao, the i.g. and v.a. and tonight we are going to address ongoing issues of systemic wait times, manipulation that occurs

throughout the veterans health administration and negatively impacts the veterans that we serve and the health care that they should be provided. v.a. wait time answer scheduling issues have been the subject of numerous investigations by the committee for many years. we have many outstanding requests for information, and have held hearings to address the problems within v.a. that have led to veterans waiting so long for needed care. the v.a.'s office and inspector general has also repeatedly warned the v.a. about its substandard scheduling practices. from as early as 2005 in numerous reports, v.a.oig noted medical facility dis not have effective waiting list procedures, their outpatient scheduling procedures needed improvement nationwide, their data was often unreliable and they overstated their success

regarding patient wait times. in december, of 2012, gao found that v.a.'s reported wait ties remained unreliable. vha's position continued to be implemented inconsistently across v.a., schedulers in fact lacked proper training and vha's appointment scheduling system was outdaded and inefficient. despite these repeated warnings that have come from congress, from the gao and even from v.a.'s own investigative body, issues with patient wait times and scheduling remain a pervasive problem today. last year, this committee requested that gao conduct a separate investigation to confirm the extent of problems throughout the vha regarding ongoing issues with patient wait times and consult delays. gao will testify as to its findings here tonight. recently the committee received whistle employer complaints

regarding the phoenix v.a. health care system that explained how the falth was keeping numerous wait lists to give the impression that its wait times were much shorter than they actually were. one of the secret wait lists at the facility sources found that as many as 40 patients may have died while they were awaiting care. after the committee was able to confirm these allegations we made the issue public during our april 9th, 2014 hearing. at that hearing i asked that the v.a./oig look into those allegations that prompted its investigation. the interim results of that investigation were released on may 28th of 2014. in that report the oig substantiated a number of problems at the phoenix v.a. but noted how it opened or planned to open investigations into 42 different v.a. medical facilities.

the oig found that at phoenix, at least 1700 patients would were waiting for a primary care appointment were not on the electronic wait list. meaning that these veterans may never receive such an appointment. additionally, oig found that the phoenix leadership considerably underestimated new patient wait times which is noted is its metric used to consider bonuses and salary increases for v.a. employees. v.a./oig also stated inappropriate scheduling practices like those found in phoenix are systemic across the veterans health administration. finally we were notified earlier last week that v.a. would provide the findings of its internal audit of appointment wait times by last fry. they provided us with those findings earlier this afternoon. tonight, i look forward to hearing what v.a. has to say about its audit, how it plans to repair the damage it has caused

by tampering with veterans' access to care and with that, i now yield to the ranking member, mr. michamichaud. >> there's nothing greater than those who serve with honorary distinction. we're moving quickly to investigate the shortcomings within the v.a. especially those regarding access to health care. thousand is the time for us to identify the problems so we can move forward and implement changes. that means working together or oversight and legislative solution. it also means having very frank conversations with veterans about their personal experiences. so we know what we're -- how we can improve the system. over the years, this committee has identified how to fix many

of the problems within the v.a. but the v.a. is clearly facing a vice cyst, a crisis that is now being addressed by the media and now increase oversight efforts. in this environment, it is especially important that we are fair in our oversight and measured in our responses. but above all, we must never fall short of doing what we need to ensure that the veterans have access to the health care system that they've earned and deserved. it is important for us to work together to achieve the v.a. we envision. we must work together across the aisle and across the branches of government to fix these problems and ensure that the v.a.'s caring for our veterans. when we work together, this committee works best. we now -- that the work that we must put forward that we must ensure that the v.a. is receiving the necessary assistance and resources that they need to do what they have to. as i see it, there is critical

questions that should be asked by this committee. questions that get to the root causes of the problems. questions related to the broad strategic changes needed at v.a., changes in the leadership climate, encouragement with other agencies like d.o.d. and hhs, increased utilization of the private sector and long-term resource planning. we need to ask the hard question, what should the department look like in the future? these are not easy questions. nor do they have easy simple answers. but today, more than ever, we must ask these questions and come up with these answers. i believe thoughtful measured sound policy is needed today more than ever. the answers need to be comprehensive, and when necessary, nuanced. for example, when holding leaders accountable, we need to not only focus on senior executive members but also the

doctors and nurses who occupy administrative or executive leadership positions. as i mentioned earlier, hr-433 -- 43 the 9 closes a gap in the current package of legislation being considered by the house and the senate. mr. chairman, i've always been proud of the bipartisan nature in which this committee has operated. my hope is that we'll continue that spirit working together to help identify the problems and working towards a solution. no single individual has a monopoly on the answers. and no single individual or institution has all the answers. the work ahead of us will be hard and it will require all of us to work together in that regard. the veterans service organization, the department, this committee, the senate and the white house. and mr. chairman, i want to thank you once again for your robust advocacy for our veterans

and holding all these hearings that we're having for the oversight and it's my hope that when the committee asks for information from the department of veterans affairs that they provide that information in a timely manner so we will not have to issue subpoenas that we need. that's our responsibility and expect the department to help us do our oversight hearing as well so with that, mr. chairman, i yield back the balance of my time. >> i thank you very much for your comments this evening. i would ask that all members would waive their opening statements as customary in the committee and would invite the witnesses to please come to the witness table and as you're coming forward i will introduce you. tonight we'll hear in dr. debra draper, director of health care for the government accountability office, mr. phillip mikovsky for operations of the department of veterans affair, richard

griffin, acting inspector general of the department of veterans affairs, mr. griffin is accompanied by miss linda halliday, assistant inter-specter general for audits and evaluations for the department of veterans affairs. i would ask the witnesses if you would to please stand, raise your right hand. do you solemnly swear under penalty of perjury that the testimony you're about to provide is the truth, the whole truth and nothing but the truth. thank you very much. please be seated. all of your complete written statements will be entered into the hearing record. thank you for being here tonight and dr. draper, you are now recognized for five minutes. >> chairman and ranks members of the committee i appreciate the opportunity to be here today to discuss the ongoing difficulties the veterans are experiencing in obtaining needed medical care. in 2000 and 2001 we reported

problems with wait times and medical appointments scheduling and v.a. medical facilities and 2012 reported them again including the unreliability about patient wait times and inconsistent implementation of policy which impacted the timely delivery of care. we are currently conducting work examining v.a.'s management of outpatient specialty care consults, and again have identified problems that may hinder veterans' timely access to care. across our body of work on access to v.a. health care, several common themes have emerged. these include weak and ambiguous policies and processes which result in significant variation, confusion and increased risk of undesirable practices at the local level. software system that is do not facilitate good practices and inadequate training, unclear staffing needs and allocation priorities and inadequate

oversight which relies largely on facility self-certification without independent verification and the use of unreliable data for monitoring. my comments today focus mainly on preliminary observations from our ongoing work examines v.a.'s management of specialty care consults. we found most of the 1250 consults we reviewed were not managed in accordance with v.a.'s timeliness guidelines, specifically we found one in five consult requests were not triaged within the seven-day guideline. we also found 38% of the consults were completed but not within the 90-day guideline. 19% were completed within 90 days but the provider failed to properly close out the consult in the electronic system. and the remaining 43% were closed out the veterans being seen. v.a. medical center officials told us increased demand for services, patient no-shows and canceled appointments are among factors that lead to delays and

impact their ability to meet v.a.'s 90-daikon sult completion guideline. during the course of our review we identified one consult in which the veteran experienced delays and died prior to obtaining needed care. i want to walk through the time line of events force this case. in september 2013 the veteran was diagnosed with two aneurysms. in october the medical center scheduled the veteran for sur surgery in november but was canceled. in december they approved non-v.a. care and referred him to a local hospital for surgery. in late december, after the veteran followed up with the v.a. medical center it was discovered that the non-v.a. provider had lost the veterans information which the medical center then resubmitted. in february 2014 the veteran died prior to the planned surgery at the non-v.a. provider. this particular case is

insightful for a number of reasons including that while non-v.a. care may expand capacity there are potential pitfalls. for example, non-v.a. care requires prior approval which may delay care. more coordination is needed between the v.a. medical center, the veteran and non-v.a. provider and wait times for non-v.a. cares are not vacced by v.a. findings relative 0 our work include variation in ow head what will centers implemented new rules for specialty consults which limits the usefulness of the data for monitoring and overseeing consult systemwide and overall lack of oversight including no independent evaluation of their actions. as the demand for health care continues to escalate it is imperative that v.a. address this access to care problems. since 200 athe number of patients served by v.a. has increased nearly 20% and the number of annual outpatient medical appointments has

increased approximately 45%. in light of this, the failure to address a v.a. to address its access to care problems will considerably worsen and already untenable situation. mr. chairman, this concludes my opening remarks. i'm happy to answer any questions. >> thank you very much, dr. draper. mr mr. mikovsky, you are prepared to make comments. >> that is correct. >> good evening. no veteran should have to wait unreasonable time for their care. they have earned this care, american america's veterans deserve better. secretary shinseki and acting secretary gibson say we now know within facilities there are systemic and totally unacceptable lack of integrity. this is a breach of trust.

it is irresponsible. it is indefensible and untenable. unacceptable. i apologize to our veterans, their families and their loved ones, members of congress, veteran service organizations, our employees and the american people. after this committee raised the issues in phoenix at the v.a. health care system secretary shinseki directed a nationwide audit. i will be talking about that audit tonight and answering some detailed questions. this audit visited over00 locations involved over 400 of our national and field staff at the senior executive level, senior manager level and, frankly, line management level. we interviewed over 3, 700 front staff members. we saw this as the opportunity. the opportunity for us to set a

reset, to sweep away an established clear-eyed assessment of our actual performance, not our reported performance and to establish a systemwide understanding of the change we needed to realize in our agency. we released our results this morning on all v.a. medical cent centers, most midside cbcs and these results confirm the oig interim report our may 3rd initial release and, frankly, the gao studies. i'm here to answer questions about this audi and other concerns. our audit revealed a number of things, number one, we have hard-working staff on the front line who work at a high-stress, complicated environment with, quite frankly, completely outdated technology. the most frequent challenges cited by our staff are frankly a

lack of appointment slots into which to schedule veterans. they have a difficulty understanding our policies and they rely on an antiquated system that requires numerous work-arounds by well-intentioned staff. i have to admit that, unfortunately, we found that our staff were -- had received instructions to enter a date other than the date of veteran wanted to be seen. we know there's an integrity issue here. among some of our leaders, we can and will address this issue. i want to make a comment about reprisals against employee, acting secretary gibson mentioned this, that it is not tolerated in our system. we need our staff at all levels, but most importantly at the point of care. we need them to tell us how to improve our system, to be able to deliver care better for veterans and they must feel safe to identify problems and they must feel empowered to find

solutions. acting secretary gibson has announced immediate actions. we will expand and create new veteran satisfaction surveys for patient care. we will begin with veterans and their perspectives. we are holding senior leaders accountable. all of our senior leaders in the field over the next 30 days are expected to inspect their practices in their facilities and to be personally accountable for the integrity of those practices. we remove the 14-day scheduling goal from employee performance plans. we are increasing the transparency in the reporting of our data and we will be releasing our access and time limits data bimonthly from here on out. acting secretary gibson also announced an independent external audit of the scheduling metrics. we are deploying a team to phoenix to fix all aspects not

just their scheduling and management practices and formal lyzing a practice for high performing sites in both quality access and integrity to be able to provide guidance and leadership to our staff and facilities at facilities that require support. guidance and l at facilities that require support. we've directed staff to phoenix to hire additional staff to bring in temporary clinical staff, to bring in mobile medical units that are currently on the ground, to increase local contracts, to include for primary care. and we are removing leadership where appropriate. we are going -- we have -- i'm sorry -- suspended all ses performance awards for vha and we are freezing hiring for staff. so we may focus our hiring efforts on bringing on needed clinical engineering and administrative staff to the field. secretary gibson will travel to a series of v.a. facilities over the next few weeks to meet with

families, staff and identify obstacles to quality health care. secretary gibson has said we need to restore trust in the v.a. system and we must restore that one veteran at a time. our dedicated workforce over a third of whom are veterans are engaged. mr. chairman, thank you for your dedication to and your care for our nation's veterans. >> mr. griffin, you are recognized for five minutes. >> chairman miller, ranking member, and members of the committee, thank you for the opportunity to testify tonight, to discuss the interim results of the office of inspector general's work related to delays in care at the phoenix health care system. i'm accompanied by ms. linda halliday assistant inspector general for audits and evaluation. the issue of manipulation of

wait list is not new to v.a. and since 2005, the oig has issued 18 reports that identified at both the national and local level deficiencies in scheduling resulting in lengthy wait times and a negative impact on patient care. we are using our combined expertise in audit, health care inspections, and criminal investigators to conduct a comprehensive review requiring an in-depth examination of many sources of information necessitating access to records and personnel both within and external to v.a. we are charged with reviewing the merits of many allegations and determining whether sufficient factual evidence exists to hold v.a. or specific

individuals accountable on the basis of criminal, civil, or administrative laws and regulations. veterans who utilize the va health care system deserve quality and timely care. therefore, it's necessary that information relied upon to make mission critical management decisions regarding demand for vital health care services must be based on reliable and complete data throughout v.a.'s health care networks. to date, we have ongoing or scheduled work at 69 v.a. medical facilities and have identified instances of manipulation of v.a. data that distort the legitimate yaes of reported waiting times.

when sufficient credible evidence is identified supporting a potential violation of criminal law, we are coordinating our efforts with the department of justice. our work to date has substantiated serious conditions at the phoenix health care system. we identified about 1,400 veterans who did not have a primary care appointment, but were appropriately listed on the phoenix electronic wait list. however, we identified an additional 1,700 veterans who were waiting for a primary care appointment but were not on the electronic wait list. we reviewed a statistical sample of 226 phoenix appointments for primary care in fiscal year 2013. v.a. national data, which was reported by phoenix, showed

these 226 veterans waited on average 24 days for their first primary care appointment and only 43% waited more than 14 days. however, our review showed that those 226 veterans in our sample waited on average 115 days for their first primary care appointment, with approximately 84% waiting more than 14 days. we did not report the results of our ongoing clinical reviews in our interim report as to whether any delay in scheduling a primary care appointment resulted in a delivery or a delay in diagnosis or treatment, particularly for those veterans who died awaiting care. the assessments needed to draw any conclusions require analysis of v.a. and non-v.a. medical

records, death certificates, and autopsy results. we've made requests to appropriate state agencies and have subpoenaed -- subpoenas to obtain non-v.a. medical records. all of these records will require a detailed review by a clinical team. while we make recommendations to the v.a. in our final report, we made four recommendations to the v.a. secretary for immediate implementation ensure veterans receive appropriate care. we will address the sufficiency of v.a.'s implementation of these recommendations in our final report. our recommendations include taking immediate action to review and provide appropriate health care to the 1,700 veterans identified -- not listed on the waiting list at phoenix, and to take the same action at all facilities in the

v.a. system. mr. chairman, this concludes my statement and ms. halliday and i would be pleased to answer my questions. >> thank you very much for your testimony. members, we will all do a round of questions at five minutes apiece, and we will do a second round, i'm sure, after the first round. dr. draper, in your comments, you said that 43% of the consults you reviewed were closed without the veterans being seen. can you give me an explanation as to why the care wasn't provided? >> there are various reasons. one is patient no-shows, canceled appointments and this is canceled either by the patient or the medical center, and we also found instances of some records we couldn't tell, we looked at it and there was no documentation as to why the consults were closed. >> how does v.a. schedule

appointments? is it through a telephone call to the veteran or is it by a letter? >> it's typically through a telephone call with the veteran. the veteran may call us. we may call the veteran. we will notify the veterans on a recall reminder process which does involve a letter, sir. >> that's interesting, because i've heard numerous veterans telling me that they receive letters when their appointments will be and not asking whether they can attend that particular appointment. i'm a little confused. >> circumstance i've heard that as well. that is not appropriate. that increases our rate of no-shows. we need to change that. we need to find out when they need to be seen and scheduling around their requirement. >> v.a. has consistently stated that the alternate list or secret list in phoenix that was being used to populate electronic wait lists was destroyed immediately after the ewl was populated, so my question is was there any

independent verification in fact that every veteran on the alternate wait list was successfully transferred to the ewl or can you provide any documentation or assurance to us that no veteran was left off the alternate wait list? >> i've had a team on the ground, sir, reviewing their practices, and their scheduling processes. i have a report that's only their first draft report. i'll get a final report from them and i'll be able to dig a little bit deeper. at this point in time, i don't have any reason to believe that any veterans were left off the final ewl count, but i will wait for the final report, sir. >> can you tell the committee who at the central office, if anybody, knew or instructed or coached anybody how to manipulate wait times? >> i do not know if anyone had done that, sir, not in my direct experience. >> so you don't know whether they have or they haven't?

>> i certainly hope they have not, sir. that would run counter to our policy. i certainly hope not. >> in a brief in may of 2009, dr. mike davies, the national director of systems redesign indicated there were 49,743 veterans waiting for care as of september 15th of 2008. now more than five years later, v.a.'s audit shows and has been reported in the media that it has risen to 57,000 veterans waiting more than 90 days for their first appointment and an additional 64,000 veterans that appeared to have fallen through the cracks. how can this be? >> the correct use of the electronic wait list is the number that's 57,000, sir. we use the electronic wait lists if we are unable to schedule a veteran who is receiving their first special care consult within 90 days. the correct use of that is to ensure that we can work a veteran into an appointment

sooner. the 57,000 number is a much more conservative number. the known direct clinical care is only 40,000. we have to get eyes on the ewl. we have to manage it. we have to make sure there are front line staff at our medical centers are accurately working that list. getting veterans from waiting for an appointment into an appointment. as for the 64,000 that was the new enrollee appointment are request list. mr. griffin had told us that was one of the recommendations. if we can find that in phoenix, that we should look across the entire country. as we had a team review the new enrollee appointment request list, we identified every single veteran from the beginning of period of enrollment who may have at one point in time requested an appointment at a given facility where they provided their enrollment data. if we can not verify that they had an appointment, we went ahead and added them to the list so we can begin contacting them

tomorrow. >> mr. griffin, one final question before i yeel to the ranking member. have you found evidence of criminal activity in your assessment? >> we have found indications of some supervisors directing similar methodologies to change the times. we have been in discussion with the department of justice concerning those and whether or not in the opinion of the department of justice they rise to the level of criminal prosecution. that is still to be determined in most instances. >> i appreciate you talking with the department of justice. the committee has written a letter to them also asking they open an investigation. we haven't heard anything from them to date other than the fact that they got our letter, but i appreciate it. >> thank you very much, mr. chairman. dr. draper, in follow-up on the

question the chairman asked about the v.a. closed consultants due to no shows, what percentage were no shows versus v.a. canceling? >> well, we look at no shows and cancellations we went through the 150 consults and did a research all consults, the 150 cases that we looked at. to look at the history of the consult request. we found that more than half either had a no show or a cancel appointment. so that's a large percentage of the consults. so it's a big problem for v.a., and what we see is that the policies at the local level vary as to how the local facilities handled no shows and canceled appointments. >> thank you. gao reports that wait times are generally not tracked for non-v.a. care. why don't you track wait times for non-v.a. care? >> historically, sir, we have not -- congressman, we have two

initiatives. both of them in full deployment at this point. the first one is for nonv.a. care coordination. effectively what is occurring now is when we refer a veteran to care in the community, if we cannot provide it, it creates an appointment inside a clinic that allows us to monitor that and watch that appointment. we are now collecting timeliness data on that. we also have a nationwide contract called patient-centered care in the community. that contract has a performance requirement from our two contractors that they both schedule and see veterans within 30 days of the referral from us. we think those two approaches will help us in the long run ensure coordination and management of non-v.a. care. dr. draper also alluded the requirement to manage the coordination of that care. it's not enough just to refer care into the community. we do need to follow through as well, ensure that the veterans needs are met. that that non-v.a. provider is respectfully working with a

veteran, her or his family to get into care. >> gao also reports that there is a consistent problem across the vha with policy and procedures for handling no shows and canceled appointments. i'm aware that v.a. -- that you are working on an update to this scheduling policy. when do you anticipate this revised policy to be released and will it address the no-show consistently throughout the v.a. system and canceled appointments? >> i expect it will, sir. we had a team last week reviewing the existing policy we have today and to determine whether or not we should rescind that policy and replace it with a clear declarative set of instructions for our schedulers in the front line. we expect to take that action. we will replace that policy with a revised policy that allows us to have much more concrete instructions on how to schedule,

specific instructions for what to do for staff if we're scheduling within 90 days, what to do on day 91 to actually offer that specific instruction, and tie that policy to training. a lot of our current policy mixes two concepts. scheduling and practice management and we're going to have to make sure that we have a clear scheduling policy and a clear practice management policy. management of no shows can be handled by contacting veterans, working with veterans to ensure that they are reminded of their appointment, frankly. making sure we talk to veterans and their families when we schedule their appointment. when we do those thing, we can reduce our no-shows. >> can you explain to what extent exercising non-v.a. care requires additional approvals? jenchts. in some of our medical centers they require approval at the chief of staff level to use non-v.a. medical care. as part of accelerating care, we

worked on that in the -- i think the second to last week of may, we worked open the plan may 21st and rolled it out may 22nd and began execution on the 23rd of may. we have released instructions to the field that particularly where we have confidence in our wait time data that the field is required, if they cannot offer that care in the v.a. facility, first they must assess their capacity, increase their capacity by running nighttime clinics, overtime, weekends, if they cannot, then they are instructed to offer non-v.a. care to the veteran and then we ask asked them to tell us what you need to make that work. to work with a veteran, it is a veteran's choice to get timely care and to make sure we offer it. >> thank you very much. >> mr. lamborn, you are recognized for five minutes. thank you, mr. chairman. i appreciate the work you are doing on this issue. one of the areas that is going

to get further review is in colorado springs, colorado, and there are three aanonymous whistle blowers who have come forward and said there are problems with manipulating waiting times and i've talked to the leadership in both denver and colorado springs. they have told me personally that this is not going on, and i believe them, but at the same time we have whistle blowers saying that it is going on. how does the v.a. treat whistle blowers and what i'm getting at ises there is intimidation taking place? how do we change the culture of intimidation of people are free to step forward? >> part of how we designed this audit was to have direct access to the front line to the senior staff. when our auditors went to the field, they met at the same time

with union representation at the field and the facility management. not two separate meetings. one meeting. we did not provide announcement of who we wanted to interview. we provided that when we showed up. so we could have a direct conversation. i will tell you i have read through the open-ended comments of all of the responses that i could, and nothing -- nothing saddened me more than an employee who says i was trying to do it right. i know what is right and i received instruction to do it wrong. that is simply not tolerable. retaliation against whistle blowers is also not tolerable. we cannot condone that. we require a leadership and cultural shift in our way of managing. >> and i raised this a couple of weeks ago at our last late night hearing, and that is if you can't rely on the data, if you

can't rely on the records because secret waiting lists by their nature are meant to conceal the truth from someone who is doing a review, like yourselves, is the alternative to go in and do a case-by-case analysis, talking to every single veteran who tried to get an appointment and doing this on a one by one, even if that takes hundreds of thousands of contacts, how do we get to the bottom of it when the records or the reports are not reliable? >> i believe we have to begin with the end in mind. if what we want to do is to provide veterans with timely quality health care, let's ask them, how are we doing, how is our care, how is our access, is our access meeting your requirements, is it not, if not, let's fix it. the thing that's terrible about this crisis is this isn't even

an output measure, right? it's an activity measure. what happens when we change that activity measure is we can't tell where we're not timely. if we can't tell -- in no cases were we finding front line staff who were delaying care by moving the appointment later in the calendar. they were changing the reference point. when that happens, we don't know where we're late. when we don't know where we're late, we can't identify where we need resources or to realign resources, when we don't know that, our entire system is thrown off. >> i hope we've seen the final days and never again where bonuses or promotions are based on metrics that can be manipulated. instead of like you mentioned and i've mentioned this before and others have also, outcomes, like patient satisfaction, or good care that can be documented. not metrics that can be manipulated.

>> i concur. >> and do either of you other two folks want to comment on that issue? mr. griffin. >> i think it comes down to accountability of the senior leadership out at these facilities. and once someone loses his job or gets criminally charged for doing this, it will no longer be a game and that will be the shot heard around the system. >> thank you. i yield back. >> mr. brown, you are recognized for five minutes. >> thank you, mr. chairman. mr. chairman, thank you for having this hearing, and colleagues, i want to make sure that we're firing at the right target here tonight. we all on this committee because we care about the veterans and you can be sure that the only reason i'm on this committee is i care about the veterans and i've within on this committee for 22 years, and so i have a

couple of questions. dr. draper, you mentioned, and i want to thank you for your service, but the case that you gave about outsourcing that particular case and it wasn't the right kind of coordination, can you expound on that a little bit more? because a lot of people want to see us partner with veterans, if they can't get their service right away. >> yeah, i think it's an important point because there is a lot of talk of sending more veterans out to the community for care, and while that is a way to expand capacity, as i mentioned there are some pitfalls because v.a. does need to do a better job of monitoring wait times, managing the coordination, and just making sure sure that the veteran actually receives the care that they are going out to the community for. that was why we illustrated this particular case, because at many points, that did not happen, and, the veteran waited a long

time, and ultimately died waiting for care. >> i have a question about the survey because a lot of veterans tell me and a lot of discussions, once they get into the system, they think the system is the best. no complaints about once they get in. can you -- both of you, can you expound upon that? and a lot of specialties that is involved in the v.a. is not necessarily out in the community, i mean, we're the cutting edge as far as different kinds of technology, working with their unique ailment. >> i would say in my experience in reviewing various v.a. facilities, i think there is variation among facilities. there's some that are very, very good, and some that are more problematic. i think it's not consistent across all v.a. facilities the quality of care. >> congresswoman brown, i think we have a good system. it's not the best it can be.

the system belong to vit rans and their families. we are a system that's designed to understand their needs, to work for them, and on the front line, you find our staff are so engaged. i think their passion is unequaled. >> what percentage of the staff of veterans that work at the v.a.? >> over 1/3 of our staff are veterans themselves. it's a matter of making sure sure however that we have integrity in the system so that we can identify where access is not working. it's not okay anymore with all due respect to say it's great care when you can get it. it must be that it is great care and you can get it. >> timely. >> timely. >> that's the key. mr. griffin, any comments about -- one of the problems it seems is that a lot of the equipment, the technology that the veterans have is outdated. you know, the computer system

and the different systems. could that affect part of the scheduling problems that we're identifying? >> absolutely. going back to 2005 on the audits that we've done, one of the recommendations has been that they needed to have an automated capability to review wait times remotely. a lot of money has been wasted, millions of dollars have been wasted on contractors trying to create a better system for capturing this data, and over the past 15 years, going back to 2000, it hasn't had any success. >> if i may congresswoman brown. i think it's important to understand that our scheduling system scheduled its first appointment in april of 1985. it has not changed in any

appreciatible pg manager since that date. >> what about the equipment that i'm asking you about? the technology? i mean, we've had lots of meetings about technology, even people coming in to the system, you know, we brought in the banking community to make sure that people can't go in and what do they call it, steal your identity, so i mean that's part of the system also, right? is that correct? >> it is. so we have -- some systems are evolving and improving. we have a new veterans health identification card which has removed the social security number from the bar code from the magnetic change. across the board, if you look at our engineering, building systems, administrative systems, these are old systems that in in cases date 20 and 30 years ago, before the internet. i was still in college, you know. these are old systems. >> yes, sir. thank you all for your service.

and i'm looking forward to round two. >> thank you. >> thank you for holding the hearing. i have a question and i know mr. -- i want to follow-up on a question. this is for you. in gao's testimony it was stated there are no detailed systemwide vha policies on how to handle patient no-shows and cancellations. are you aware of any departmentwide policy for cancellations? >> we do actually have -- in our directive, we do actually have policies for managing no shows and cancellations, and we also have a policy that is supposed to guide our staff on how to manage veteran appointments and communicate with vet vans and their families to minimize --

>> describe that policy briefly. i don't have a lot of time. >> for instance, if we have a veteran who has once not shown up for an appointment before or has repeatedly not shown up for an appointment before, we have a no show list that allows us to contact veterans and that's actually part of our policy. and sites are supposed to be implementing it. we need to do a better job of training, following up and ensuring that practice is performed. >> i agree with that. i hear about the long wait times. i had a town meeting last week but i meet with veterans frequently. three-hour town meeting and one of the complaints of course was the wait times. everybody knows about that. missed appointments, for example, the veteran gets the appointment finally, and maybe through no fault of their own, they can't make the appointment. maybe an illness or maybe somebody just forgot, and then they have to wait another two months, for example, for an appointment. let me ask you this question, because that's a huge problem, is there any input, i mean, i hear about the lack of

communication between let's say the schedulers. you can call over and over and over again. does the veteran have input on when that appointment might be? you know, for example, they could have a conflict. a family conflict. a medical conflict, what have you. >> could i answer that? >> yeah. because that was an issue with the case that you cited. >> it is. and part of the problem is and i wanted to elaborate a little bit more on the no shows, part of the issue is the v.a. needs to better understand why the no shows and cancellations are happening, part of it is that the wait times work, pretty good scheduleser are engage in what is termed blind scheduling. they schedule appointments without being in contact with the veteran. the veteran receives the appointment through the mail and sometimes it may not be convenient or it could be that the appointment was -- the letter was received after the appointment actually was scheduled, and then we also see

that sometimes the v.a. contact information is bad so the veteran may never receive that appointment notice. so there's a lot of factors that go into the no show and cancellations, but that is a part of one of the factors that also affects that. >> have you ever asked the question of the veteran how would he or she prefer to get this information with regard to appointments? >> we need to improve the ways that veterans can see their appointments, manage their appointments, and frankly asked for appointments. we need to make that an integral part of our online system for my healthy vet. we do have a patient scheduling application which we are trying to roll into a state of production, but frankly it starts with the phones. pick up the phone, call repeatedly, and talk to a veteran and find out their preference, and then schedule. >> thank you. and again, the my healthy vets,

it's a great thing to have, but again that should be in addition to the personal contact and, of course, a lot of -- some people don't have access to computer either, so -- let me ask you one more question. i know i don't have a lot of time. again with regard to the wait list, in the hearing, this committee held on may 28th, 2014, members of this committee repeatedly and i know i asked who authorized the destruction of the interim electronic wait lists? however, dr. linch maintained it was protocol for when the appointments are canceled. if there is no departmentwide process for no shows or cancellation, now you stated there is, but what was he referring to? >> i don't know specifically. i've not been on the ground in phoenix myself. i do know that one of the things they were working on was to try

to move appointments sooner, and what they may have been doing which he referenced i believe in his comments was printing, red scheduling and then shredding the evidence because it contains personally identifiable information. i think that's what he referenced, sir. >> all right. we'll continue to ask the questions. thank you very much. i yeel back. >> thank you. you are recognized for five minutes. >> thank you, mr. chairman. for mr. dpriven -- griffin. in your investigation, did you identify any sort of pattern when looking at wait times and scheduling practices and what i mean by this is are there some types of facilities better or worse than others, are wait times longer for certain types of care? primary care versus certain specialty care, for instance? >> i would say one of the principal methodologies that we

have witnessed is a veteran calling in for an appointment. he gets an appointment. 120 days out because that's the first available appointment at that facility, and then that appointment gets scored as the desired date of the veteran and, therefore, zero waiting days. the vast majority of the cases that we have seen involve that scenario. the other scenario would be you get that appointment 120 days out, two weeks before the appointment, it gets canceled in the system, and then it gets recreated. veterans no wiser for the fact that his appointment was canceled because it's recreated for the same time and date, but once again, it reflects a waiting time which does not reflect the reality of the amount of time that veteran has been waiting for care.

>> those are similar to what we found as well. i would say in terms of the wait time data for new veterans, we tend to be able to trust that data better because it has a computer date stamp in it. it's not perfect, but it's better. we do find special care has longer waits a -- among those receipt vans we also note wait times in primary care. >> thank you. that was a very clear illustration some of the pattern. can you tell me, so in phoenix, there is both wait times of this nature for both primary and specialty care? i mean, i saw that the primary care numbers were -- >> we did see a significant count for primary care. there are a number of veterans on the the electronic wait list waiting for primary care appointments. what will typically happen is that you will then see a subsequent demand for specialty care, so as we're bringing in resources for primary care, we're also very cognizant of the

fact that we're going to require to address specialty care in phoenix, sir. >> i don't want in my question, i don't want to excuse at all the manipulation of wait times. that's not the point of my questioning. but i want to ask you if from your data and your audits are able to comment on whether there's an underlying shortage of providers. you mentioned a scarcity of appointment slots. how much of that is attributable to a shortage of providers and how much is that attributable to maybe inefficiencies in the way the facilities operate? >> i think we have to check them both. i think that in some cases we have provider shortages, but i think frankly we owe it it to the american taxpayers to run an efficient system as well. we have to look at productivity data and the amount of time in clinic serving veterans. i think it's both. >> if i may, i think an integrated health system is the

best system for veterans who have multiple conditions that they need care for. the further you dilute the locations where that care is provided, the greater chance of the care not getting properly reflected back in the medical record, the greater chance that that particular provider for that one instance of fee care may or may not be fully aware of all the other conditions that veteran is facing. i think what it's about is a business process of return on investment for getting your own doctors who are committed to the v.a. mission, who are full-time employees at v.a., as opposed to the 4.8 billion in fy 13 that we spent for fee care. i think there just has to be a strategic analysis of what in the long run is going to be the best outcome for veterans and it's something that has to be

continual because you'll have different mix of conditions from one facility to the next. >> along those lines of the integrated care question, is there a pattern in your research to the quality of care related to whether or not a v.a. facility is facilitated with a university hospital? >> i don't think so. i think our affiliate hospitals tend to be the more complex hospitals and we'll have a more complex set of services available to veterans, but we have some of our highly rural, unaffiliated hospitals and also wind up being top performers in health care industry rankings. >> thank you. my time is up. >> thank you very much. >> last week, during the recess, i had an opportunity to do something that was very personal to me as a vietnam era veteran. i went to vietnam, and we talked

to the folks there that were looking for our 1,200 mias and quite frankly we owe it to the honor of those who didn't return to provide for those who did. and we're not doing a very good job of that right now and one of the things that i think the problem with the v.a. system is is that the financial incentives are lined up to not provide the care. let me give you an example. in no-shows, for instance, when that's a problem with a consult, in our office, when we had patients who were supposed to come in as a consult, not a regularly scheduled patient, we had ways to check for those folks, if they didn't show up, they took up a slot that we couldn't fill with somebody else. there's no penalty with that at the v.a. that's free time. i'm looking here at a medical center that saw 68,798 patients. that was an entire medical center. our practice of ten doctors saw 40,000 patient visits in a year.

so i think part of it as you said is productivity. it's the incentives to make sure when you have a consult on there, you consult that. i just don't put a patient on my list and say show up. i think is it convenient with you, the baby-sitter, maybe my wife is sick, there's lots of reasons and you can call a -- there is a thing called a telephone. you can pick up and call somebody and mr. jones, are you going to be able to keep your appointment next week at 10:00. those are simple things. it doesn't require computers. it requires just a human being and a personal touch to check with that person. i can tell you they appreciate it. the patients appreciate it and they will keep their appointments if you do that. when you make something for me in september, i may forget about it by then or have ten other things to do and i think that's part of the problem. the financial incentives and making sure -- making them so

far out. the question, did you notice any particular kind of consult? there are areas maybe in cardiology, you have know, but rheumatology, maybe neurology, those are very difficult positions to fill anywhere, did you notice a difference in the type of consult? >> we looked at three specialty areas, gastroenterology, physical therapy, and cardiology, and we heard from the v.a. medical center officials, particularly in the areas of physical therapy and gastroenterology, that there was an increase -- the demand did not keep pace with the number of providers that they had, so, you know, the demand kept increasing, and they really didn't have the providers to always take care of the patients or fill the slots. >> so it did matter. i thought it probably did. >> we didn't look at all specialties but those were the three we did look at. >> i have one question. how much is your -- is your pay for performance, i asked this for last week or week before

last, when you are evaluated as a senior person at the v.a. is your pay for performance related to how many veterans are sent out in the private sector along with the wait times? is that part of it? no one could give me an answer. >> i don't believe it is, sir. >> that's fine. if it's not, it's not. >> right. >> and also mr. griffin, you know, for me personally, i know the chairman asked this question about the potential, when you have put a system in place that fraudulently puts information out there and then you gain financially from the taxpayers, that would seem to me to be a fraudulent case, and i'm just simply looking at it -- i'm not a lawyer. i'm simply looking at as a layman, when you've gone out there and on purpose misled, knowing that you will get a financial bonus if you did that, which is exactly what's happened, is that -- is that fraud? i think it is.

>> i agree. the issue is you start with the g 5, gs 6 scheduleser who have many layers above them. you have to work your way up up the supervisory chain to determine who put the order out to do it in this manner. that's what we're having to do at 69 facilities other than phoenix right now, with additional facilities reporting in every day. so it's not an easy task. i suspect if people do start getting charged, maybe that middle level person will say wait a minute, i'm not going to take a fall here for somebody higher-up the food chain than me who directed us do this. >> i certainly don't want see some schedulers head roll for

somebody else. that's not right. >> thank you, mr. chairman, thank you again for your leadership on this committee. my first question is to i -- -- >> live coverage of this house veterans affairs committee hearing will continue now on our companion network c span 2. if you would like to keep watching, we invite you to switch over now to c span 2 while we continue with other programs here on c span 3. as the hearing has progressed, we've been asking you what's the best way to improve the v.a. health system. several folks weighing in on facebook so far this evening. gail says the v.a. hospitals, clinics, have all said the same thing. money would help. stop cutting. tommy says how to improve it? get the politicians out of it and let the folks there do their jobs. again, live coverage of the hearing on the v.a. continues now on c span 2. coming up next on c span 3, a

discussion on the future of the european union, and in an hour and 15 minutes, a look at how the treasury department plays a roll in national security affairs. structure reform that's occurring, doesn't have payoffs >> next a discussion on the future of the european union. you'll hear from foreign policy analysts and the center for a new american strategy, along with a former german ambassador to the u.s. some of the topic discussed include the recent european parliamentary elections, the relationship between the u.s. and eu and response to the intervention in ukraine. this is a little more than an hour.

>> on his ard work inputting these events in place. we've got four fantastic speakers for this session, so i'll do you all a favor. not waste any more of your time. we're going to go in order, starting with andy moravcsik on the far right. >> andy. >> great. thank you very much for having me.

i wanted to dispel a little of the gloom starting with optimism. it will be sweet and sour here. every american administration starts by turning to asia, somewhere in asia and ends up back in europe. this administration has done the same. there is a fundamental reason why this is true. and that's because observers always underestimate europe's power and influence in the world. i think we should reflect on that for a moment to put all this in perspective. so europe, judging by practical results and what it's achieved over the last couple of decades is the other superpower in the world besides the united states. it is ambitious, it is successful, it's extraordinarily powerful. europe sometimes works formally, sometimes individually, really across the entire spectrum of ways of influencing the world, military, economic, ideational,

europe is the only counterpart to the united states and in all these respects has much more influence in the world than china. that gets much more press. it's the world's second largest military power. it's had on the average over the last two decades 75,000 combat troops in action throughout the world compared to china between zero and 2,000. in various operations like libya, it's led those operations. most problems in the world don't have military solutions. europe is the preeminent trade and investment power. in the world. larger than more influential than china or the united states. it might be in trouble, but that shows how important it is because we see what might happen if it goes south. it's the world's largest supplier of foreign aid. it's the most dynamic expanding regional power.

so the single most cost-effective instrument that any country or political body has had in the world to promote peace, security and economic well-being in the world over the last couple of decade has been european enlargement, and european enlargement continues into the western balkans. it has influence in places where there is little hope short term of a country joining the european union like ukraine. to which i'll return at the end. it's the major supporter of international law and institutions. not just in the region, but throughout the world. everything from the icc to the u.n. organizations and everything else and trade. it is the world's most important source of soft power ideas. if you poll people across the world or look at what they write into their constitutions, most of those ideas come from europe not from the united states, china or elsewhere. it educates students, it does

dozens of other things of that kind. throughout all this, it has a firm alliance with the united states, which is an enormous asset. something that permits it to work in cooperation with the other great superpower in the world, and again something that can't be said of china or india or any of these rising powers. you will remember in this room just a decade ago bob kagan telling us europe and the united states were from two different planets and destined to drift apart that. hasn't come to pass at all. moreover, europe, the eu as a whole is, i believe, and to a greater extent than the conversation we had up here might lead you to believe, completely stable because pulling out of europe would be suicidal for any country. the euro, we can talk about how stable it is, but britain is not going to go anywhere any time soon. and even today, the eu is more

popular and more trusted by publics in european countries than national governments are. that is even true for the british. if you poll british today and ask them, which institution do you trust more, the european commission or the british parliament? they will tell you the european commission. this is an institution that has a tremendous amount going for it. it has one major problem that started in 2008 with the economic crisis. because in 2008, i lived for a year in china. all the chinese wanted to know about was europe because europe had managed to convince people, and i think rightly, that it was a real force in the world. since then, europe's achievements and global influence have been called into question by the failure of one policy. that policy is the one we recently discussed, the euro.

so as simon pointed out correctly in the initial panel, it's a kind of tragedy of europe that its success has brought about questions because the euro has become a threat to european integration itself. there are three possibilities. one possibility is that europe moves forward toward a federal solution. that will be extremely costly, politically and economically. the second is that it slips back fragmenting into different euro zones or into single currencies. that will be also a traumatic, difficult and costly. the third and probably most likely is that it stagnates in a kind of japanese solution of low growth and muddling through, and that, too, will be economically and politically difficult. any of these options mean that

europe's economic and political capital will be lessened over the coming years and decade. so i would concede david's point that there are some public opinion and political constraints to what europe can do internationally, but i don't think they're as gray as people think. for example, europe has continued to enlarge now to 28 and continued the process of enlargement, despite the fact that process has never had strong public opinion support in europe, and many countries that public opinion support is single digit and has been for decades. nonetheless, european leaders continue with it and have done so successfully. the more important problem is that in order to pursue effective foreign policy, one needs economic resources and political wherewithal or room to move, and that is difficult. the difficulty here is that there are issues in the world

for which europe, because of its great power, is essential. you see this very clearly in a case like ukraine. we're only in the situation in ukraine because of the extraordinary attractive power of europe. that is how we should remember the crisis started. ukraine is closer to the western camp today than it was six months or a year ago, and putin is in worse shape than he was six months or a year ago today or trying to get back to where he was, precisely because the attractive power of ukraine, of europe managed to change the government in ukraine and change the status quo. but to the current situation in ukraine, there is, as ambassador ischinger will state in more detail, no military solution. the solutions in ukraine are going to be economic and political.

the western tools we have are only marginally military. nato's nice, but nato can't really do very much in the region except reassure poland. for influencing ukraine what's needed is action on trade, action on energy, action on foreign assistance, action on immigration, action on education and other assistance. those kind of policies are going to have to come primarily from europe. it is europe that dominates economic relations, social relations, political relations and cultural relations in that part of the world. europe is the entity that matters. so what we see is that in the end, it is the civilian power of

europe more often than not, and the return to europe that emerges when we look beneath the surface of issues in world politics like the ukraine. now, europe may not do as well as we hope as a result of the recent crisis, but it still possesses large power resources to influence the ukraine situation, and that is what we should look for in the future. >> thanks. i'm always tempted to say we should stop there and go for champagne now. i suppose we should plow on. charlie. >> thank you. like andy, i'm delighted to be here and to share the panel with the distinguished colleagues, and also because this is a conference that is being held in memory of clara. i didn't know her extremely well.

i had many interesting conversations with her about her passion, which is european defense and european integration. she is one of the most decent people i knew in washington. i speak for people here and in london who worked with her that she is sorely missed. i don't take fundamental issue with andy in that i share his view that europe punches above its weight in a civilian respect. the best testament to that over the last six to eight months is what happened in ukraine where you had a popular revolution take place because when ukrainians were offered a choice between a future that was with russia or a future that was with the european union, they took to the streets and said resoundingly, we want europe. and that suggests its attractive power despite its internal difficulties is extremely strong.

that having been said, i'm a little bit more worried about the political trials europe faces as a consequence of the euro zone crisis and recent parliamentary elections. let me begin by saying a few things about those elections and the surge in the right. a couple of quick comments on ukraine then i'll end with a thought on the implications for the united states and the transatlantic relationship. i don't think that the parliamentary elections that took place 1 1/2 weeks ago represent a political earthquake or a fundamental turning point in the trajectory of the european union for the following reasons. one is that most of the folks that will be sitting in what one

could call the populous quadrant are not scary folks. there are scary folks, yobic, golden dawn, neo fascists, nazis, anti-semites. most represent people who are anti-immigrant, who are skeptical about the european union, but they are within the confines of what you would call a respectable political spectrum. second point they represent a broad set of views. it will be difficult to see a

pro-eu have number one taxed to the center since the end of the cold war. and number two, been in power. the bad news is they have steadily lost market share with a couple exceptions. that means even though they tacked to the center and there isn't much difference between social democrats and christian democrats, they have seated the left flank and right flank to these growing populous parties. that doesn't mean those populous parties are in power. they are not. it means two things. one, they are having a greater and greater effect on those centrist parties because those centrist parties feel a need to cooperate them or appropriate

some of their language and policies. and secondly and more worryingly, they could win a national election. in the uk, in france, in denmark, populous parties actually got the largest share of the vote. that means in a french election you could have a candidate named le pen become the next president. i don't think it's going to happen. if it did happen, even though i agree with andy getting out of the euro or getting out of the european union is a very tall order, it would fundamentally change the equation. i'm less confident than andy that the uk is there to stay. i would say if cameron wins,

there is a better than even chance that the uk will leave the union, but that's obviously a speculative venture and at least the polling numbers right now don't put cameron in very good position. bottom line is it's worrisome what happened. the european union has been shaken by this event. it will make europe harder to move forward which is worrisome from the perspective of what happens if another major economic financial crisis emerges. the germans in particular aren't ready for full scale banking and fiscal union. i'm not convinced the eu is out of the woods when it comes to the financial crisis. this particular europe is not well prepared to deal with that crisis if it re-emerges. let me end with a quick comment on ukraine. i would say on ukraine transatlantic perspective, the glass is more half full than it is half empty. the united states and its european partners generally stayed on the same page, which is no small task in the europe of 28 members that reside in a very different geographic and geopolitical space.

that having been said, a couple of things worry me. one is the debate in germany where i think you have a government that is actually very close to the obama administration, and a public that is actually very far from the obama administration. it leaves an exposed political policy. i leave it to wolfgang to say a few things about this. having been in germany twice the last few weeks, there are weird things going on there about germans being closer to russians, about germany not wanting to move in a direction of taking on more responsibility. the debate on ukraine there is all over the place. in a way i don't think i've seen since the end of the cold war. secondly, i'm a little bit uncomfortable with how readily the g-7 partners opened up to putin over the last 48 hours.

i would have been more comfortable had they met with putin one-on-one and give a stern talking to. to have these one-on-ones with most of the european partners, i think sends the message that it's too soon. to kind of bring him back into the fold. what he has done in crimea, what he continues to do in eastern ukraine is over a red line. over a fundamental red line, and i don't think we should mince words when it comes to that question. finally, implications. what does all this mean? not much. why? number one, the ukraine crisis led to a recommitment of the united states to europe. we saw in the last 48 hours a $1 billion commitment from the

president to beef up defenses in central europe. number two, i don't think there is much elasticity in this relationship. i think 20 plus years after the end of the cold war the resilience of the transatlantic partnership is, to me, stunning. europeans and americans keep coming back to each other come hell or high water. that's in part because of common values and common interests, and it's in part because there isn't much in the rest of the world that offers anything close to the transatlantic partnership. whether it's indonesia, turkey, brazil, india, china, you name the emerging power, and you say are these countries stepping up and providing public goods? the answer is definitively no. they're not anywhere close to playing that kind of role in international affairs. it's because of that that i think even if europe weakens,

even if they stay a civilian power and don't move in a more decisive direction on amassing military capability, which i think right now is probably not going to happen, we are going to complain. we are going to talk about smart defense. we are going to talk about 2% spending gdp on defense, but the overall relationship is, in my mind, in very solid shape. >> thank you. andy, can i come back to you quickly on one thing. i got the impression you don't think the shifts in politics within europe are affecting its world role at all. it does strike me in one area, at least, they are. which is how we deal with the countries to our south in europe, where we adopted a very security-driven, anti-immigration driven stance which seems wholly holds to your view of europe. our main part with dealing with immigration was colonel gadhafi we paid to set up camps to keep him away from our shores.

in that way you see it as a slightly less solitary shift in our europe is dealing with the world. >> i think that's true. i do think europe has been more moved to, no doubt, europe has moved to a more closed immigration policy, particularly with respect to southern countries. that's true. whether it's moved to a more closed immigration policy all around or not is a separate issue. i think we need to look at all the political pressures and all the obligations europe has. there is no doubt what you say is true. >> julie. sorry. >> thank you for the invitation to be up here on this stage with so many friends and colleagues. i'm thrilled that i could be part of a tribute to clara. i met her a couple of years ago when i was working at the department of defense on

european defense. her favorite subject. and she came in, i think it was in late '09, to interview me about ten minutes in i was interviewing her, and the conversation flipped rather rapidly and i realized she should be sitting at my chair and working on european defense because she was incredibly knowledgeable. of course as we all remember, it wasn't just she had incredible depth of knowledge and expertise, but such an enjoyable person to be around. no ego, no hidden agenda. you could sit for hours, and i think it was supposed to be a half hour meeting and i think it went 90 minutes. again, i was peppering her with questions. after that i always made sure i had time for clara and would come hear her speak when she was here at brookings or around town. she is dearly missed and we are thrilled to pay tribute to her today.

on the question of the eu, the election results we saw a couple of days ago and foreign policy, i would echo what charlie said in terms of the election results probably not having a drastic impact on the foreign policy agenda inside circles across brussels. i think the emergence of slightly greater representation of some of these populous parties will muddy the debates and create complications in a couple of very obvious areas. obviously, russia would be at the top of that list. to the degree the eu will continue to have conversations about altering energy policy, t-tip trade policies, and certainly enlargement to the extent the eu is interested in continuing to have a debate about that. one can imagine how this cast of

characters that are arriving on the scene would alter those debates. i think it's a mistake to make drastic assumptions about how this will fundamentally force the eu to alter course on any of the issues i just mentioned or any of the other issues that it's juggling from ukraine to iran to russia or asia and a whole list of other foreign policy concerns. but i have been worried about eu foreign policy. i'm not as optimistic as some. i worry not just about the european union and europe's approach to foreign policy, i really have deep concerns right now about how america, the united states and europe are handling their common foreign policy agenda. i think what we are seeing is both sides of the atlantic find em