actually pushed. >> it's a combination. frankly, when something is going on for as many years -- not every -- but at a number of the facilities, it almost becomes the accepted way of doing scheduling. again, when you have lowest level employees involved in scheduling and they come in as a new hire and somebody says this is how he we do it, they may not realize that someone's telling them the improper way to do it. so it is a combination of things. bottom line is -- who's in charge. and when you get them a policy directive from v had hfha, do y

enforce it or do you ignore it? i think that's the bottom line. >> my time is expired but let me say once again, i thank you an your staff for the process you are going through. it is invaluable to our country's veterans and to the agency. >> senator, thank you very much. senator tester. >> i want to thank you, too, for your work and your professionalism. it is very helpful to us so thank you for your work. your investigations, whether phoenix or the other 93 facilities, is focused on scheduling. correct? >> what's that we dgo in to loo at but sometimes along the way you see other things you need to look at that may be tangentially related. there are some places where it is expanding. >> is it fair to say that the

investigation started out in phoenix because of some pretty damning things that were being said about phoenix. is it fair to say that the scheduling problems are pretty pervasive throughout the va? >> absolutely. >> okay. specifically for phoenix, look. a good portion of montana heads down there for the wintertime. was it that way parts of the year or all the time. >> we did not try to carve out the snowbird aspect that may impact phoenix. >> i was just curious. >> we did not have a good quarter in any of the quarters that we looked at. >> okay. what would you say to the folks -- because in the conference committee opening statements we heard a lot from members of the conference, from both houses, that talked about that this isn't a workforce

issue. in your investigations what would you say to that? >> i would say it is a complex issue with many aspects. one of those aspects is performance standards for the physicians that you do have. without those standards it is hard are to determine exactly how many doctors and nurses you need. it's a clinical space issue. vha guidance talks about a panel of 1,200 patients for primary care, but it assumes that there are three separate offices for each doctor so that you can have your patients ready to go when you come in and in phoenix there was only one office per doctor. so i think it's a combination of, yes, there's, this some facilities, they're understaffed, both nurse and doctor staffing. we have sought the implementation of staffing standards for years. we did a review in 2012 on

specialty care staffing standards and found that only 2 of 33 specialties had standards. i think you need to know how many veterans can we anticipate this specialist seeing in a given day, and then make sure the schedule is properly structured so you can fill those slots. >> you've got a number of m. 2k6m.d.s on your staff. are you an m.d.? >> no. >> when you talk about staffing standards, do you use the private sector for your staffing standards? should this be directed to one of the m. 2k6d.s on the staff? i'm not an m.d. either but it seems to me if you apply private sector staff iing standards, do

you apply the staffing standards or do you say va, you need to set up the staffing standards? >> we have said that we believe they should have standards so that if you're in a like-size va facility in one part of the country or another, the expectation is a certain level of productivity. i would ask dr. day if he would like to elaborate upon that. >> sir, we indicated that va create their own standard. aware of civilian standards. but without that data i don't know how can you make proper business decisions about what you're to make or what you're going to buy. >> that's good. thank you very much. there are 1,700 health care facilities in the va. 93 are being investigated by you at this time in time. can you give me any idea -- or is it pretty evenly split

between hospital cbox and small clinics? >> i would be guessing to give you that number. >> can you check on that number? >> yes. absolutely. and if someone at the table here has it, i'll glif ive it to you right now. >> there's nobody nodding yes. one more. >> we'll get it to you. >> my time just ran out. when can we expect a report from you guys on those 93 facilities? a full report. >> as we finish each individual report, and to be finished, if it's a criminal matter, we have to present it to the u.s. attorney's office for prosecution decision. if it doesn't meet the threshold for prosecution, we give the report to the department so that they can take administrative action, where appropriate. >> would it be fair to say -- don't want to box you in -- these would be done by the end of the year? >> i hope so. >> thank you. >> i want to go back on your

initial comments on the report. the draft report versus the final report. some of the changes that were made in that report. get some clarification as to timelines. it was reported that a line was inserted. if you're the va, this is the line you'd want inserted in that report. that line says, while the case reviews in this report document poor quality of care, we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans. obviously that was pertaining to the phoenix hot. just some timelines. was this line included in the draft report? >> there are many versions of a draft report the majority of the changes in our draft report came about as a result of further deliberations by the senior

staff of the inspector general's office. no one in va dictated that sentence going into that report. period. >> so was the line include in the draft report that was sent to the va? >> it was not included in the first version of that draft report. what i would like to do, if i may, is provide a timeline in writing to the committee -- >> i'd like that. >> -- that can, you know, make it very clear what is going on with that allegation. >> okay. i guess the question that needs to be asked, did the va play any, any part in the inclusion of this line? >> no. >> in your report you obtain the list of 171 patients who were waiting to seek services. most of them were mental health therapies.

you also denoted -- and noted in your report that between january of 2012 and 2014, that you identified 77 suicide. these patients did not have their appointments scheduled or were yet to be scheduled. what i'm trying to get to is, would a reasonable person come to the conclusion that wait time manipulation, would that contribute to patients deaths? would a reasonable person come to that conclusion that the manipulation of these wait times contribute to an individual's death? >> i'm going to ask dr. day to describe the clinical process review. but i would say, in general, we're not in the business of making odds on whether something did or didn't cause a death, whether it's likely, unlikely, 50%, 30%, 80%. that's not our purpose. dr. day will describe how we conducted those reviews.

>> we looked at the fact pattern of each of the cases that we described for you. so one of the issues you have to understand is, because you were on a wait list for audiology and you happen to die of a cardiac problem, the wait list factor was not very important. if you were under the care of a urologist intensively, but were you on a wait list to see primary care, then we may have concluded that, yes, you were on a wait list. yes, you died. but we don't see a relationship there. so for each of these cases we've reported, we wanted the fact pattern to demonstrate that a delay in care we thought would have led or dramatically impacted the likelihood that that patient would die and we didn't see that. we saw harm. we saw 28 cases described where delay negatively impacted care.

but i couldn't say delay caused a patient to die. >> so with the 171 patients that were delayed in mental health therapy, and you identified 77 suicide, you see no link, no link, between delayed care and these -- >> i didn't say no link. i said that if you're trying to say that -- >> i'm in the business of trying to find conclusions and of figuring out what reasonable people would believe. we had a female veteran, veteran, with diabetic problems in nevada. had to wait six hours. six hours to get care. two weeks later she died. i have to believe that there's a link between the kind of care she was getting at that hospital and her death two weeks later. i think any reasonable person would come to that conclusion. >> so we looked again at the fact pattern for each of these

cases. we had two physicians on my staff agree on the cases and the fact pattern and the conclusion we came to on each of these cases. when we began this review, i thought we would find patients with delayed care leading to death. i agree, that's the likely outcome. i haven't seen it. all i can do is report the news that i find. this is with a we find. >> i don't want to give the va a pass on this. i believe that's what this line does. it exonerates the va of any responsibility in past manipulation of these wait times. >> i just have to disagree. i described 45 cases. 28 of which were negatively impacted because of delays. the only argument is i can't say that those that died died because of the delay. and in addition, i found that there was care that didn't meet the standards of care that we

would expect of the va for an additional 17 cases. so i think i've laid those fact patterns out in the report. so i have a conclusion and the reader can come to their own conclusion. >> dr. day, thank you. >> thank you, senator. >> thank you, mr. chairman. just following up on the previous question, general griffin with you would you agree that attribution of negligence as a result of delay in care as a causation of death is basically a investigative process that needs to be taken. >> yes. >> wait times were not the only issue you focus the on. and when people do not follow headquarters' directives and mislead headquarters there have to be consequences. you are investigating some 97

facilities. have you completed those investigations on any of those facilities? >> we have completed 12. we've turned offense 12 files to the department for their whatever action they deem appropriate. all the others are in process. >> as a result of these 12 files, has the va undertaken any criminal or administrative proceedings, disciplinary proceedings? >> the criminal decision lies with the u.s. attorney's offices that we're working with around the country. va owns the decision on administrative action. and in fact, shortly after our first report was sent to the va they did take administrative action. we are trying to get these done as quickly as possible so that they can move out in every instance where they need to, but we have to make sure we have all the facts right prior to declaring that we're through and this is the final product.

we're working diligently on that, but we have a lot of other prosecutions outside of wait time areas which have led to over500 arrests a year for the last six years that you can't just drop. a lot of them are threat and assault cases. drug diversion cases. abuse of fiduciary veterans. i mean so we're working very seriously to try and get through the wait times but all these other investigations that were already in progress need to be seen through to fruition. >> thank you for giving us a fuller context in which the va is undertaking these kind of proceedings. you mentioned in your testimony and in your conclusion that the va must address cultural chan s changes, cultural issues. can you talk a little bit more about how a system as vast as

the va can make cultural changes and what sort of cultural changes are you talking about and what do you suggest that they do to implement these kinds of cultural changes? >> well, i think if you have a culture where it is okay to disregard directives from the most senior people in your administration, that you need to come to realize that that is not acceptable behavior and perhaps will you no longer be employed by the department. when people realize that it is a new day in that respect, i think they will be a little more vigilant in how they receive directives from their senior leaders in washington, and i believe that the efforts that are undertaken in the various town hall meetings and feedback sessions with the vsos and so on can also make the entire

organization realize that these are the types of things that we need to be doing. >> do you think that the provisions in the law that was passed, the veterans bill, that would allow for more expeditious processes for disciplining, that that would help to change the culture in the va in a positive way? >> i think that in a number of personnel areas in the federal government, it can be frustrating at the pace that it requires in order to go through all of the due process activities. i think the ultimate impact that it will have on the department is to be determined. it will depend on how frequently it is used, whether there are any challenges being that va is the only department in the government with the new abbreviated time frames and so on.

>> your report put forth a number of recommendations, specifically looking at recommendations 17 to 23. the va has said it will meet those recommendations by september 2015. are there any of those recommendations that you consider are more priority than others for the va to meet? >> well, there's a reason why our number one recommendation was that the department had to get with the regional council in phoenix and with vha medical professionals to look at the names of the 45 veterans we identified and to take appropriate action regarding potential liability or institutional disclosures and so on. >> so basically your recommendations are in the order of priorities. >> no, it's in the order of the presentation of the report.

but i personally would have to say that i think that's one of the most important items. i would also say that as we were doing the work and we discovered 3,500 veterans that weren't on an official list anywhere, we immediately turn those over to the phoenix staff so they could be seeking out those veterans and not delay their care any more than it had already been delayed. >> thank you blb chairma, mr. c. my time is up. >> thank you. >> thank you, mr. chairman. i do appreciate the hard work mr. griffin, of you and your staff. i think you've done a very, very good job. the report that you came out with is very helpful as we try and solve some of these problems. i'd like to ask a little bit from both of you, you and dr. day. normally when you see -- when a patient goes and sees a provider, the provider becomes the responsible person in the

situation. if you sign a chart and say come back in two weeks, sometimes there are situations where perhaps he is going to be out of town, are or this or that, or somebody's not available, i can't imagine a situation where the scheduler wouldn't ask the one that was scheduling, you know, this can't be done, what do you want to do about it. so can be elaborate on that? what happens in the va? when the provider actual ly writes on the chart or however they do it, does a scheduler overrule that? and the other problem, too, i've got is, is when the provider sees somebody back, say you have a patient like this, the cardiologist you see on the chart was supposed to come back in two weeks, now it's two months, where is the outrage from the provider at that point

as to why this wasn't done in a normal fashion? >> sir, i think what we found at phoenix -- what you talk about very reasonable steps an office has to have in order to maintain both the trust of their patients and deliver quality care. and so what we found was that, for example, a person would go to the emergency room as the point of care. emergency room physician would provide appropriate care and, for example, diagnose diabetes. say you need to go see your primary care provider. at phoenix, there simply were not enough -- there was not enough access in primary care to accommodate patients who needed to go to their primary care provider. so what would happen was the patient then would be given a consult, would be put in a space that wasn't acted upon, you'd next see the patient show back up in the emergency room with diabetes again with more problems with diabetes.

so you could track that a consult was referred, didn't get acted upon, you see the patient re-enter the system as a point that was not appropriate. it's what they needed to do but it wasn't what should have happened. so what i think you have when you don't have primary care properly structured, both with are the to the way they schedule, the way they staff the office, the efficiency with which they run the office. you get chaos. i think that's what we were experiencing, was you're looking in on a group of people who all knew they couldn't get it done correctly, they're all struggling to save patients who they thought would be at harm, and you see skirls tchedulers to schedule patients in slots that don't exist. it was just quite a horrible view of what was going on there. >> well, not just there though. i mean has that happened multiple other places? >> i think this would be the worst example i have seen.

>> i guess what bothers me is that e.r. deck tooctor, turning over in the first place, then not getting seen in two weeks or whatever the time frame is. in sometimes it is appropriate -- you mentioned audiology, that might stretch on without any problem or all or a routine follow-up. but when the e.r. doctors see them again in the e.r. and they see that that consult hasn't been done, there has to be -- that's the responsibility of that physician. i mean where is the outrage from the guy that was seeing him knowing that they hadn't -- >> i think there was outrage. they expressed their complaint to the leadership at the facility. again, if people aren't hired or money isn't put to address the problem you speak to, then after a while you realize that nothing is going to happen. if the facility talks to the

national leadership and says i have a problem and you don't get a response, then people get conditioned to, well, this is just the way it has to be. this is the way it is going to be in this system and that's unacceptable. so in hearing physicians and providers on the ground, nurses and docs on ground, i think they were all anxious and upset what they saw trying to deal with it the best they could. >> i know this is about scheduling. you mentioned that you felt like there weren't any deaths involved as a result of the scheduling. but in looking at some of the cases that you present, there might not be deaths, but there was certainly very poor quality of care in some of those. poor quality of care means malpractice. are we following up on that? are we in the process of doing an ig study regarding quality of care with these cases and other cases? >> we already concluded that

there was poor quality of care on those. >> are those -- >> the problem as far as tort claims activity, as was previously stated, those are adjudicated in a court of law and the experts that have to be involved in that adjudication in the case of the state of arizona have to be people who have practiced in that area of specialty in the state of arizona. and it is a program function of the department to address allegations of malpractice which is why we provided them with the 45 names and said that you need to look into these 45 cases with your attorney staff and with your medical staff and determine whether there's something that needs to be done for these people. >> no, i understand. and the chairman is going to wrap me in a second.

but i guess my concern is, when you see these cases in that particular situation, we have a culture of, again, breakdown in scheduling, breakdown in communication among physicians and schedulers, whatever, my concern is that this sort of activity is throughout the system and that's what i was referencing. are we going to investigate and see if we have this quality of care throughout the system. >> thank you, senator. senator blumenthal. >> thanks, mr. chairman. thanks again to all of our witnesses here today. i know that in response to senator tester's question, inspector general griffin, you mentioned that these individual cases will be turned over to prosecutors if criminal violations are found. that correct? >> that's correct. >> and they'll be turned over on

an individual basis? >> right. because they're in different judicial districts around the country. >> and they involve different facts. >> right. >> who will make the decision about whether those cases should be turned over to criminal prosecutors? >> when we have evidence of potential criminality, it's our job to take it to the assistant u.s. attorney or the u.s. attorney in that district, present the facts, and they make a determination whether or not it rises to the level of the types of things that they are presently involved with prosecutions of. >> in effect, the prosecutors will be making those decisions, just as they would with any investigative agency, whether it be the fbi, or the drug enforcement administration. >> correct. >> and what is the timing for beginning to turn over those investigative results? >> turn over to the department

or to the -- >> i'm sorry. i was unclear in my phrasing. what is the timing for presenting those cases for judgments by the prosecutors if there is determined to be potential criminality. >> when we feel that we have developed the evidence that would support a criminal charge. >> has the prosecutor in any of those jurisdictions said to you, we need that evidence as soon as possible. have they given you a timeline. >> no. no. we are working feverishly to accomplish these things. another point that i had made in your absence was, our criminal investigators make over 500 arrests a year. we've had a number of cases that were already in the investigative and prosecutive pipeline before this happened. as you know, it can take forever to work it through the prosecutor. >> hopefully, not forever.

>> well, it can sometimes feel like that. >> and i know that much well. >> sure. >> when i was a u.s. attorney, i would say to investigative agents, some of the best in the nation, here's my timeline. not that the world would fall apart if they didn't meet it, but there would be timelines for completing investigations. i gather you haven't been given any. >> no. but i can tell you that the assistant attorney general for the criminal division sent out a memo to every u.s. attorney's office and all the chiefs of criminal, basically giving them his point of view on what potential charges under title 18 could be brought for the various tice of manipulations or different things. >> falsify case of records,

destruction of documents, obstruction of justice. >> right. right. >> and i'm going to sort of segue to the next area of questioning. you and i have talked about this issue, and i appreciate you have some very skilled and experienced investigators working for you. but my feeling is there simply are not enough. do you disagree with me? >> i would say that we are fully engaged and could probably put twice as many people to work as we have at this time in the organization. >> you could put twice as many to work and they'd all be busy. >> yes. >> and they'd all be very busy doing very, very important work. which leads me to the conclusion there aren't enough of them. because criminal investigations here serve a vitally important

pups. i don't need to tell you because are you a very skilled and able investigative officer and inspector general and watchdog. but the deterrent effect of a criminal prosecution -- there's nothing like a deterrent effect of a successful criminal investigation to deter criminality. we're not talking about deterring carelessness or even negligence which can be serious enough in their consequences. but real criminality. so i simply would urge you to be as aggressive as possible in asking for resources that are necessary for the va to really do its job and deter criminality

assuming that it existed here and may be ongoing elsewhere in the agency as it may be in any agency of our government, state or federal. so thank you for your service and my time has expired. thank you, mr. chairman. >> thank you, senator blumenthal. senator murray. >> thank you, mr. chairman. mr. griffin, i was really deeply disturbed to read your findings about how many cases of suicide and veterans with serious mental health problems were affected by delays in care and substandard care. many facilities in my home state of washington are facing staffing problems and long wait times for mental health care. i just wanted to say, if hospitals in washington state are on your list of facilities for further investigation, i really hope your team looks very closely at the mental health care problems like they have done in phoenix. i want to ask you, the phoenix report really criticizes vha's resistance to change. both your report and the white house review found serious

cultural and ethical failings across the system. what do you think the va should be doing to make these kinds of system-wide changes? >> i think you have to hold people accountable when they ignore directives on how to do business. i think after a while people will begin to toe the line rather quickly when they realize there is a price to be paid. >> and that has not been done. >> no. i mean how can you have a certification requirement that you abolish because some of the managers in the field are pushing back about it, because they might not be sure if it's up to them for certifying something was true. you just don't tolerate that.

>> yeah. okay. you've mentioned several times here that you're following on 93 facilities, investigation. and the results here are confirming some of the things you found at phoenix, that wait times are being manipulated. >> right. >> when your reports are completed, i really expect the va to implement your recommendations quickly and hold people accountable as you just referred to. but i wanted to ask you this morning, is your impression that the motivation for these inappropriate practices are more to show false information or is it more just a lack of training? >> i think it is a combination of a number of factors. in each of our reports going back to '05, one of the recommendations was to ensure that the schedulers were properly trained on the way it was supposed to be done. that was a repeat recommendation. >> so they've been hearing this for a long time. >> oh, yes. as you know from your previous

time on this committee. 2005 was the first time in this report that we had that. so as i mentioned earlier, i think you have to have a person working the scheduling side that has some clinical knowledge of being able to triage how bad does this veteran need to be seen today as opposed to somebody else. that is not currently the case, i believe, at a lot of facilities. >> some of the facilities are saying this is low level, we have a lot of people coming in, is that an excuse? >> no. i mean i don't think there is an excuse for -- i mean i believe that over the years, va's budgets have pretty much been matched or exceeded by congressional appropriators.

but if you don't know what yu demand is and how many are on secret lists and you don't know, gee, we need 30% more clinicians, or whatever the number is, and they can't even ask for it. so i think the responsibility is, you have to do a serious, strategic analysis, not just of your clinicians but also the blend with fee-basis care and come up with a solid number that you can hang your hat on and say, in order for us to treat veterans in a quality manner and in a timely manner, we need this number of doctors, and we need this amount of money for fee bases for rural areas or what have you. >> mr. chairman, i know you've heard me say it a million times -- this congress, the country wants to be there for our veterans. but if we do not know what the need is accurately, we don't know what to provide. so i echo that point. let me just ask one other thing.

you've been doing this a long tile. we've been hearing this for a long time. you've been doing a lot of investigations. have you found any facilities or networks that have done a good job of regularly checking for scheduling gimmicks? >> we found a number of facilities out of our 93 where we concluded that there was no manipulation occurring. which is a good thing. maybe one-fourth. the bad news is, on the our three-fourths, we're pretty confident it was knowingly and willingly happening -- >> that's a pretty high percent. >> and we're pursuing those. >> thank you, mr. chairman. >> thank you, senator murray. >> thank you, and all your team. >> let me thank mr. griffin, not only for being here but for the excellent work that he and his department are doing and we thank all of his staff for being here as well. thank you very much. >> thank you, mr. chairman.

>> mr. secretary, thank you very much for being with us. again, my apologies for putting you on second, but i thought it was important for you and for the committee to be hearing from the inspector general first. but the floor is yours. please take as much time as you need zb need. >> thank you, chairman sanders. we obviously thought it important as well that the inspector general go first. we are very pleased to be here after the inspector general. chairman sanders, ranking member bird, distinguished members on

the committee for veterans affairs. thank you for the opportunity to discuss with you the response to the report regarding wait times and scheduling practices at the phoenix va hospital. i said at the time of my confirmation hearing that i will put veterans at the center of everything that we do at va. so let me begin by offering my personal apologies to all veterans who experienced unacceptable delays in receiving care. it's clear that we failed in that respect, regardless of the fact that the report on phoenix could not conclusively tie patient deaths to delays. i'm committed to fixing this problem and providing timely high-quality care that veterans have earned and that they des e desire. that's how we regain veterans' trust and thousand how we regain your trust and the trust of the american people. the final ig report has now been issued, and as the inspector general said, we've concurred

with all 24 of the report's recommendations. three of the recommendations have already been remediated, and we're well under way in remediating many of the remaining 21 because we began work when the ig's interim report was first issued in may. for accountability, we've proposed the removal of three senior leaders in phoenix. as we learn more about individual supervisors and employees' roles and the problems there, we may find that additional disciplinary actions are warranted, and we will take them. we're grateful for the committee's leadership in establishing the recently passed veterans access choice and accountability act of 2014. this important act stream lines the removal of va senior executives and the appeals process if misconduct is found. however, it does not guarantee va's decisions will be upheld on appeal or allow va to fire

senior executive officers without evidence or cause. we've taken many other actions in phoenix and surrounding areas to improve veterans' access to care, including, first, putting in place a strong acting leadership team, good people with a proven track record of serving veterans and solving problems. they're in place, they're operating in phoenix now and i have visited them on site. increasing phoenix staffing by 162 people and implementing aggressive recruitment and hiring processes to speed recruiting. reaching out to all veterans identified as being on unofficial lists or the facility electronic wait list and completing over 146,000 appointments in three months. as of september 5th, there are only ten veterans on the electronic wait list at phoenix. where va capacity didn't exist

to provide timely appointments, we referred patients to non-va care. from may through august, phoenix made almost 15,000 referrals to non-va care. we've secured contracts to utilize primary care physicians from within the community in the future. since my confirmation as secretary, i've traveled to va facilities across the country speaking to veterans and va employees, as well as visiting and speaking with members of congress, veterans service organizations and other stakeholders. during these visits, i've found va employees to be overwhelmingly dedicated to serving veterans and driven by our strong va institutional values of integrity, commitment, advocacy, respect, and excellence. the acronym we use is i.c.a.r.e. i am wearing that button today. our people make a difference.

nationally they've enabled the following critical achievements. as of august 15th, vha has reached out to over 294,000 veterans to get them off of wait lists and decrease the veterans on the electronic wait list by 57%. vha has developed the accelerated care initiative to increase timely access for care for veteran patients, decrease the number of veterans on the electronic wait list longer than 30 days and standardize the processing tools for ongoing monitoring and accessing management at all va facilities. where we haven't been able to increase capacity, we've increased the use of community, non-va care. between may and august, we've made almost a million total referrals for non-va care. over 200,000 more referrals than for the same period in 2013. the 14-day access measure has been removed from all employee performance plans to eliminate

any incentive for inappropriate scheduling. over 13,000 performance plans have been amended. we're simultaneously updating our antiquated appointment scheduling system and working to acquire a comprehensive state of the art commercial office shelf scheduling system. va medical center directors and visiting directors are completing in-person reviews of their facility's scheduling practices to be completed by the end of this month. so far, 3,000 of these reviews have been conducted nationwide. we've restructured vha's office of the medical inspector to better serve veterans and create strong internal audit function. on august 7, i asked all va employees to re-affirm their commitment to both our mission and our i.c.a.r.e. values -- integrity, commitment, advocacy, respect and excellence. i intend this re-affirmation to be repeated by each and every

employee each year on the anniversary of our establishment as a department. if an employee refuses to recommit, i want to meet with them personally and will decide actions after that. we're building a more robust continuous system for measuring patient satisfaction to provide realtime site-specific information, collaborating with vsos in this effort and learning what other leading health care systems are doing to track patient access information. we're working hard to create and sustain a climate that embraces constructive dissent, that welcomes critical feedback and that ensures compliance with legal requirements. that climate mandates commitment to whistle-blower protections for all employees. yesterday we announced the beginning of our road to veterans day, our 90-day plan, which begins with our mission to better serve and care for those who have born the battle and for

their families and for their survivors. we'll focus our efforts offense the next 60 days to rebuild trust with veterans and the american people, to improve selves delivery, and to set the course for long-term excellence and reform. as we move forward, we will continue to work with the ig and other stakeholders to ensure accountability. as you heard, there are over 100 ongoing investigations at va facilities by the ig, by the department of justice, by the office of special counsel and by others. in each case, we await the results and will take appropriate disciplinary actions when all the facts and evidence are known. but we will not wait to provide veterans the care that they earned and that they desire. we're going forward. we'll focus on sustainable accountability in the future. more than just adverse personnel actions, sustainable accountability means ensuring

all employees understand how their daily work ties back to that mission of caring for veterans. we want them to understand how it ties back to the mission, how it ties to our values and how it ties to our strategies and we want to make sure that everybody's behavior every single day is guided by those values and that mission. we also want to make sure that every employee understands it's their responsibility to provide feedback to their supervisor when they're asked to do something that is impossible to do. we want to make sure that feedback loop is daily and that every employee is getting daily feedback from their supervisor and that every supervisor is giving daily feedback to their manager. sustainable accountability requires we do a better job of training our leaders. we need to flatten our hishg c hierarchical culture, encourage innovation, encourage collaboration and we need realistic ratings of everyone's

performance. everyone cannot be the best. with sustainable accountability, employees fulfill their responsibility to veterans and to the department to provide feedback and input on how we can better serve veterans. who better than to improve -- help us improve our department than the employees who every day are interacting with our veterans. we will judge the success of all these efforts against a single metric, and that is the veterans' outcomes. we don't want va to meet a standard. we want va to be recognized as the standard in providing health care and benefits. i know we can fix the problems we face and i will utilize this opportunity to transform va to better serve veterans. mr. chairman, members of the committee, thanks for your unwavering support of our nation's veterans. i look forward to working with you and implementing the law, and in making things better for all of america's veterans.

dr. clancy and i are prepared to take your questions at this time. >> mr. secretary, thank you very much for being here, for your patience and hearing the discussion with the inspector general. and i think i'm paraphrasing one of the other members on the committee that the perception is you have hit the ground sprinting, which is exactly what this committee wanted from you and we appreciate that very, very much. i want to reiterate the point that you just made, and that is that the vast majority of va employees, and i know this is the case and i know it's all over the country work tirelessly and work very hard to do everything they can for our veterans. we should never forget that. and we should also not forget while we're focusing today on the issue of timeliness and the need to make sure every veteran in this country gets timely care, we also know that i can tell you absolutely in vermont that most veterans believe that the care they're getting once they're in the system is of high

quality and they appreciate what care they're getting and the work that their staff is doing. what i just want to do is -- and in a sense, you've talked about this in your opening remarks. but let's focus on three or four basic issues. every member of this committee is outraged by the long wait periods that veterans in various parts of the country are experiencing. so number one, i want you to tell us briefly what kind of progress that you have made in reducing those wait periods. number two, we all agree it is unacceptable for va staff for high ranking people to be lying, to be manipulating data. what have you done to get rid of people who are acting d dishonorably and what plans do you have in the future? and thirdly -- and this is tough

stuff -- how do we make sure -- how do you lay the groundwork that what we have seen in phoenix never happens again and how do you address the fact that it is a national problem? i think some of the -- is the issue.it is no great secret that we have a crisis in the number of physicians we have, especially primary care physicians and the number of nurses we have in some parts of this country. we have given you some tools. i'm proud of the work that's come out of this committee. we have given you some tools in the education debt reduction program which now gives you the tools to go to medical school. maybe you can tell us a little bit about that, and tell people who otherwise would graduate, young doctors in debt that we have a strong indebtedness program. in other words, what are you going to do to address the very difficult issue of bringing more quality physicians, nurses and other medical personnel into the system?

so those are my questions. >> thank you, chairman sanders. first in relationship to the first question, access to care, we reached out to over 294,000 veterans to get them off wait lists and into clinics as of september 5th. as a result, va has decreased the -- nationwide since may 15th. that's from over 57,000 in may to around 24,500 in august 15th. we've reduced the new enrollee appointment list to right now approximately 1,700, which is a reduction of about 62,000. >> in secretary, this is a combination of expanding va capacity and sending people out to the private sectors? >> yes, sir. it includes things like in phoenix we moved in three mobile units from around the region.

we've increased clinical hours. we worked on overtime. it's a matter of putting the resources where they need to be put. we collaborated with the department of defense in some sites, collaborating with indian health service. these were the things that were done. we've had more people that we put into the private sector, 246,300 more patients have gone into the private sector. and each one of those referrals has resulted in, on average, seven appointments. so in a sense, that number understates the care that's been provided. so we're making progress there, but more work needs to be done and obviously the bill that you mentioned is going to help us do that by providing greater access points, 27 more new points, and the ability to hire more doctors and nurses. you asked about disciplinary action. i talked in my opening remarks

about the three individuals in phoenix who we proposed disciplinary action for. we have a new acting director there in phoenix. in my american legion speech, i mentioned that we have over 30 actions that we've taken. around five include members of the senior executive service, about two dozen include medical professionals. so we are following up as quickly as we can. as soon as we get information that suggests we should take this kind of action, we're taking it. we've stood up a separate team called the accountability team. i met with them as leently as yesterday. we report to me and their single job is to get after these as quickly as possible. >> let me interrupt you. >> yes, sir. >> i'm running out of time. i wanted to ask you the third question. the inspector general made a good point, that it's hard to

know what you need and whunless you have good information. in your judgment, how many more doctors, nurses, medical staff do you need and how in a time when this country is not producing enough primary care physicians, etcetera, are you going to get them? >> we need tens of thousands. deputy secretary gibson said in his testimony, i think it was around 28,000. we are now going through a process -- >> let me repeat that because that's an important point. you're telling us you believe you need 28,000 new medical staff? >> including clinicians and other employees. we're in the process of going through a big recruitingest. i was at duke university medical school. i was with senator burr in charlotte and i then went to duke. and we talked to over 500 members of the duke medical community. i was in philadelphia last friday. i talked to members of the

university of pennsylvania medical school. we are trying to demonstrate to young people studying in the medical profession that va is where they want to work. they want to work there because we've had three nobel prize winners, seven lasker award winners, we do great up front research. did you know that the nurse worked at the va who developed the use of the bar code for tracking patients and medication? we're known for innovation and young people should come work for us. and the help that you gave us with student loan forgiveness, debt forgiveness, doubling the number is going to be very helpful to help us recruit. >> i've far exceeded my time. senator burr. >> thank you, mr. chairman, mr. secretary, welcome. thank you for the role that you're filling. i've just got a couple areas.

one, every private sector referral triggers seven additional visits. if you would, and you could have dr. -- do this, i would love to see the data on that. i know that that's what va actuaries have stated and what they believe. i think we need to get to the bottom of it, figure out why. is this a contractual problem where we've contracted with a private physician where they see an opening to bring a patient back seven times? under medicare, that would all be under a bundled payment. if we're going to do private sector right, we have to figure out whether we're doing it right today. but i can't envision where every time we referred somebody to a private sector doctor, it triggers seven additional appointments, visits that we're going to pay for and if that's the case, i would love to see the specifics on that when you're able to do that. with everything that you just went through, it's probably hard to believe that i'd ask you this question.

you've detailed greatly all the changes we're making. my question is this, how do you plan to change the culture at va and how do you plan to measure it? >> first, we will get you the data on the seventh. as you know, many of our veterans have multiple illnesses, but we'll get you the data and we'll sit down together and talk about that. in terms of changing the culture, changing the culture is probably one of the most difficult leadership challenges whether it's in the private sector or the public sector. i think the most important thing we've got to do is to open up the culture. as i described earlier, high performance organizations have the improvements made by the employees, not by the leadership. the leadership certainly helps. they pick the strategies, they pick the leaders and they help create the culture. but we've got to get every employee involved. so on the very first week, i met with the union leadership. the majority of our employees are union members. about 65% are union members.

i met with the union leadership and i've met with them three times in my first five weeks. and i'm asked them to recommit themselves to our values, our mission and to help me engineer the changes that we need to make. every time i go to a site, i meet with the union leadership, as well. i include them in our leadership meetings. i also make sure i talk to the whistle blowers from that site and i always do a town hall where i explain to the employees that i want every employee to be a whistleblower. i want every employee causing us to change. i've used a diagram. i used it yesterday and i've used it with employees that basically says that most people think of an organization structure like a pyramid. at the procter & gamble company, you would have a ceo. at the department of veteran's affairs, you would have a secretary. well, i take that and i turned it on its head and i'd say, this is where our veterans are. our veterans are at the broad

base of this pyramid. the people caring for those veterans are the most important people in the organization. i'm at the bottom. i'm at the apex. what i have to do is make sure the communications point up and down that pyramid to make sure we care for those veterans. so the boss of this operation is the veteran. the boss is the person next to the veteran. serving the veteran. and thankfully, some of the things that have happened in the past don't fit that picture. for example, we had some of physicians who serve the veteran downgraded and the annual salary is tens of thousands of dollars less that we're able to pay them. those are important people. i've encouraged all of our leaders to seek exceptions to that policy and we have to get back to putting the best talent up and working and serving the veteran. change is difficult, but i think we can do it.

>> just to make one point about measurement, the va has a unique employee survey which is now going out into the field. it's much more thorough than other federal departments. one of the areas that we can measure and track hopefully is psychologically safety. in other words, do people feel empowered to say we've got a problem here on the front lines, i need help, this isn't working. so we will keep a very close eye on that. >> we sent that out last week and i would be happy to share the results with the committee once it comes back. >> thank you. one last question. in the press release that va sent out prior to the release of the ig's report, the release stated that you had asked for an independent group pup, scheduling and access practices beginning this fall by a joint commission. i've got a very simple question.

why? why do we need a joint commission to look at the same thing the ig is looking at in 93 facilities right now. the ig has reported on since 2005 and are we waiting until the fall to implement changes in that until we've got a joint commissions report back? >> i'll ask dr. clancy to clarify my comments. but it's not just any commission. it's a commission that does this kind of work for a living and -- >> i'm full of commissions. and as soon as we hear the word commission, we all start looking for who is hiding. >> it's not about hiding. it's about benchmarking best practices. and this commission does this across the country and will help us understand best practices in all facilities, not just the 93 that the ig is looking at. so we plan to use this commission to improve. it's unfortunate their name is commission, but that's -- >> so just to expand for one

moment, they do credit the vast majority of private sector hospitals? in fact, they do not get paid by medicare and medicaid if they're not so this is following a standard practice in the private sector. this is going to be unannounced surveys. so we have put a huge amount of effort into making sure the schedulers are trained, we're looking for ways to get exceptions to get their grades increased. but this is going to be looking at is it really working? how does patient flow work? what happens to people who wait in the emergency room who leave because they've been waiting too long and so forth? so it's going to be an independent check for us and it will give us an opportunity to spread both good practices and opportunities for improvement across the system. >> thank you. >> thank you, mr. chairman. >> thank you, senator burr. senator testa. >> thank you, mr. chairman. just as a sidebar, i would love to have you incorporate montana into your travel plans sometime.

by the middle of next month, it would be great. second number per capita of veterans in the country and they're some of the best veterans in the country, too, but i'm partial on that. let me ask you this, you said you moved three leaders from the phoenix office. were they reassigned or were they terminated? >> what i said is we have proposed disappearing action to three leaders. this is the progress that has to be taken for leaders who are in that strata of employee. so we've proposed the disciplinary action. it now goes to a board and there's a process that it goes through. since we have proposed that action, we have taken the leaders i talked about, moved them to phoenix and they are in an acting role. >> new leaders? >> yes, sir. >> i think one of the concerns we had was i think you have to protect employees' rights. but we also need to be able to terminate people when they deserve to be terminated. >> i agree with you entirely. believe me, we are -- as i said in my prepared remarks, we are

following the disciplinary -- we're following the investigations and as soon as we're capable, we're taking action. >> the ig made many good points. one of the things he brought up was the analysis, because of the schedule i scheduling, really don't have a clear pattern of how many people need the services they need. and there's a fee-based situation out there. i don't know if that's better or good or the same. how can you make a determination that you need 28,000 medical sta staff? you're a wonder worker, probably, but the fact is, that information still hasn't been hammered out. >> no. we are going through a process right now where we're going location by location, specialty by specialty to understand how many people we really mead. >> when do you think that process will be done? >> let me ask dr. chancy a comment on that because she's leading that process. >> sure.

>> in response to a previous report from the inspector general and dr. day mentioned this briefly, we have created and are deploying a tool to assess productivity. >> gotcha. >> with the space and all that. i would guess by early -- at the end of this calendar year, early next year. >> and then you'll have a firm grip on how many medical staff you'll need to have when that process is done because you will stead up standards for doctors because that's part of the thing, too, right? >> yes, in addition to how many support staff do they need to make them as efficient and productive as possible. >> okay. now back to something else the ig said, because i tried to pin him down on the sfaving thing. he said staffing is part of it. the other part of it is facilities. where are you going to put these docks and medical staff if you have them? in montana, facilities -- i don't know if there as big of a problem but they're pretty close to a problem.

you'll have docs there, but no examination rooms. do you have a construction plan moving forward? and i know it's unfair. you've only been on the job six weeks. i'm not trying to be critical. >> i think it's five, actually. >> okay. good. >> facilities are very important and the action you took with the bill gives us the ability to have 20 more facilities and not surprising where the facilities will go in phoenix where obviously we have a need. we have an issue right now that we're working. it's around leasing. we have been following an appropriate, i think, strategy of leasing facilities rather than building them because the population is moving. we're currently working through the gsa on this process because the gs -- >> but to get down to it, secretary mcdonald, i appreciate you telling me what you're doing, but all i want to know is

do you have a construction plan moving forward for the next three, three years, five years, so that you can come to us when it's appropriate on this committee and say look, guys, we need this much money if you're going to serve the veterans coming back? >> we have a construction plan, but we're going to be renewing our forecasting as i mentioned during my confirmation hearing because i'm not happy. i'm not satisfied that our forecasting is robust enough. >> okay. i want to talk about the arts program briefly because i ain't got much time. is it -- let's say the great falls hospital in great falls, montana, wants to get into the arch program. what do they do? >> let us know. again, our principals will look at everything through the lens of the veteran. >> okay. >> and if it's good for the veteran, we want to do it. >> okay. i think in these particularly rural areas, that's going to be

critically important. i've got some other questions i'm going to put in the record for you as we move forward. but i be you're committed to the job. i know you're surrounding your people with the job. middle management has been a problem not only with this administration, but with the previous one. i think you need to hold them accountable. >> i want to spend some time with you on the plan, road to veterans day. one of the steps we're going to take is reorganize the department. we have 14 websites that all require different user name and passwords. the veteran doesn't want that. the veteran wants one geographic map, one website, and that simple simplefication will provide the information you need coming down and up very quickly. >> thank you for your work. >> thank you, senator testa. >> thank you, mr. chairman. secretary, thank you for visiting reno. >> reno and las vegas. >> and las vegas. on behalf of myself and the

governor, perhaps mine is to -- tesla relocating in the state of nevada, it was a terrific opportunity for him to discuss with you the concerns that we both share about the veterans. thank you again. >> you're welcome and may i say working with the state governments is kit krally important for our success. >> you're proving that and thank you for doing so. i want to talk about the nevada baro for a couple minutes. as you're probably aware of the inspector general's report, they did a two-year claims initiative and were able to recognize that about 32% of those claims reviewed were inaccurate. unfortunately, for the state of nevada found that 51% of the claims reviewed were inaccurate. and that being the case, have you had an opportunity to review

these reports from the ig? >> i have, but i also have to say that i have asked the ig to give me all of the reports of the last five years and give me a triage version of those reports because i want to go back and i want to look at all the reports that have been issued and have not been acted upon. i know the situation in reno, having been there, we have new leadership on the ground. we're making some progress, but we're not where we need to be. and the new leadership knows that. >> let's talk about that leadership for just a moment as you called for management changes in the reno nevarro. do we have a permanent director there at this point or what's the timeline for getting that? >> we have an acting right now, but we're in the process of identicaling the permanent director. we also mentioned -- >> and we'll partner with you on that. >> you also mentioned that perhaps there is a need for four

additional employees in that particular office. what's the status of that? >> i have to check the hiring status, but we do need more employees in the veteran's benefit administration and we need them in that office. there's nothing holding us back from hiring them. we do need more employees and veterans benefit administration. right now, we have, as you know in that office and elsewhere around the country, we have all of on our employees working overtime. we're stopping it october 1st because it's not sustainable. but in order to sustain our progress going forward and continuing to drive this claim, this backlog down, we have to hire more people. and as a -- there was some money in the bill that was recently passed that was taken out of the bill. i think it was $400 million. we're going to need some of that money back and we're going to cost save to try to find money

to be able to hire those employees and continue to work that backlog down. >> i'm sure you tend to agree with me that over time isn't an answer, long-term. short-term for us, we could make some headway. but long-term, overtime pay and overworking some of these employees probably isn't the answer. i think there really is a structural overall change that needs to happen. at 345 days out, for the benefits of medical claims, it's just unacceptable at this point. >> i talked to the management in reno and they told us additional resources were not necessary. please let me know. anything i can do to be of help, because it's absolutely unacceptable. i think a change needs to occur.

you have a direction that you really want to go for these changes that are going to be necessary to reduce these backlogs. >> deputy secretary gibson said, and i agree with him, that the changes made in the veterans benefit administration over the last couple years has just been astounding. but you're right, we've done it by brute force and what we need to do now is re-engineer the process we need to do it on a sustainable basis and drive down the backlog to zero by 2015 which is our commitment. >> if there's anything i can do to help and support, we have an issue here, senator casey and i are working on those. we also like to office our services any way we can. there are nearly 2.3 million

women veterans that have served in the military. since you've been secretary, have you reviewed the care and services for them these women veterans to make sure that it is adequate? >> i have and we have work to do. in fact, every stop i go to, whether it's phoenix, memphis, las vegas, and i go into the medical center, one of the things that strikes me is how we built facilities years ago for male veterans because there weren't female veterans. i also check in to say, do we have ob/gyn and other areas. are we used to making prosthetics. we were just talking to gather of the disabled american veterans and they've done a study now on what it means to make a prosthetic for a female that's pregnant. these are things we've never had to deal with before. but now with 11%, 12% of the veteran population being female and continuing to increase in

absolute numbers, these are things we have to go after. >> i think it may take some legislation to expand this. i'm eager to help your administration. i think something needs to be done and look forward to assisting. >> we would love to partner with you on that. >> thank you very much. >> there's a lot of work left to do in terms of privacy and doctors that know how to care for women. but we also know one of the barriers for women is child care. mr. secretary, thank you for being here. i want to start by talking about the fact that the ig found several cases in which veterans space delays or care and substantial care and subsequently took their own

lives. va's newest wait time data still shows it was far too long to get into care. simply meeting the wait time metric isn't enough. veterans need to be assigned to a regular provider. they need care coordinated across the hospital and the type of care they need when they need it. i wanted to ask you today, why do you think the va continues to struggle with providing appropriate mental health care? >> i think mental health care is a problem in the united states and i think it's a problem in the va. one of the things that excites me about this job is many of the things we see at the va is we're kind of the path finder for the country. whether it's, for example, the use of the bar code in a hospital to make sure somebody

gets good care and i think one of the things we have to do is we have to increase the number of students studying mental health in school. when i was at duke university medical school, i met with 17 residents who graduated from the medical school all working at the va. only one was a psychiatrist. and i asked the question why are young people not going into psychiatry and mental health? because it's an area we're learning a lot more about today than we knew in the past. he never wanted to talk about it until he joined a va group of p.o.w.s who wanted to talk about it. what they told me was the biggest issue was insurance reimbursements for mental health are far below the cost.

somehow we've got to get a handle on what's going on in this area and find ways to encourage people to go to school in mental health. in all of my recruiting speeches so far, i've talked about the importance of mental health and i'm trike to encourage young people to get into the discipline. i really think it's a national problem. but va is on the cutting edge of it. >> continue work on that because that to me is a serious issue. but our veterans are at the front of this line. >> absolutely. >> we have to make sure. we have the providers, but we have the understanding across the va and across the culture of the va to really watch for this. in your testimony, you talked about improving the department's leadership training and breaking down some of the va's bureaucracy. that's the way of enhancing accountability. that needs to happen at all levels. but there's a lot of people between you and them. we need to make -- >> that's why i gave out my cell

phone number. >> we need to look at everything from training new clinic managers to oversight and effective intervention by medical centers and network leaders. how do you make sure that these changes happen at all of those levels across the va? it's a huge system. >> it is a huge system. it starts by getting out and going to these different sites and meeting the people and understanding are we providing the right leadership? do we have the right strategic choices, do we have the right systems? are we doing things that will repeatedly lead to a good result? and do we have the right future? i was at a site in reno and a young person was talking to me in a town hall about ways we could improve our computer system. and one of the senior managers stepped in front to try to stop the conversation. and i had to ask that senior manager to move out of the way,

but it wasn't appropriate. or i was in philadelphia last week, a site that had a training program on town halls that used oscar the grouch in there. and i had to talk to those employees about no matter what the intent, perception is what's important and the perception of oscar the grouch on a presentation is not going to be acceptable. so we simply have to dive into the culture and dig and figure out what's going on and set the example to do it right. i tell everybody to call me bob. we need to reward people who turn in problems, nos chastise them and not ostracize them.

it's hard work, but it's under way. >> quickly, you've said you committed the va to fielding a modern scheduling system? can you tell me when you think that will be done and the training for employees to use that? >> right now, we're doing some quick fixes on the established system. those quick fixes are coming out periodically over the next few months. we will like it to be done in 2015. >> and that includes the training? >> yes, of course. in that case, when you put in a new system, we want to commission it, verify people know how to use it before they sit down and are qualified to use it. >> thank you very much. >> thank you. >> mr. chairman, thank you. mr. secretary, i don't think i'll call you bob in this setting, but mr. secretary, thank you very much for your

presence. as i said earlier, a series of perhaps convoluted questions all related to the same topic. first of all, i'd like to offer my assistance as i have done with previous secretaries. you have testified. it helps the va to have the necessary officials to meet the needs of veterans. i've asked the previous secretary for how can i help? what do you need? what tools don't you have to help solve this problem with no response? so, again, if there's changes in the law, processes necessary to forgive loan forgiveness, whatever the story is, i'd like to be of assistance, i'd like to be an ally. so here is my scenario of a couple of stories. lee mand, a smith center veteran. i mentioned him in my opening remarks. and he had the good fortune or the va calling him to tell him that he no longer needs to drive four hours to have a

colonoscopy. that's the piece of good news. so that suggests to me that there is a change of foot. thank you. down the road about an hour in plainville, kansas, larry mcintyre tells me last week he drove three hours to wichita to get a cortisone shot in his shoulder. he goes to wichita several times a week for other minor procedures. there is a -- within 25 miles of plainville, but it doesn't have the professional capability, as i understand it, of providing cortisone shots. what does exist is a hometown hospital. rooks county medical center, plainville, kansas, that could provide a cortisone shot that's in the same town as where mr. mcintyre lives and certainly less than the 3 1/2 hour drive to wichita. so on the one hand, we've had some success. on the other, there still

remains issues we're trying to get at. implementation of the care act, what -- when the 40 miles is the determining factor as to whether or not you can access health care, how do you -- how are you going to treat what that cboc is capable of doing in determining whether or not that veteran lives within 40 miles of it totally? is it a facility or is it a facility that can perform the service that the veteran needs? >> that's a really excellent question. i'm glad you brought it up. one of the technical changes we're working with the committee on is to give the secretary the authority to interpret that the way it should be interpreted. in other words, let's look at it through the lens of a veteran. does it make sense for that veteran to get a cord zone shot closer to home? what makes sense? and one of the things we're asking is what gives the

flexibility to authorize that in the care bill. >> you do not believe you have that authority now? >> no, sir. i think by simply putting in a phrase, it could be simply handled. we've been working on that with the staff. >> does there seem to be any impediment in accomplishing that? >> no, sir. >> let me go back to arch in the interim before the care act is implemented, which my guess the november is the best scenario. you have set aside $25 million for outside of the va care. th that, i assume, funding expires a couple three weeks away. arch is in existence and the care act gives you the authority to do things with arch. one is to extend the contracts, extend the program. and the second is to expand the program beyond the geography that is currently served by an arch program. do you have any questions about

your ability to extend the program, arch, or do you have any questions about your ability to expand the program? >> one of the technical changes that we're asking for in the bill that pertains to arch is the ability to just extend the contracts that we already have, which will allow us to accelerate the expansion of arch. >> so the language in the care act is insufficient to allow you to extend the contract? >> i just needs a modest modification. but how do you -- >> when do those contracts expire? >> i don't think it's the expiration as much as it is the assumption that we can move them going forward so we can move more quickly. so rather than going through an entire rebidding process for new contracts -- >> arch is not going to go out of business -- >> no. >> those pileup programs before you get a technical change? it will continue? >> i think -- let me check on this to make sure. it's extended for six months, but what we're trying to do is

extend the expansion as quickly as we can and the way to do that is this technical change. >> so you don't need technical language to expand for six months, you need something to extend for six months? >> no. and your expansion authority? >> we're okay on that, but i think the technical change we're seeking would allow us to accelerate the expansion. >> mr. chairman, with your indulgence, i would only say that i was surprised that an author of this legislation that the pilot programs were so narrow to begin with, very small geographic areas. my expectation was that the va would choose five sites that are statewide orr visnwide. we expected the entire visn to be part of the program not a matter of a county or two. do you have thoughts about your alsoness to expand arch to a larnlger geographic area?

>> again, consistent with what deputy secretary gibson said, we need to look at this again from the standpoint of the veteran. if it's good for the veteran, then we should expand it. i think that's what he said, we will expand it. so we're looking forward to working with you on that. >> if you can get us the analysis of the arch program than we've done by the va that we've looshgd at for months, we would like to see what if va says about how it analyses the program. you would assume it was take good things. >> all right. it's been a long hearing, i think it's been a productive hearing. >> mr. chairman, may i say one thing? >> sure. >> first of all, i want to clarify one comment i made. i recall i said the funding for vba, roughly $400 million, that was part of our original 17.6 billion dollar request.

i did not end up get can passed. that's why i brought that up because we want to try and continue to drive down claims. leasing becomes very important. leasing is a strategy that we're using to move our footprint out, providing greater access and care. right now, we have an issue that we're trying to resolve with the general services administration, the gsa, where they rescinded our blanket delegation of authority in july for these contracts. so now every one of our leased contracts is an individual delegation from the gsa and those that exceed $2.85 million, which many of them do. 59% of the 27 do. need to go through a relatively laborious process. is so we're working with gsa to

resolve this, but while we do that, we believe there's a need and a case to be made for an independent 20-year medical lease authority for va. to carry out its mission and to continue to provide these points of access. >> sure. this has been a long and ongoing problem. we're looking forward to working with you. >> thank you. mr. secretary, dr. chancy, thank you very much for being with us.. thank you for the horde work that you are putting in right now and for the changes we're seeing. this hearing is now adjourned.

this morning, president obama joins bill clinton the marking the 21st anniversary of americore. the names offers community work to young adults in the area of health care. you'll be able to watch it live at 1 1:30 a.m. eastern on c-span. now also coming up today, the center for american progress is hosting a discussion on u.s. strategy for combatting isis in iraq and syria. former u.s. ambassador to syria

robert ford. live coverage starts at noon eastern on c-span2. thern attorney general eric holder speaking about the 50th anniversary of the vifl rights act. he'll talk to an audience beginning at 12:30 europe. c-span will carry that live. this weekend on the c-span network, american history tv is live from baltimore's ft. mchenry for the 200th anniversary of the star-spangled ban he. and later at 6:00 p.m. eastern on american history tv, we'll tour ft. mchenry and hear how war came in 1814. saturday night at 8:00 on c-span, the presidential leadership scholars program with former presidents george w. bush and bill clinton and sunday afternoon at 3:30, live coverage of the harkins steak fry.

and sunday at 8/o'clock, the evolution of politics on c-span. ken silverstein on the secret of oil. and then at 6:45, kirsten jillibrand, and her call for women to rise up and make a difference in the world. find our television schedule and let us know what you think about the programs you're watching. call out as 202-626-3400. e-mail us comments@c-span.org. or send us a tweet, #comments. last night, the cato institute held a discussion on public opinion and war. a pam of the past arguments made by anti-and pro war advocates. sharing conflict between vietnam, iraq, afghanistan. they discussed the influence of

politicians. this is an hour and a half. >> good afternoon, everybody. welcome to the cato institute. my name is justin logan. i'm the director of foreign policy studies here at cato. and it's my pleasure to welcome you here to our event on public opinion and war in addition to the people who are here with us physically, we would like to welcome those online, cato.org as well as via c-span. we always worry planning these events that a topic that seems important and pressing a few months ahead of special sometimes won't deliver.. but unfortunately, i guess, the question of public support for war is quite -- given the president's news. so today we want to discuss a lot of the academic research on when and why the american public

supports war. there's a lot of visit sur and a lot of disagreement on this subject. so be totally honest, we were able to piggyback on the american science association political meeting since many of the scholars who wafrt this panel. when it comes to the question of public support for war. i also go ahead and introduce the panelists in the order in which they'll speak and then turn over the podium to the first speaker who's john muellor. he's a senior fellow at cato as well as a member of the political science department and the mershon center at the ohio state university. he needs very little introduction, but i'll venture one nonetheless. in addition to his seminole work, war presidents and public opinion, he's more recently made

himself into an expert on both terrorism and nuclear weapons authoring most recently terrorist security and money, balancing the risks, benefits and costs of homeland security, coauthored where, how politicians in the terrorism center with nature security threats and the atomic object sessions, nuclear harm weapons from from to doubt. securities studies swb the american political science review, foreign affairs, we're very pleased that john is here. his ph.d. is from the university of chicago. he studies political behavior, public opinion about foreign policy, correcting factual miser

perceptions held but how would it works. the coauthor of any american costs, american conflicts, he has a b.a. from colby college. his ph.d. is from duke university. our third speaker today is adam luwinsky. as well as serving as the director of m.i.t.'s political research lab. for our purposes today he authored "in time of war" understanding american public opinion from world war ii to iraq. he similarly has published a very impressive array of journals, the american political of journal science, public opinion quarterly and a inspect

of ourselves. the final speaker today is perhaps cato's newest minted adjunct scholar at george mason university. trevor thrawl. he is the coeditor of american foreign policy and the politics of fear, threat inflation since 9/11. and another edited volume entitled why did the united states invade iraq, question mark? prior to arriving at nathan, trevor was with the university of michigan deere born. he received his ph.t. from m.i.t. so you can see -- normally on these panels right there, we have a lot of university of chicago, m.i.t., conspiracy. today it seems like we have a mini men m.i.t. overlap with

john bringing up the chicago end of the deal. so i think with that introduction, speakers, i'll go ahead and turn things over to john. >> thank you very much. i'd like to be here, like to change the order of things i was talking about because i didn't realize i was going to be going first. and i'd like to get on the table, essentially, that fit into this. the first one is probably the most light ranging, sort of sets the overall -- the united states has brought four wars, long ground wars since world war ii. and it's possible to fairley well compare the degree to which these wars have been supported. because the same poll question, do you think it was a mistake to have gotten involved in this

conflict has been asking each of the four wars. and the patterns for the four wars are there. iraq, vietnam and korea are down below. the main thing that basically happens on this is that there has been a decline overall. and part of the decline happens earlier rather than later. in other words, there's a fairley steep drop-off early on typically and then sort of gradual ee hoegz or just a stabling reachness of stability. the -- i should say there's a couple of things. these are years, as you can see, since the war began. but the key thing is the question of cost. the argument is that as it has been crew, the important for the

dwandels. sometimes that stays put. as soon as they see the body bags coming back, they stopped with the war. if they can't see the body wars, then doctor i was trying to make it badge to delay you can't. the other speakers, as you'll see, don't necessarily agree with that way of explaining it. one issue, though, i want to say before moving on is that this is by time, it isn't by casualties. and a good question would be how will does it go prior to a casualty increase? and comparing the war in vietnam

and the war in iraq. in the case of these two wars, there's a considerable difference. both lines go below 50% of approval. there were about 2,000 americans that had died and went down below 50% approval for vietnam. it was more like 20,000 or 18,000 americans that had died. my interpretation is people simply aren't going to pay as much time for the stakes in iraq as they were for the cold war. now, when we talk about casualties, everybody basically agrees, people don't know what the casualties are. if you ask how many men have been killed, you get all kinds of weird answers. however, casualties basic obviously good measure of the intensity, the kuk lafb casualties of the board both in

terms of human losses and economically. however, there is some indication, one question which gratuitously was asked before this most recent war, before the iraq war in 2002. george bush mite send troops to iraq. do you agree with that? 54 period she would go to what been. the next question was supposed some are killed. examine them they're asked what if a hundred are killed? it dropped again, but only by three percentage poirchbts and further down as it went along. so it does seem to be -- even though i have certainly been saying from the beginning that people don't understand numbers very well, when you put it this way, maybe they do.

particularly, would you still favor a war if 35,000 were killed? as it happened, that question was asked. and when in the first section it's 5,000 were killed, about 32% said they would still favor the war. in actuality when 4,000 or so american fatalities took place, it was 33 pun. so maybe these numbers hold up better than i appreciate thought. i don't want to spend too much time on it, but there's a decline and sort of bumps and wiggles and stabilization of sorts. one of the things peculiar and one of the things i've been interested in more lately is the unpredictability of american public opinion. and this gives you a bit of a consideration. and, you know, why do people do certain things and after tracking sort of explained it. but it's extremely difficult to

predict in the future. will they buy a hula hoop? who knows. it turns out they did. will they buy the edsel? no. will they buy new clothes? no. >> as you can see, there's ups and downs at various places and they seem to be associated with things which variably, you related to war. though then it bounced back to writ was more or less previously. after the london bombing, there's a spike upwards and that was the terrorist attack in london caused support or seemed to have caused support for the united states efforts in iraq to go up. but it did not go up with the madrid terror attacks took place a year earlier. katrina caused support for the war to go down, it seems. and the argument was basically why do we have a bunch of soldiers in iraq when they should be help with that

hurricane. basely, one of the strangest things was, there was a spike -- on 9/11. it was not something you would overall predict. okay. the -- so that is the basic outstanding of the things we're talking about and the expectations are there if you want to see it. >> it's extremely unlikely you can get support to go back up. the reason for that, if i'm right, is that americans -- you can make a calculation. the war has cost too much. is it worth this? if the war then proceeds to go better, you're still don't think the war is a good idea. you already said it wasn't worth the cost. basically, you reach a point where you see it wasn't worth

it. it's basically like buying a car and paying four times more than it's worth. you may later come to like the car, but you stim think you made a bad that would be sort of the approach. one possibility coming up is the issue of how many -- of what happens with -- what happens if the war does go well. somewhat to my surprise, that actually happened. in 2008, there's a period of the surge and the surge basically causes people to think the war was going better. 16% thought it was making things better, no impact went down, significant progress went up by ten percentage points over that period of time the united states is winning the war went up by 16 percentage points. at the same time, however, the support for war didn't change much at all. has the war been worth it, 36 to 36. war was the right decision,

surge 42 down to 39 and should we stay as long as it takes from 26 to 26. also approving bush's handling of the war, you would think if people say the war is going better, bush is in charge of the war so he should get more points for having aed good war comparatively. that didn't go up either. okay. that's my first point. let me go back to -- there's no way to skip past this stuff except going the hard way around.w

on the shelf. we should bomb syria, we shouldn't. buy the argument, accept the argument. if they do accept the argument. let me give you a couple of illustrations of sort of how this may be happening. it's possible two things are paired precisely. the run-up to the war, the first gulf war that george bush the first did in 1990, war was 1991, and beginning -- this is a trend

line. there are a whole bunch of trend lines that follow the same basic pattern. do you think we should go to war, essentially. beginning in the middle of this about 1998, november 1990, the bush administration started to sell going to war. and as you can see basically nothing much happened. it stayed pretty much the same as it had been before. the same thing happened for george bush the second's war in 2002 and into 2003. the question has been asked for a long time, would you favor invading iraq with u.s. ground troop troops in an attempt to remove saddam hussein from power. before 9/11, the position was basically -- was about 51%. it went up very high with 9/11 then came down and basically stayed pretty much the same the rest of the way through. no what's interesting about this

is that there was a huge partisan division. these are -- i'm sorry -- and what happened in the first gulf war was that there was an intense partisan leadership split on whether support should be used -- whether we should go to war and for the second one the democratic party basically folded and accepted going to war. the vote was 52 to 47 in the senate to go to the first war in 1991 and 77 to 23 in the second one indicating basically that the democrats were now on the same side. nonetheless, the partisan differences were much bigger in the first war -- in the second war even though the democratic leadership was saying we want to go to war. okay. let me turn finally to the end thing here, past all the stuff i did before.

going too far. there we go. i want to conclude with this point. basically the situation we're in now, it seems to me we're basically in the war in iraq, we're in a situation now of debacle. everything the united states has fought for, died for, spent for, trillions of dollars, 5,000 or 6,000 lives, has gone down the tubes in the last year. and so the question is basically, you know, what's the likely reaction to that to be. it seems to me a useful comparison is with a previous debacle which took place with iran -- i mean with vietnam in 1975. 1975 the communists took over south vietnam, completely obliterating the efforts of 55,000 dead americans and the huge amount of money, et cetera, they spent on that war. everything went down the tubes. virtually overnight. in 55 days.

and so the question, what was the public reaction to that, and communism and keeping a defense budget going, and the big change was they no longer wanted to use one tactic. vietnam demonstrated that was an idea. part of that is they were willing to say essentially that

i don't care if communism advances, i do care if communism advances, i want to stop it from advancing but i'm not willing to use ground war to stop it. and if you have to use ground war, i prefer to let it advance. and indeed communism did advance in several countries after the fall of vietnam. i think those three lessons probably hold today as well. it seems to be very likely that the american public will be able to accept this debackle with a fair amount of good grace and go on to other things, shrug it off. i think that's most likely. and the other two things i also hold, one is they're going to continue to support the war on terror compared to the cold war, in other words, still want to do it and there's been very little change in opinion about the war on terror since 2001 as far as i'm able to see, but they're not willing to use ground war to stop the advance of communism. let me just conclude with two final cross tabulations from a

poll at the same poll. this question was as a result of the recent violence in iraq, do you think the threat of terrorism against the united states will increase, decrease, or stay the same. 44% of people, this is just a couple months ago, said it will increase. so that's bad thing. on the same poll, a question, would you use ground force to stop it? only 19% said they would. so consequently it seems to me that the same thing will happen even people are not willing to use ground war to stop the advance of terrorism. they're still opposed to it just as they were opposed to communism and the advance of communism, but not change their strategy but they have changed their tactic. their willingness to use ground war as a technique for stopping it. let me end on that. thanks for your attention. [ applause ]

>> great. i'm just going to turn on the clock here so i can keep track of how long i am. so thanks very much for invite megato this. this is great. i lived in d.c. in the mid '90s and this was always one of my favorite buildings architecturally from the outside. this is my first time inside cato so it's fun to see the inside. so in my portion of the talk today, i'm going to try and make three main points. the first is the view that with my co-authors, chris and peter, the importance of perceptions of success in shaping public support for willingness to use

military force. the second is to rebut some of the criticisms that have been made of our work, particularly some i think adam is going to make following me. third to try to make the case in a modest way that citizens engage in some form of cost/benefits approach when thinking about decisions of using force. and so the goals for today is to really try and maximize some of the difference in our different perspectives. friends who sort of study things related to this area say don't you all mostly more or less agree? sure, maybe at some level, but it will make a much better panel if we say we disagree a lot more. and also i think it's important to try and push each other to make the work as good as it