in the future. it's just not going to happen. what we're doing is we're having design committees we're having outside people review our processes, we're using the corps of engineers the best practices available in industry today in order to make our system better. one thing we have to be careful of, that process started then. and i don't know how forthcoming v.a. was in admitting the process was there. and even now when you ask how much is it going to cost to reinstall, we get terms like, i think, procurement sensitive or something like that. that's not appropriate. >> i agree. we are trying to be more transparent than ever before. and i would hope that since i've become secretary, you've seen an increase in my presence and the transparencies as a department.

i do catch instances where i wish we were more transparent and better about customer service. >> the other thing i'd like to mention. we had a group get together in little rock to discuss reimbursement to providers that have provided outside care. you'll have situations that arise, now with this 40-mile rule that the v.a. owes this money, it appears the v.a. owes a lot of people in arkansas a lot of money. and has not been very forthcoming in paying those bills. it's another thing that makes it such that the trust issue that we talk about. the other problem is, if you don't pay your bills they're going to quit dealing with you. and then, that's the greatest thing. and that really is going to affect quality of care. can you quickly mention that? >> i will, and maybe i'll ask

carolyn to comment. i talked about the five strategies from my v.a. one of them i talked about was improving our internal support services. and going to assured services model where we centralize the bill paying. so that's all the people do is something that we're in the process of doing. we're not done yet. we have more work to do. that will improve the are rates with which people get paid. >> carolyn? >> yes, i would just add that we are tracking this rates of payments and how old the claims are on a weekly basis. and i am pleased to say that what had been struggling for a while is actually improving faster than other networks, but we will keep a very close eye on it. because you said it well, senator, if you don't pay your bills, people are going to say, gee, i'd love to help you, but i have to pay rent to veterans, and that's not going to work. >> mr. chairman. and, again your people were very helpful and did a good job in arkansas.

>> thank you sir. >> mr. udall. >> thank you very much, mr. chairman. and let me along with the rest of the members echo your new aggressive leadership in what you're doing in terms of, in terms of veterans. i really respect the team that you brought in and this more business like approach to what is an incredibly important issue for veterans in my state and across the country. and let me thank you, too for the constructive dialogue we've been able to have moving the v.a. forward as you near the b end of your first year as secretary. as we discussed during last week's visit, new mexico's key issues can be narrowed down to ensuring the veterans have access to care. too often they're prevented from receiving the care they deserve.

many veterans are not able to have their claim adjudicated in a timely manner. in new mexico, progress to reduce the backlog is stagnated. and that's this chart i have behind me here. i think i've showed you that before where we've come down dramatically. we've made good progress, but it's stagnated. and i'm hopeful we can get the resources to make progress in reducing the backlog once again and where it's stagnated, started in a downward turn. with regard to scheduling and the scheduling issue around the veterans v.a., last summer showed we had a lot of work to do to ensure that veterans are seen on time and that the scheduling system was not being utilized in a fraudulent manner. as i mentioned, i asked the v.a. oig to look into this matter. i'm awaiting their findings, furthermore, we need to do more to find creative solutions to

the recruitment and retention problem facing the medical community in rural clinics. that is not something solely a v.a. problem but i believe that it is an area that v.a. can take a leadership role to address. based on the budget requirements and the vha's experience, which would be the best way, and this has been mentioned by several questioners here and some of your answers. which would be the best way to improve access to quality care and expanded fee for service program? or a program which aims to recruit and retain rural physicians and nurses at rural and which helps to expand telehealth? and which would be the most cost-effective way for the american taxpayer? >> well sir, i think we need to do both.

a combination of v.a. care and community care, working together in a network to make sure our veterans get the care they want. i'd like to briefly comment on your chart. >> please. >> i think if you back the time period up, you'd see a more dramatic decline in the claims backlog, and also -- >> go back a couple of years? >> yes, sir. >> and i also think the reason it leveled out was we had 660 additional head count because we'd been working mandatory overtime in the administration to drive this backlog down to zero. as i was doing town halls. i was seeing increasingly, not surprisingly, increasing conflict between labor and management. you did not give us continuing

to drive it down. that straight line is when we took off mandatory overtime. it didn't work we had to put it back on. so we're still doing mandatory overtime, which we've been doing now for several years which is not a good idea. we've got more people in the 2016 budget that we need in order to get the backlog down. we're going to get to zero by the end of the year, but we need those people. also, i think there's a couple of months that are not on your chart. danny, could you update us on that? >> yes, senator. first of all great chart. your numbers are dead on. did a really good job on it, your staff. if we -- >> we should say we published our numbers every two weeks. so we want to be transparent, and we want you to know what our numbers are. >> and we appreciate that. >> you see the dark orange that's your number pending.

that's come down as of right now in april you're down to 40%. 47% backlog, claims pending and 1,500 of those claims in the backlog. you'll see the continued downward slope you saw earlier at your chart for the next three months and a huge dropoff this summer because pretty soon every claim we're going to be working going to be in the backlog and that won't be just for your state, that'll be for the entire nation. >> this is a really important -- >> i've run out of time. just if you could just very briefly, carol. >> i would simply say that new mexico is really a model with dr. aurora at the university of new mexico working closely with us. this is a matter if the veteran can't come to the medical center. we can use telehealth to bring that expertise to the clinicians working out in the rural communities.

we're using it in other parts of the system, as well. >> thank you for your courtesy. >> thank you mr. chairman. and i want to thank the secretary and others for being here today. it's nice to see you, again. as you e noknow, in a state like mine, west virginia, it could be hours in a car sometimes. making this change helps veterans across the country. thank you, i know you're aware of this issue. we've talked about it. there's an outpatient clinic there. it's been closed three times. i think i read it's going to be serving the 2,400 veterans in that area.

i know this is specific. but if you had any other alternatives that you're going to replace that facility, or what your plans are for that. >> i'd like carolyn to comment about the specifics by just simply like to reiterate what i said. our facilities are too old. hvac systems need to be replaced every 25 years. i talked to you about facilities over 100 years old, 90 years old, this is unacceptable. and we've got to decide which facilities to close. i talked about that. and which to refurbish so we don't have these chronic problems. we can't do that with a budget marked down 1.4 billion by the house and the major construction part has been gutted by almost half. >> so i would say that we are hopeful for the moment that we may actually be able to resolve these air quality issues. i also want to point out that in terms of 40 miles from what that

cblock is not part of that calculation anymore. that should offer more flexibility to the extent there are community providers and the mobile unit. those are the plans that we have right now. this will remain high on our agenda. >> thank you yes, it's definitely a problem. and obviously. and i understand the facilities. i would just briefly ask you. and i wanted to ask you this. this is my last question because i ran out of time. but since you were on it on the facilities, you mentioned excess properties, 336 buildings are empty. you said you need help with that. how do we help you that? it's not just budgetary. is it statutory? >> the public's put forward what i would call a civilian brac. to have an up or down vote across the federal government, i think that's a brilliant idea. we've got to become more efficient. i would suggest it be passed and we go at it.

>> you mentioned these are my v.a. regions. >> yes ma'am. >> and dr. clancy mentioned vision. so this is v.a. 101 for me. is it gone? >> we've started a process where we're aligning the visens and seeing if there's an opportunity to reduce the number of vizons. and this is a huge issue in accountability. 91% a new lich team member. we're really weak on leadership right now. we have new leaders in place. and what i don't want to do is reduce the spans, increase the spans of control so much that we take immature leaders or leaders with less experience and put them under more pressure.

so what we're looking at right now is a modest reduction in the visns and align them to state boundaries. >> i notice we're in the same, my v.a., three different visns, which makes no sense. >> that's one of the things we want to fix over time. >> and the leadership issue, the clarksburg v.a. in clarksburg, west virginia, has, unfortunately lagged behind as one of the top people who had the biggest wait times. or just had a leadership change at that v.a. are you seeing anything yet? too early to tell? do you have anything to report there from clarksburg? >> i would be happy to follow-up with you on that. i want to make a point for you and all of your colleagues that we are tracking the access in quality issues on an almost daily basis. but i'd be delighted to follow up. >> okay. well, thank you for that. >> we would be happy to invite any of you to come to our daily stand-up that we do where every morning we review the data.

>> okay. >> and take action. >> all right. thanks so much. thank you. >> i know the chairman is working with dod so the two can share medical records electronically, but progress, as you know has been slow. gao specifically cited the lack of progress as an issue when it added v.a. to its 2015 high-risk list. according to gao, quote, the two departments have engaged in a series of initiatives intended to achieve electronic health record interon rablt but accomplishment of this goal has been continuously delayed and has yet to be realized. the ongoing lack of electronic health records, interon rablt limits the v.a. clinician's ability to readily access records and so on. so what kind of progress are you going to be making? and when can we expect for you to be off the goa high-risk list?

>> well, first of all i -- when i met with the head of gao, i asked to be put on that list. with the crises that have occurred, i that thought it was appropriate we are on the list. >> i would like to offer, we would be happy to come to your offices and demonstrate the inner operatability. and once you see it, you come more conversant in the progress being made. >> very briefly, if you wouldn't mind. >> yes, sir. >> from a standpoint, we've been hitting on three levels. the first one is moving the data within the existing systems. and we share more data than any health care system in the nation or in the world. our future is how do we get all of the data in a single view?

and that is the demonstration that the secretary offered. where today you can now see all the v.a. data for any medical center and dod data as well as third party provider data in the same screen. so the data's been normalized the providers can look at it, and they can actually make decisions based upon a continuum of time in terms of what data -- >> so what remains to be done? >> so the two next things that need to happen is the viewer that chose that data is just for viewing. we're not able to actually go in and change the data. that's the next generation. >> is that a data base breakthrough? doesn't sound hard. >> it's a two-part. the first part is making sure there are common standards. >> okay. >> so working with onc to come up with national standards where there are no national standards, we work with dod -- >> clinical standards? >> database, so we have the same units, same definition. a lot of effort over the next couple of years to make sure the right standards are in place.

the second piece is to make sure the tools there that shows the data at the same time, we can start changing the data at either end. and so -- >> time frame for all of this? >> the enterprise health management platform, we are programmed -- >> let me step in here and deliver a threat i've been saying to dod if they insist on having different standards that we will go with just the v.a.'s standards because you represent ten times the number of patients in the population. >> a lot of strong work and if i can bring the third party in the office of the national coordinator. does the standards for third party providers. and with more care going outside, it's knot justnot just the dod but how do we get the private providers in the same standard so their data can come in and be part of that continuum?

>> so start to finish, able to use this work as you're moving along. what's your total to completion time? >> the enterprise health management platform will be at 33 sites by the end of the calendar year. by the demo next generation. and we'll be adding capability on over the next three years till we phase out what we have today. >> thank you and mr. secretary i want to ask you quickly about the vets center i've talked to you a couple of times about it. this will double the availability of clinical services for about 1.2 million people and tens of thousands of veterans in the sitting county of honolulu. could you give me an update? >> so this is going through the planning process right now. we suspect it'll be advertised late fall of this calendar year. and then the award will probably happen in the first quarter of fiscal year 2018.

so it's going to take time, but we're very, very excited about the excess opportunities. >> you said it'll advertise this year and then the award will go out in '18? or did you mean to say '16? >> no, the actual final award and construction will happen in fiscal year 2018. and the construction will be complete in the last part of 2020. >> okay. my time has expired but i'd like to understand we can take it offline. i'd like to understand why you go two years from advertising to the award and beginning of construction. thank you, mr. chairman. >> thank you very much, mr. chairman. mr. secretary i, too, want to thank you for working with many of us on the 40-mile rule to change it from as the crow flies to actual driving distance like senator capito, i represent a state where as the crow flies

and the driving distance are two very different things. but the v.a. still does not consider whether or not the type of care that the veteran needs is available at a v.a. facility that is within that 40-mile limit. for example, in western maine, there's a university that operates only two days a week. we're glad to have it but obviously, it's nowhere near a full-fledged facility that can provide and meet the needs of our veterans. now, that means that veterans in jackman, maine could go to a hospital, local hospital that's 35 miles away, still a distance but much much closer than going to the v.a. hospital for care.

or they could go to the local community health center right there in jackman to get care if the 40 miles were considered to be measured in terms of whether the service is actually available. the service obviously is not available at a two-day a week mobile clinic. it is available at the community health center and data hospital that's 35 miles away. but these are not options available to our veterans in this area. due to the interpretation of the 40-mile rule. are you giving any thought to being more flexible in that area, as well? >> we're in the process of analyzing it and working with members of congress on what we discover. first of all, the idea that whether or not you can get care from your local facility is actually written into the law. it's not an interpretation.

that was the way the law was written. so if you would like it changed, you need to change the law. secondly our initial calculation suggests that if we were to make that change, the minimum increase would be about $10 billion a year. not over the three-year period of the choice act, but a year, and it could be as high as $40 billion a year. if we opened up that capability or that appiture very veterans. and have the discussion if that's a law change that you would like to make. >> in the case i gave you where the facility is not even cboc,

it's a mobile unit open only two days a week, it just doesn't seem like a reasonable interpretation. >> there's a middle ground point we can take to in a sense change the geographic burden to give the secretary more flexibility to allow people with a geographic burden of some kind to use the choice care, the community care, and that we're also working on and we'll come back to you with the definition of that and how that will affect and how many people that will affect. >> thank you. >> i also want to associate myself with the comments of the senator from arkansas about slow payment to physicians and hospitals. this is a problem in my state, as well. and the problem is that if the v.a. ultimately denies the claim, the hospital has missed

the deadline for filing a claim for reimbursement to a secondary insurer such as medicare. what happens is the health care provider ends up not getting paid at all. >> it's one of our most important strategies, we have to get it right. >> thank you. >> so there could be respite care for our veterans who are living at home but may be suffering from alzheimer's or other dementias. and that has been in process since october of 2008.

far proceeds you. but that's more than six years ago. and for the record since i'm now out of time, i would ask you to give me an update. this would make such a difference to so many of our veterans and their family members. and it also would reduce nursing home costs and costs that your state -- the veterans the state veterans homes. so i really think this is something that should be finalized and should not have taken six years and still be pending. >> we agree and we'll get back to you. >> thank you very much, mr. secretary. >> thank you mr. chairman, and ranking member for this hearing today. secretary mcdonald, you noted in your testimony that the v.a.'s

really at a crossroads. and you struggle with significant challenges including internal management controls as well as the delivery of safe appropriate care. and we've talked a number of times as i have with dr. clancy about how these two failures have had really tragic results at a particular medical hospital in wisconsin, the v.a. medical facility. and i look forward to working with the members of this committee on a number of steps we can take including legislation legislation legislation. dr. clancy, your clinical investigation into -- into the v.a., you have initial and

interim findings and i know it's ongoing. but with regard to opioid prescribing, you found it was double the national average when it comes to diagnosing concurrently which is an unsafe practice at the v.a.'s own clinical practice guidelines for opioid therapy warns against. one of the patients prescribed both of these drugs if you believe the v.a. adequately managed the implementation of the clinical practice guidelines for opioid therapy at local v.a. medical centers.

>> i'd say we made a good start and that's what we're doing right now. the initial approach that predates both of us to start at the network level and then go down to the facility. and if we had a chance to brief you and your colleagues, this is now getting down to the individual clinician level because we can do a much much better job. the irony of course is at that facility, toma, you are -- veterans are less likely to be on narcotics than in the network or the national average but if they're on them they're getting very high doses. and far more likely to be on benzodiazapines. one is as you would expect to reduce the use of opioids probably were most successful with those veterans struggling the least. and what we have now is a group of veterans with the most challenges with chronic pain and

other complications. i think we desperately need to figure out, what is the risk point at which someone someone transitions taking narcotics sometimes safe for low back pain. is it a month? a couple of months. the academic detailing initiative that has now been mandated and will be required for full implementation by the end of june. >> i want to follow up on two points you just raised and then answer. one, you know, one of the problems was the dangerous prescribing practices were considered within the bounds of acceptable care.

-- do you believe that the current prescribing guidelines which were last updated in 2010 are due for an update? and then the second question and may have to wait for a second round relates to driving these down to the patient level and involving patients and their families protocols. >> so two quick responses happy to follow up with more. first is that the guideline which was developed jointly will be updated this year. they're going to be starting that process this fall. we know that practice guidelines need to be updated about every five years absent some kind of new breakthrough evidence. that's the first thing and the second thing is that we now require that all patients on narcotics actually sign an informed consent and that's part

of their medical record every year. i would say that's a down payment on the kind of thing you just referenceded and happy to follow up further. >> thank you for calling me. first of all, mr. chairman chairman kirk and senator tester, i would just really like to congratulate you and the work you've been doing in v.a., you've had the usual sense of bipartisanship that's been characteristic of this committee and both of you have been fighting for our veterans. the vice chair the full committee, i want to thank you for the job and do what i can to get you a juicy allocation. >> i would like to, first of all, say hello to secretary

mcdonald and to his team here. i'm going to engage, though, in a bit of a maryland question. thank you for the job you've been doing but you've got a big job and i think you're finding under every rock is another rock. and we found the same thing in maryland. i asked the inspector general of the v.a. to investigate claims that have come to my attention in my constituents somebody who didn't get mental health appointments and then later committed suicide. it was not me to finger point but to pinpoint and the inspector general. the facilities in maryland

didn't follow the outpatient feeding policy, that they needed to comply with policies related to basic protocols or mental health services. what the inspector general did was come out with nine specific recommendations. rather than taking the time of the committee to read them, you know them. i had the report here now. could i have -- can i have your commitment that you'll do whatever you can to follow up on the recommendations? >> yes, ma'am. i'm a big fan of the inspector general and the work the inspector general does. when i was confirmed, i had, i think, about 1030 i.g. investigations pending. i think we're down to something less than 70 now. so they're still coming out, and most of them date a year to two years ago. but we take them very seriously

because they're an -- and we remediate every finding they come up with, and we will certainly do that in the case of maryland. >> did you want to say something, dr. clancy? >> no, i just added to exactly what the secretary said. we will follow up on this closely. >> are you familiar with this? >> yes. >> some of it is kind of surprising. first of all i appreciate it and look forward to staying in touch in the follow-up recommendations. they're not only for maryland, but they're also for the rest of the country. like home feeding tube protocols, mental health response time protocols, the basic really bread and butter. >> the other is the question related to choice, the implementation of choice and i've been an advocate of that.

have you all covered that in the questions? >> yes, ma'am. somewhat in my -- but go ahead and ask and we'll fire away as quickly as we can. >> we've also covered the replacement that's been stripped out of the house budget. you're replacing perry point. >> yes we had in the 2016 budget money to replace the community living center in perry point. and that was stripped out of the house mark-up. >> well, i would like to mr. chairman mr. vice chair talk with you about this. this is a facility oriented to mental health. and it takes care of veterans with significant mental health challenges as well as alzheimer's unit. some parts of that building are oh my gosh, preworld war i.

and i won't ask the committee to come up if the staff would -- i think it's a compelling need. and we'll -- >> we do too. >> but on the choice card, i understand that, and it's a program that i supported to shrink the waiting list. but i understand of the 8.5 veterans that have been issue choice cards, only -- less than 1% have been authorized care, none v.a. facilities. could you give us the status of the choice program? is it working the way we hoped? if it's not working is it bureaucratic delay? what's the issue here? because this was meant to be an opportunity. particularly -- >> first let me start, senator

with a thought that community care is important to the future of v.a. currently today, even before the choice act about 20% of our appointments are community care, meaning outside the v.a. we haven't had a number of veterans go outside the system and use the community care. we've redefined the 40 miles, how you measure the 40 miles driving distance. we think that will double the amount of veterans using the choice card. we think that's a big improvement. we're also looking at other improvements. we're doing marketing, and we're doing websites. we have a public service ad we're writing letters, making sure they understand the system. many of the cards went out over the holidays, and admittedly, people don't look at their mail over the holidays. marketing is necessary. we're looking at everything we

can to maximize the impact of the choice act. >> well thank you. my time is up. i would just say to my colleagues the choice act does offer opportunity. and perhaps you could use the 535 members of congress. our news letters to help trub dor that. we hear the complaints, we'd like to be able to share with them an opportunity. >> that's a great idea. not political, nothing political, but really about this opportunity, particularly for the primary care that this could provide. >> we'd love to join you in writing letters, we'd also love to put a link on your website to the choice care website. anything we can do to increase communication. we'd love to work with you on that. >> i think that would be fantastic. thank you very much for letting me come in. >> dr. cassidy.

>> listen, a friend of mine, tells me that the budget for treating hepatitis c has been exhausted. that currently, the only folks that can access the medicine used to clear hep c are those with cirrhosis. if you have cirrhosis, that's great. but really, you want to catch it before it gets to cirrhosis. once you have it, you have a lifelong risk to cancer. first, any comments on that, then i have a follow-up once that asked. >> as you're aware the treatment for hepatitis c is krr expensive. in the private sector, it's roughly $1,000. >> a pill. >> we get it for about $650 a pill. so our treatment is cheaper and arguably, we have the best protocols of any medical system. so we do want to use it. but it has become a huge

proportion of our budget. and as a result of that, we've asked for incremental money in a supplemental appropriation for hepatitis c specifically. because i think it's a moral and ethical treatment. we know what to do and we have patients that need it. because our population is disproportionately has hepatitis c. and we can't use it. carolyn, you want to go ahead? >> sure, we are doing a far better job than the private sector in terms of screening and identifying veterans who have hepatitis c and actually getting them identified and so forth. we have a cure rate almost twice as high. >> it's about 90% in the private sector. >> but the proportion of eligible veterans who have been cured. i used the wrong terminology. >> just a follow-up. the fellow told me listen, what

we're told is send someone out to get their prescription from an outside provider which would trigger the choice act fund of money, but then they can get their -- once they have the rx, they can get the follow-up in the v.a. you alluded to this. if the pot of money for the choice act is not being used for pharmaceuticals we cannot -- that's not fungible, i'm gathering. we can't say, listen, no one's treating hepatitis c except the v.a. docs so let's let them access the pharmaceutical portion of the money. is that correct? i'm asking. i don't know. >> your point is correct. that the inflexibility of moving money causes us to try to do different things with different pots of money. so by sending one out, we can

use the choice care of money and get them treated whereas if they were internal given our budget issues in the pharmacy, we may not be able to treat them. >> so the pharmaceutical portion of the patient's care is under the choice act. it's also the pharmaceutical? >> our doctors have very, very strong opinions because we have we would refer eligible veterans to a community provider but they would come back and get the medications from us, which we think would be -- it would be what we pay. >> but going back to your protocol, if you've got a good property come of whom to treat and whom not to treat. you're going to be followed up

here because ef with the better protocol for management. it's critical at the outset. should we treat this person and have them counselled, et cetera, is there no way around that? >> we're trying to get as many veterans access to this life saving treatment as possible. this probably wouldn't be the ideal design. it would have some payoff i think, of expanding the capacity in the private sector to take care of other patients with hepatitis c. but it would require a lot of very close coordination back and forth between v.a. docs and docs in the community. and it wouldn't work everywhere. it's not going to work, for example. >> there's no way for the v.a. doc to access that choice account for pharmaceuticals. you see, it almost seems like we're trying to really -- >> right now, that's not the case. and it gets back to the secretary's point about inflexibility. >> i yield back.

>> we would not need a liver transplant as i know. it's about $1,000 a pill. a liver transplant is about $300,000. if we can avoid curing the veteran, it's a much better outcome. there's four stages with cirrhosis. you really want to catch in that third stage. the third stage slides into the fourth. so if there's any way to expand coverage, and i was going over and i thank you for your indulgence. >> mr. chairman, could i just -- for speaking as vice chair here. >> i have referred to -- >> oh. first of all, there's the medical reason of staying with one place. in other words, the v.a. is your medical home. and it seems, then, this sending

them out is because your inability to have flexibility in money. so here is what i'm suggesting to my leadership here. i'd like to hear what are the -- why -- what is it that you need from us to give you the flexibility to do that? and number two what are the impediments to do that? either we have to go to authorizing, could we do language here. could we do something because it would seem patient/doctor relationship, you want a medical home. >> yes. >> you actually get these pills at a cheaper price because you can buy in bulk. >> correct. >> and now there seems to be just bureaucratic rigidity maybe based on our law or something that did. so i would -- in both your capacity and with the

concurrence of senator cochran, to talk with you about this. i think dr. cassidy you've identified an excellent point here. >> mr. secretary, you look like you're -- >> well, this is a bigger issue -- ma'am, this is a -- this is an important issue for hep c because we're putting our doctors in the position of making decisions about somebody's life or death, whether they go to community care or our care. but this is an important issue for the committee in general because once we decided the choice program -- from choice care to v.a. care. yet, we've introduced the invisible hand of adam smith allowing the veteran to choose. and i don't have the ability to move money to care for them. so my biggest nightmare is that somebody goes for care and i have money in the wrong pocket. you wouldn't run a business this way. >> well, can you help us? >> yes, ma'am, i'd love to.

i'd love to. >> well, i would like you to communicate with the chair and the ranking member who will then work with the leadership at the -- >> we have talked with both of them. and they're both supportive. >> i think senator cassidy's brought up a great point and you've hit it right on the head. and i think the challenge is going to be we're the problem. congress is the problem on this. and the challenge is going to be congress pointing fingers at the secretary saying you didn't promote enough. both directions depending on where the veteran demand is. thank you for all of you for taking so much time today. we probably have exhausted for the implementation of the choice program. but let me just add another wrinkle for you from our

experience in connecticut for you to ponder as you're thinking about how to implement this in a way that works. you certainly are going to have to prove that you have extended the reach of the choice program. to everyone that deserves to be under its umbrella before you're going to get the ability to transfer money. and so let me add another way in which that may happen to your laundry list. it was largely meaningless in the state of connecticut. when it moved to 40 miles by way of car travel, that helped. probably not exclusive to connecticut, i bet you it plays out in places like chicago and los angeles. which is that often the 40-mile car ride brings you into new york city. which is a route that veterans from many parts of connecticut are not going to make.

and frankly, should not make. but because they are technically 40 miles away from a new york v.a. facility, they don't get access to v.a. choice in their in their hometown because they technically could get in their car and wait in traffic for three hours to try to get into manhattan or queens or the bronx. i know this is tough to solve for because what you're essentially trying to figure out is adding the ways in which people commute to the -- to the very basic numbers that you've assigned based on mileage. but is this something that you're thinking about in terms of how you make sure that you're bringing as many people into the program as possible? >> yes senator murphy. we're looking at something called the geographic burden statement in the choice act and allowing the secretary to have the flexibility to determine that geographic burden.

and that would solve the problem that you're describing. and so, we're working with the interpretation that currently exists. we're looking to reinterpret it, and we were going to work with you on that. >> okay. good. thank you very much. work with you on that. okay, thank you very much. >> west haven our facility first of all has been a really great facility for veterans in connecticut. notwithstanding the wait times backlogs accounting scandals in other vas. we've been able to get veterans in pretty much on time to west haven. they've done a really phenomenal job there but it is an old facility it's got an h vac system. it's still got ward style bedding in the hospital. no parking which is a big deal in connecticut. big deal everywhere. so if you don't get the ability to transfer the dollars to the extent that they are unused by va choice, where else do you go

for these kind of capital dollars? you're just going to have projects that simply aren't going to get done and dollars that are going to go unused potentially if you don't get this transfer authority? >> that's exactly right. we have about 70-plus line items that money is not movable from one to the other. as we talked about the house mark-up on the construction bill, virtually cut it in half. eliminating many of the projects that are very important to us. we don't have anner an alternative. it is ironic to me congress passes laws to tell us what benefits we need to execute to give to veterans. we're all for that. but if we don't get the money to do it i can't make the two match. and i think when i look back at what happened in 2014 to the va before i became secretary, i would say it was a total mismatch of demand versus supply. you would not run a business that way the way that an agency has been run is working to a

budget, not working to requirements. not working to what customers needs are. so i'm going to change the department, get us much more focused on veteran needs. i need the wherewithal to do that. i can't print the money myself. so there is a choice for congress. the choice is decide some different benefit profile for the veteran or provide the money that's needed for the benefit profile you've already approved. >> i have a long question but i'll save it for the second round or for the record. thank you, mr. chairman. >> just very quickly because i've got to go. i've got several questions for the record on billings regarder er in mental health. we'll look forward to the response. thank you for your service. >> thank you, mr. chairman. secretary, welcome to the committee. dr. clancy. and i appreciated the

opportunity that we had to visit last week as you kind of walked us through some of the changes. i was so appreciative that you took the time to visit with katherine gottlieb who of course is not only an alaska leader but truly a national leader in innovation and working between systems, federal systems whether it is ihs and nba but to really provide for an innovative level of care. i'm excited about this proposal. mr. chairman and ranking member, and to our you aaugust vice chair -- she didn't hear that -- i do think that at some point in time it wolfnderfully instructive for this committee and those around the country to understand the very innovative models we are utilizing in alaska where given large spaces and limited facilities, we are figuring out

a partnering through systems, working for the i had. ihs, working through our many times our community health centers and it is providing a level of service to our veterans that is immediate. we're breaking down some silos. i think we can look to some models that may work in rural parts of our country that will provide the ben if its that our veterans have so honorablebly earned but in a way that is -- is good care. we call it care closer to home. i don't know about you, but when i'm on the road, i'm always sicker than when i'm away from home. if i can get back home where you've got family and with our native people being with their native foods, being in a place

that is comfortable. so it's something that i'd like to talk to the committee about further an let you know what we are doing. in that vein, secretary and dr. clancy clancy, you can also jump in on this, we do have these partnerings that are going on and i think it the range of choices is good but i also recognize that we are still offering range of choices within systems that still have their structure. i worry about moving of records and sharing of data and really making sure that these separate rules within these differing programs don't cause more confusion. and thus limit our veterans in terms of their abilities to access these. so either dr. clancy or secretary mcdonald, can you give me any greater assurances to how we're coming along with a more fully integrated system with this very unique model that

we're seeing play out in alaska? >> we have a lot of work to do together to get to a single model that's integrated. let me give you one example. we have five different ways that a veteran can get care in the community. of those five different ways, each one has a different reimbursement profile. so when senator tester and i were in montana and he organized a town hall meeting of providers, doctors hospital systems and so forth, everybody there wanted arch. they loved arch as a system. well, arch pays medicare-plus. choice, pc3 made medicare-medicaid minus. to get to the right integrated system we need to get all the providers on board. to get the providers on board we need one integrated reimbursement system and we'll come together, come to you and hopefully get that passed so

that we can have no question as to get providers on board and veterans having a place to go outside va. >> the sooner that can be done i think it is so the veterans' benefit. >> if i can add, in alaska what is working well is sharinge ing arrangements with services. we're thrilled about that about $10 million from va has gone to those services. >> i appreciate that. know that we want to work with you. i will make one comment. we had an opportunity so sit down and talk about this regional alignment or the re-alignment. i have to tell you, i am concerned because as i look at these divisions, it seems that we're getting bigger. it looks like the territory that alaska is in is almost identical to what the 9th circuit court of

appeals looks like. we've been fighting to break that up for a long time. so i'm just sending the heads-up to you that i am concerned that when you have one region that's covering thousands of miles, three different time zones the concern that the regional offices will be able to provide for that level of care that our veterans expect. i'm sending out the signals. i have several different questions that i would like to ask. we've talked a little bit about how we're focusing on reducing the backlog and i know it's always about numbers but at the end of the day for the veteran, they want to know have you heard me, have you sat with me what kind of care have you provided me. i know that my case workers in my offices back in alaska work hard and we're not pushing them to close out constituent cases boom, boom boom and we're

assessing you on that in that level. sometimes it is hard. but when we have one great success with our veterans it makes our staff feel better like they've really provided a service. i'm concerned that as we focus on, we've got to reduce the numbers, we're forgetting the customer service. and as we forget the customer service, we're forgetting not only the satisfaction to the veteran but the satisfaction to the va employee who gets great personal satisfaction in knowing that they have provided a level of care. they've fixed a vet's problem today. and if they can't feel that they're doing that if they feel that they're j uft processing s, the difficulty in recruiting and retention is going to continue which means that our backlog is going to continue. >> i agree entirely. this is why we're all doing this. it is not because of the stock options you get from government. we are doing this because of the inspirational mission that we have of caring for those that

have protected us. we can't lose sight of that. it is more than numbers. it is the picture of the gentleman behind you. every one of those we feel -- it is exactly the reason i gave out my cell phone number during the first national press conference in september. i take calls every single day from veterans and i listen to them because you got to keep that visceral empathy of what we're trying to do. it is all very personal. >> well with shall thank you for your dedication. thank you mr. chairman. i do have some questions that i will's submit to the record. >> thank you, mr. chairman. also, secretary, thank you for being here today. appreciate it. i've visited with you before about legislation that i've put forward. the veterans access to extended care. it's all about making sure that we can encourage nursing homes to take va reimbursement for veterans by eliminating the small business contracting requirements that they're

currently under when they take va reimbursement but that they don't have to deal with when they take medicare reimbursement. that's a burden that really makes no sense for them. and they even have to undergo separate inspections so there's a lot of red tape, lot of splins ish compliance issues so many nursing homes won't take that reimbursement. just comment, if you would, on how you can help advance that legislation so that we can get it put in place. >> we're very much in favor of it so we'd like to talk to everyone who is going to vote and make sure they vote in favor because we think that that's the way to go. we got to focus on veteran outcomes, veteran customer experiences and there's just so much red tape that's getting in the way of it. since our people are trying to work in a system where they're prisoners of the system, in a sense, rather than working on meeting veterans' needs. we're very much in favor of legislation you have described and want to work with you on it. >> thank you, mr. secretary.

that's very helpful. i recently had a roundtable in my state and many nursing homes were represented there. they said if we could get this passed that they would then look at taking the va reimbursement so i think we'd be very helpful and appreciate your willingness to help. second question for you, it's similar with you been it goes to the health care medical care from local providers. you've touched on it here in a number offy you are responses but i'm co-sponsor -- senator moran is the prime sponsor and there are others of us on the bill be but it is similar. it is the veterans access to community care. you've touched on that and some of the cost factors. but essentially the idea is to get veterans care closer to home when they have to go a long distance to a health center. they may have a cbot. in my hospital we have one va

health center. covers most of north dakota and western minnesota. they do a good job but it is an 800-mile round trip from places like williston which i think is the fastest growing community under 50,000 in the country now. maybe over 50,000 now. i don't mow. but where they can't get that efforts that is cbot we have real geographical issues here. your thoughts on what we can do to address in a way that serves our veterans and then makes sense in terms of dollars and cents to affordability. >> i think job one is to really execute the redefinition of the 40-mile limit and do that as quickly as possible so we can really determine how many people will want to use community care. we really don't know today how many people we want to use community care. we know that the redefinition of the 40-mile limit will virtually double the number of veterans who will take advantage of it. that's what we think, but we need to find that out. secondly, i want to redefine or reinterpret the geographic

burden so that we have more flexibility, i have more flexibility to provide the ability for people to call it a geographic burden and go to community care. then the third thing we're looking at which we talked earlier is whether or not we look at whether we define it as a va facility that can provide that service or a va facility that doesn't. opening up that aperture could potentially be extremely costly, as i said earlier. could be $10 billion a year to $40 billion a year. and of course, the whole choice act, this part of it was $10 billion over three years. so that's a conversation we'll have to have. but we need the numbers. we need some experience to be able to develop that ael gore ism algorithm. >> i think that's a really important area to be a ibl to figure out how to do this. again, if they're in 40 miles of a va health center then that 40-mile rule works pretty well.

but if you have these really long geographic distances it is a real problem because there is a big difference. if they have to have open heart surgery, well sure, maybe that trip, i understand, and so do this they. but there are a lot of situations in between where a cbot can provide and where it would actually be cost-effective for the va too, because that veteran may have to travel one day, get the selves is the second day travel the third day and you're going to pay for both the travel and the accommodations as well as the service. it's not only about figuring out how to do this for the veteran, but i think it can be cost-effective for the va, too, if we do it as you say, if we figure out numbers and how to do it.

there is a difference between carte blanche and doing it in a way that makes sense. thank you for your help and look forwarded to working with you on it. >> thank you very much. mr. chairman. mr. secretary, good to see you again. last year i introduced legislation to expand the caregiver support services that va offers and to finally make the full program available to veterans of all eras. i'm going to be reintroducing that legislation tomorrow. senator collins is my co-sponsor on that. i want to work with you to make sure we strengthen the program and make sure it has the resources it needs to take on an additional work load. i really was happy to see the department requested a significant increase in funding for that program and i've also asked for additional resources for the department to hire more caregiver support coordinators. i want to ask you today, do you know how many more caregiver support coordinators you think you'll need over the next two years to support the current

needs, and to take care of new veterans while eras coming into this program. >> i don't know exactly but i do know we are very supportive of the legislation you've written. we think that pre-9/11 caregiver caregivers should get the same benefits post-9/11 get. i spend a lot of time with caregivers myself. they are the unsung heroes of our nation. many of them have to give up their jobs. >> absolutely. >> and many of them have to purposely not take on work and not take on income because then they would fall out of the program. so it is a real conundrum for them and it is life changing for families. we've got to do this and we are eager to take it on and we're eager to hire the people we need. i've been to several college campuses. there are people who want to join the va to do this job. they're really eager to. we'd love to work with you on the legislation. >> if you can let us know what you think you are going to need

over the next few years, particularly with the addition of this, i think it is absolutely vital so thank you. i also wanted to ask you about the spokane va medical center. as you are very aware the emergency room at the spokane medical center has dramatically cut back its operations because of staffing problems. the medical center has repeatedly pushed back the date to resume full-time operations, and now i'm being told that isn't going to be until next fall. the spokane va has also recently asked for its surgical complexity rating to be downgraded. i'm really concerned about that request and the potential impact on the access to care for our veterans in that region. last year i asked secretary shinseki and the under secretary whether there were any plans to reduce programs and services at the spokane medical center and they assured me there were not. yet we now see this facility being downgraded. the medical center is not getting the job done, so i want to know what you're going to do

to restore emergency services and surgical care for veterans that rely on the spokane va. >> so one of the big challenges that we've had, senator -- we've discussed this previously -- is actually recruiting top-notch -- >> i've been hearing that for ten years. >> yes. well, i'm meeting with the college of emergency physicians either next week or week after that to try to see if we can help with them. american legion also has some idea about how we might work with some of the hospitals in there. we've also raised the available salaries that we can be paid to people there. ultimately if we can't recruit top-notch talent i think we're going to need to explore some kind of partnership between the spokane facility and local hospitals vis-a-vis emergency care. >> well look. this has been ongoing forever and it's not being resolved and it is a huge issue for our spokane veterans. so i want to talk with you again, mr. secretary. we've got to get this resolved, however we do it.

>> while i know it's been going on forever -- we accept full responsibility for it -- i have been to over a dozen medical schools recruiting doctors. i've been to the osteopathic convention recruiting doctors. we are the canary in the coal mine. we see the problem that exists in american medicine. we need more primary care doctors, we need more doctors that will live in rural areas and we need more mental health professionals. we're working extremely lard to do that and to find them, identify them and convince them. then give them a monetary incentive to locate there. we're going to continue to work very hard until we get that spokane facility up and running. >> i really appreciate it. one other question. i just have a few seconds left. right now the vnseterans affairs committee is holding a hearing on va service for women. i want to stress how important it is to prepare for the needs of a growing population of women veterans. i was pleased to work with senator heller to introduce the

women's access to quality care act this year. that legislation will go a long way to helping the va provide safe, private health care for women. va already has a serious backlog in construction but it is the number of women veterans increase, as and they age, there is going to be a need for more space dedicated to gender-specific care. so i wanted to ask you what the va's going to do to meet the treatment space for women veterans over the next ten years. >> some of our budget that was cut dramatically in the house mark-up was slated for women's clinics. we're installing women's clinics in our facilities. we're hiring the gynecologists and other specialties that we need in order to staff those clinics. and to us, this is critically important. 11% of veterans today are women. it is going to go up to 20% by 2017 or so. so we've got to get this done.

many of our buildings, as i said earlier, are over 70 years old. >> they don't have private space for women i assure you. >> and they have single-gender bathrooms. we've got to get this fixed. that's why our construction budget was as high as it was. >> mr. chairman, i am out of time now. i'll submit the rest of my questions but i really appreciate that. i want to keep working with you on this. >> mr. secretary, let me talk about the hippopotamus smoking a co- cohiba in the room. where do we go in your view? >> where do we go in terms of -- >> what is your end state for denver? >> our end state for denver is to finish constructing the medical complex. we would use -- >> i would say finish constructing the medical complex under the supervision of the army corp of engineers. >> yes. they're already on the project. and they would complete the

project with us. and we plan to use the army corp of engineers in the future for major construction projects. >> i'll make it simple for you. my position is cory gardner's position to make sure you work very closely with senator gardner. >> we agree. >> thank you. >> in fact, the deputy secretary was out in denver yesterday and has been there i think seven times since he's come in to position. >> let's go with senator baldwin. >> thank you, mr. chairman. hopefully three questions i can get in this second round. i'm sure there will be follow-up, for the record, also. dr. clancy you were at the field hearing in wisconsin on march 30th. i joined the -- i'm member of the senate homeland security committee that jointly held that with the house veterans affairs committee.

it was -- we heard incredibly powerful testimony from family members of veterans who had lost their lives at that facility or after care there, as well as whistle blowers. now several months into this investigation, even at that hearing we were hearing of more deaths that were unexplained that we hadn't heard before. in fact, i sent you another letter today, not based on testimony at that hearing but somebody who came up to me after the hearing and said, my husband was treated there and i have concerns related to all of those that you've been hearing testimony about. and so i just want to stress how important it is to have the investigation, sufficiently expanded to review those deaths and i want your assurances that the degree that we can follow up on every one that has been reported during the conduct of your investigation that you will

follow those -- follow the evidence where it leads. >> you have my full commitment. absolutely. >> i appreciate that. >> if the senator would yield let me add i would associate my comments with senator baldwin because a lot of illinois veterans would use the toma facility. we want to make sure we fix the candy store, it was called -- >> candy land. >> candy land. yeah. >> on the issue of property treatment for pain, secretary mcdonald, not only do we have to increase -- to crack down on individual use of narcotics we have to better manage.

we're here in the appropriations committee so i want to ask you how the va budget request supports the expansion of complimentary and alternative medicine and wellness programs that would help veterans dealing with accuse and chronic pain. >> as we look at va opioid use which is -- dr. clancy said we closely it is moving down. the reason it is moving down is i think because we are the largest users of alternative approach in the country. we had tremendous success with acupuncture, with yoga with electronic stimulation and we want to continue that. anything we can do to provide a different approach than opioid use we want to do. and as i've been touring all of our facilities, i think i visited about 125 so far.

imooh always i'm always inspired by those people teaching yoga. in one location there was an art instructor who was helping use art as a way to allow people to become themselves again without opioid use. equine therapy in placed like bedford, massachusetts. anything we deem to be a successful program we also want to do. >> i woulded add add we are doing a lot of research in this area to predict better responses to opioid use because that's very, very critical. that gets back to the notion of an informed conversation between a clinician and a veteran, family and so forth. >> right. one final question. we were just talking about the

health workforce at the va. one of the things that i've certainly observed in rural medicine for example, if you receive your training there, perhaps if you were born and raised in a rural environment you're likely to make a commitment in your career to remaining there. i think the same is very much true with regard to the va. in the va reform law passed lat year i authored a provision that included an increase by 1,500 over five years the number of gme residency positions. it is my understanding in this first year of implementation 204 new resident positions were added. i would like for you to give me a status update on the program's implementation. >> so, senator first, thank you

for that additional residency slots because i think that's something that will keep paying dividends in terms of capacity. we didn't actually think that we could start residency positions until a year from this july because of the slow ramp up. however, what we did was go to our existing partners and ask do you have additional spaces. that's where we got the 204 slots. we don't know what the uptake has been. every year for the national match for medical students -- it's kind of like "the dating game" -- primary care slots tend to go unused and so forth so we can get you a report on the 204. match day was just two weeks ago. back to rural care what we're working on is try to figure out how do we work with facilities pand communities that would desperately like to do what you just described but may not have the infrastructure there. how do we do that to make sure we can get them the faculty

support that we need so that the residents that are trained there get the proper education and so forth. but it is a very exciting opportunity so thank you for that. >> we're also pursuing osteopathic doctors. d.o.s. they tend to be more primary care physicians. they also tend to locate in rural areas because that's also where the medical school is. today less than 1% of our doctors in the va are dos.o.s. we're looking at a way to get more d.o.s in order to get more people to locate in rural areas. >> let me call this to a close. we'll keep the record open until tuesday, april 27th so that members may have a chance to submit their questions for record. call it adjourned. thank you.

snchtsz earliery earlier today the senate reached an agreement on human trafficking bill which also paved the way for loretta lynch as attorney general. >> joining us from capitol hill to talk about the deal that was reached on the anti-human trafficking bill, burgess everett, congressional reporter for politico. and burgess what are the details in this bill and tell us about the bottom line, what this means for victims of human trafficking in terms of abortion

services that they can get. >> basically it's been a sort of compromise that's intended to let each party save a little bit of face. the initial dispute was over how to fund a restitution fund for victims and whether that money could be used on abortion procedures for victims. that money was going to come from human traffickers paying fines and than was something the democrats objected to having abortion restrictions on because that was private money it was not public government money which has previously been governed by the hide amendment which restricts abortion procedures. they're going to use money from traffickers and from the government's general fund and they'll have a firewall to make sure fines don't pay for abortion procedures. it is very in the weeds. it is kind of a minor tweak to the legislation but this has been going on for nearly six weeks now that the senate's been locked on this. even though it is a small change, it's been a big

breakthrough because now it lets the parties go to loretta lynch's nomination which has become an increasingly ugly partisan fight. >> especially establishing two funding sources so that makes the democrats happy, makes the republicans happy. why a month-long impasse over this trafficking bill which so many people wanted to see move forward? >> well, the main problem was the bill came to the floor with no opposition and once it got to the floor, democrats said they noticed this abortion provision in there which they said amounted to a major expansion of abortion restrictions. so from there it was difficult for the democrats that didn't have enough votes to strip this abortion language out and republicans didn't want to just cave to democrats. so there were five failed procedural votes in march and last week mitch mcconnell majority leader, had set up another vote that was then pulled on thursday. that was the first sign of progress. now that they weren't going to

any more tough votes that are intended to make democrats shift positions. they said they won't, the vote was going to fail. mcconnell pulled it and that's when the talks really picked up. so it was kind of a quick end to a very long impasse. >> where are we at now? where is republican support for this? where is democratic support? >> my sense is both parties are broadly supporting this. planned parenthood put out a statement in favor of the compromise, praising senators harry reid an patty murray for working on the hide amendment language in there which had become so controversial. so the next step is to figure out how many amendment votes there will be on this. republicans want to vote on some immigration amendments. so they still have some procedure hurdles to get over but the main thing is behind them now which was getting this base abortion language fixed so that each party could support it. >> they're working on this quite a bit off the floor. which senators were involved in that some of the key senators? you mentioned a couple. >> yeah. so this bill was basically

shepherded along the way from the judiciary committee by senator john cornyn, the number two republican from texas and he and patty murray the number four democrat from washington basically kind of sealed this deal and then kicked it up to their leaders, harry reid and mitch mcconnell. and then they basically took it through the caucus, made sure everyone signed off, because they didn't want another embarrassing problem with democrats not noticing another provision and after that sign-off came the announcement was made this morning. but really it sounded like reid in his speech this morning the deal was basically set in stone on thursday. they just needed to check all the boxes to make sure that everyone was on board. >> now burgess what happens next? you mentioned possible immigration amendments we could see attached to this before final passage. >> right now at party lunches the leaders are going through which amendments from each party they want to have votes on for this trafficking bill. i would think the expectation

with any major amendments would be designed to fail because if they are attached to it like david vitter has an amendment on birth right citizen slpship. if that's attached to this bill they're not going anywhere. so if they can vote on this possible tomorrow, though perhaps it could happen today. then to the lynch nomination after that, which could probably take a few more days given opposition from republicans. >> where does her nomination stand? you mentioned republican opposition. she's the longest one to wait for herconfirmation since an attorney general for the reagan administration. >> so all 46 senate democrats support her and five publicly declared republican yes votes. that would be people like lindsey graham orrin hatch mark kirk these -- so there's enough votes right now to get her confirmed. there's a couple of undecided.

rob portman, lisa murkowski on the republican side. so it is going to be close. it is going to be narrow but the votes are already there for her confirmation but there is a question of will conservatives who oppose her position on immigration drag this out because there can be a lot of time wasting that goes on on these votes. maybe harded to get a quick vote on this but ultimately her confirmation looks pretty smooth at this point. >> be following you on twitter. we'll find you at burgessev and also on politico.com. >> thank you so much for having me. she was considered modern for her time. called mrs. president by her detractors. and was outspoken about her views on slavery and women's rights. as one of the most prolific writers of any first lady she provides a unique window into colonial america and her personal life. abigail adams. sunday night at 8:00 p.m. eastern on c-span's original series first ladies influence and image.

examining the public and private lives of the women who filled the position of first lady an their influence on the presidency. from martha washington to michelle obama. sundays at 8:00 p.m. eastern on american history tv on c-span3. as a compliment to the series c-span's new book is now available "first ladies." presidential historians on the iconic lives of 45 women creating an illuminating entertaining and inspiring read. it is available as a hard cover or an ebook through your favorite book store or online book seller. next speeches from the recent new hampshire leadership forum.

>> all right. who said they wanted to vote for -- [ inaudible ] >> stand up. you're stealing my line. last time i went around telling everybody, you know what? it is either about your child or who you want to shoot pool with. what? if you want to go shoot pool, barack obama's your guy. first of all, mitt romney's not going to have a beer. and he's cool and he's fun. and he's going to shoot pool with you. but if you want to get that 26-year-old out of your basement, maybe you should vote for mitt romney.

and people kind of got it. and here we are. thanks very much for welcoming me. a lot of folks i've met over last six months in this room do a lot off q&a. raise your hand if you don't know me. be honest. and find my media people. i don't have media people. time to figure out whether there is a place for a blue collar republican in this field. that's why i've come to new hampshire a half dozen times and coming i guess for another. diane and matt, my friends here who i've met, invite me out. i come. people say i don't know who that guy was but he seemed to make some sense. so i started in the state legislature and i served two terms there. i went to congress with the class of 1994, fred barnes. the class of 1994. the majority makers.

then in 2002 after 9/11 my wife said, you know what? people really value good leadership. you thinking of running for governor. >> i said you know what? bobby kennedy's daughter's lieutenant governor and she's going to be tough to beat. she said you really need to run. when kendra ehrlich tells me to do something, i do it. and we beat bobby kennedy's daughter daughter. i'm here representing all maryland republican governors. now we screwed up because guess what? multi-party democracy broke out in maryland just a few months ago and larry hogan member of my cabinet is a new republican governor of maryland. he gave a state of the state and upset the democrats. you know why? he reminded them why he won. because of 35 40 tax increases of running businesses out of the state of maryland. so i'm here to really answer a

lot of your questions but the reporters here know -- i see some anger here. i want angry. i think we need to be angry but purposefully angry. because we love to talk about how good we are. look at this field we have this talented field. we win think tank battles and we do talk radio well. we love to talk about policy. we watch fox a lot. and somehow we think -- i'm just sucking up. somehow we think that's all good and great but sometimes it doesn't do the trick. in fact in presidential election years it doesn't do the trick at all. so the reason i'm thinking about this and i'm here is to remind everybody here that that anger needs to be directed. because we've lost 5 out of the last 6 presidential election

cycles, the popular vote. we add all the numbers up, it is minus 26 million. we're minus 26 million when it comes to presidential election years. we have proven that we are a regional party. we just proved it a few months ago. we proved we can win when we have no agenda. we said we're not the other guy. we're not the other guy. vote for us this time. we may have screwed up in the past but give us the keys again and the american public was so down with barack obama they did. but guess what? that formula doesn't work in presidential election years. all of you know this but the fact of it is, if the electorate in 2016 looks like it did in 2004 when "w" won, the same racial component, same ethnic component, if that number -- if that make-up shows up, we lose. relose. the country's a changing. the culture's a changing. here's the angry part and why we need to be angry but direct.

what's beating us? what agenda is beating us? what great ideas are beating us? well, try this on for size. the other side denigrates large and successful. they demonize wealth. they spend endlessly. remember, the vice president's words about why that great shovel-ready stimulus didn't work? does anybody remember? why did that $1.2 trillion stimulus not work? we didn't spend enough. we never spend enough. it's always the politics of yes. it is always the politics of more. and you can't disprove their theorem because it's never enough. ever. ever. they exploit class warfare and they're countercultural. joe, the plumber? you didn't build that?

their agenda is countercultural. it doesn't celebrate success. it doesn't celebrate entrepreneurism. it doesn't celebrate an opportunity in society. it doesn't celebrate the folks here that went out and took a loan and started a business in their basement. we used to celebrate that. that's us. that defines us. and that got demonized last time. that got demonized in the form of a hate campaign -- i hate that word "hate campaign" -- whatever it was, that jealousy campaign run against a guy that was wildly successful, turned the olympics around, hired people, gave away most of his wealth. and yet he was demonized effectively. they redefined religious freedom. check the hobby lobby case. president went to notre dame and said keep my hand off the conscience canlause. they took it down until the courts made them build it up.

they marginalized independence. in the first six years of the obama administration social security increased four-fold. do you think meritorious claims increased or do you think just this whole idea of dependence is cool again is taking hold in our society? again countercultural. they ignore federalism. they invent a war on women and people buy it. young women buy it. they bought the notion mitt romney's going to be intercept their birth control pills. that's why they voted democrat. we have to get it. it is silly. it makes no sense. but they do it. and they win doing it. we retreat from our allies, ask poland, ask ukraine, ask our allies in the middle east. we placate our enemies. we create power vacuums. we practice political

correctness. we can't even call war a war. we lead from behind. we preeshach moral equivalency. we send james taylor to paris. i love james taylor. is that an unserious thing to do? is it an unserious thing to do after jordanian fighter pilot gets burned alive, to go out and play golf? i love golf. guilty. republican. play golf. no problem with the president playing golf. who in the white house was in charge of optics that day? what an unserious tone that sends to the world that, a soldier can be burned alive and we have a short press conference and it is 7 iron or 8 iron, mr. president? we look weak. and probably just wrapping this whole thing up is harry reid on the floor of the senate. i know, i know.

it's early. you just ate. but think about this now. think about a culture that allows the majority leader of the united states senate to go to the floor of the senate and just make it up. just make it up. mitt romney did not pay his taxes. he just made it up. did you see interview a few weeks ago when they asked him, what for? did you see his answer? "we won." we won. they won. they're countercultural. it's weak. it started with an apology tour and hasn't stopped. it plays to young women and identity politics. it's not what we're about. and when you think about it, at the very essence of it it's all about jealousy. it's all about separation. and we need to beat it. and that's why we're here. that's why we put these hats on.

that's why we put bumper stickers. that's why we write checks. that's why we go door to door. we are care about not just our country, we care about what's taking hold in this culture. it is a culture war. people ask me the top three issues in this campaign? domestic insecurity, cultural insecurity, and national insecurity. they're the three. that's what counts. i'm a governor. i'm prenl disjudiced to governors. we have great senators. we have great business people. we have successful people. the common denominator of every candidate speaking to you is success. leading. not starting your inging presidency with an apology tour. that's what we're up against. i know i brought everybody down. now it is time we're going to come back. are you angry?

good. so what to do. what to do. first of all let's define them. let's -- everybody understands what i just said for the last ten minutes. i think you agree with it. by the way, just about every candidate here thinks the same thing. we need to articulate it. it's okay to cling to your guns. it's okay to cling to your pluralism. it's okay to cling to your federalism. it's okay to cling to your wealth. it's okay to cling to your success. it's okay to cling to this culture which we celebrate. so let's expose their playbook. let's define opportunity and leadership and u.s. exceptionalism. this is the first president we've ever seen who defined down u.s. exceptionalism. that's not the culture that i raised my kids in. it is not our country. and we're pretty bad about taking credit.

we don't take credit very well as a party. let's -- there are some young people here. i go to colleges and they don't understand sometimes what we've done as a party. every obama gun control initiative is dead. why? republican congress. when was the last party to balance a federal budget? by the way, i sat under chairman john kasich. . republicans controlling the house of representatives. remember a few months ago those ugg gli republicans,ly republicans. they told you they hate poor people. and guess what happened as the republicans stood firm and nobody talks about it. labor force participation increases because people said it's over, we're going back to work. and we don't take credit for it. charter schools, we own school choice. we own the ability of poor kids to go to legitimate schools.

it is not just discretionary. it's a constitutional obligation. we own this. i fought these battles in maryland against the teachers unions. it's a moral issue. we cannot be surprised when we sentence kids to dysfunctional schools and they end up in j skwuchlt juvi. we cannot be surprised. it is immoral, it is unconstitutional and it is unsafe because those kids who do not get quality educations are coming out on the street one day and they make our streets unsafe. we own this issue. we own choice. we should go to every inner city, every rural community everywhere and say you know what? your kid's not getting it? people talk about common core. not a good idea. let's focus on where the problem is. school systems that do not do their jobs. and we stand for and fight for and talk about and believe in and pass remedies for those

kids. we own that issue. criminal justice reform, the new purple issue? we were doing it before it was cool. now everybody's talking about it. it is a little bit nixon goes to china, i guess because democrats are saying well the republicans can't own that issue. we care about people. well, guess what? it's an issue where republican governors have led. i led. other governors have led. it's a fiscal issue and it is a common sense issue. but most of all it's a define our party issue because it's justice. it's all about justice. to the extent those people that were not voting for us understand we're the justice party. we're going to be just okay. with those blue collar votes we've been losing over the years. medicare part d, we don't like to talk about it. republicans held out. it saved billions of dollars. why? we went to a marked mechanism

because we trust markets. as republicans we trust markets. so i've gone on probably too long. i want to leave time for q&a but we need an american bill of rights. we need a freedom bill of rights. just real briefly, talk about an agenda for this cycle for this country, for this culture, for what we need now it's a freedom-based alternative to obamacare because burwell is going to be decided by the right wing supreme court. we should go to the american public and say if you love obamacare, keep it. if you don't love it we have a freedom tern foralternative for you. find a policy that meets your demands for your family and your kids across state lines. guess what? obamacare will be no more in a few years. an immigration bill born of sovereign ty sovereignty and security. remember the president's speech about the southern border?

hey, what are we going to, build a moat down there? republicans want to build a moat. that's an unserious way to look at one of our most serious issues. what happened to sovereignty? what happened to voter identification? why is it racist to require your driver's license? i have seasonal allergies. i blame my mother. they know who i am in maryland. when i go get claratin d. guess what i have to show? that! that. they say, hey, governor show me that. yet when i go vote exercise a franchise in the greatest country the world's ever seen no, no we don't want to see that. it's racist. what? you want to go see eric holder to tell him it's right, it's racist. take your driver's license. you can't get in the department of justice without one.

it's 50 years since daniel patrick moynihan had the guts to say the black family's in trouble. today the white family's in trouble. the brown family's in trouble. american family's in trouble. i spent more times in jails as a governor than most you will your entire life. a lot of them are really bad places you do not want to go. but trust me when i tell you this, the common denominators when you that ukalk to those kids, it never changes. i didn't have a father and i started with marijuana and i'm not preaching. i'm not saying anything. i'm just telling you what my experience has been over 20 years of public office. i didn't have a father, i didn't have that male influence, and i started with marijuana. now what's left of my resume is probably the most important job i've had. not governor not congressman, not member of the state legislature. defensive coordinator for the cape st. claire 100-pound

cougars. i started is as linebacker coach. i got promoted. i've coached my now 15-year-old high school safety slot for seven years. i coached those kids all the way through. best job i ever had. but after coaching kids all those years, believe me i saw one thing and all of you know how true this is. you watch a bunch of 10-year-old boys play for a bit, you can tell which ones do not have a father influence. it doesn't take long and it is not real hard. this is an epidemic in our society. it's not subject to a federal program. there's no federal fatherless bureau i'm talking about. it's a cultural value that we need to stop the bleeding and talk about every day in every way as a party and as leaders.

how. time do i have? matt? >> seven machines. >> you're tough. >> epopen up for q&a but just sort of a final thought here. we built that defines us. the fact this president said you didn't build that tells you all you need to know about the mindset controlling this country and this culture today. you did build that. we built this. it is okay to cling to your guns. you're losing your western values, your federalist values. we should be unapologetic about it. third, an opportunity in opportunity awaits us as a party, as a party of leaders. if we're willing to fight for it. thank you very much.

>> hi, governor. thank you so much for taking my question. thank you for all you co. i'm alexandria knox. i'm 2016 state rep candidate and i believe unions have too much power in this country and too much power over our government. what are your plans to do as president of the united states to control some of that big union boss power and to do something about getting right to work pass nationally. >> well, guess what? whoever the president is, whatever party the president's from, controlled the nlrb. it controls the agenda. this norb is a subsidiary of

organized labor. you see it intangible ways every day. republican will reflect our values, opportunities. not hard. sir. i'm thinking we have an agenda. we have values. we may have the highest office in the land. but i'm wonderfuling how successful we'll be if the progressives -- the national labor board education, they're stacking the courts with progressives.

often, these bureaucrat, there's no accountability to law. they actually all show contempt for congress. and they have no accountability and they show contempt for congress. and they're not held to the constitution. even the epa, for example, themt the power to tax. that's congress' responsibility. so how would a republican administration try to curb these unelected in some case, unnamed progress progressive bureaucrats, wealthy executive branch in what they want to do to the american people? >> norb changes overnight. that's direct in response to last question. that happens overnight. it's easy. done.

here's what i don't about 3 million republicans not voting for mitt romney. inexcusable. don't wabt to hear anything about proportion, guns, anything and he's hooirs why. barack obama is is going to name hundreds of federal judges and those additional four years, hundreds more. they will make decisions every day that limit your freedom and you'll know about it. so, sir, that's a second part of my answer. if for no other reason make decisions decisions, third r ux sometimes we forget this president besides one day of decision he's over. he loses every time he does something extrajudicial extra legislative, executive. he loses.

the courts have giffin him a long losing streak and i know it sometimes slow, sloppy, doesn't get to where we want to be. but it's the truth and to the extent you have judges who want to be judges who interpret the law and are not frustrated members of congress, that alone is the reason to elect. i'll repeat it. three seconds? what? all right. >> all your comments are well put. >> thank you. >> we have a tendency to be nice guys. i'm tired of being a nice guy. you look like a nice guy. negative ads work. we haven't been doing that. let's grab them by the throat and get down in the mud and do what they're supposed to do. >> my work here is done, now,

that's directed anger. that was my goal. directed anger. thank you, sir. i think we're out of time. thank you all very much, god speed, we'll see you next week. thaupg all. thank you. i want to thank dan for the more than kind introduction. it is wonderful to see all of you here today. i see so many friends in this room and to those who aren't from new hampshire, welcome to

the live free or die state. we take our politics very, very seriously. and the it's just a great day to see such a tournout for the first ever first in the nation national republican leadership summit and i see my colleague congressman here, i want to thank him for his incredible work and thanks for being a great partner. but i also want to thank all of you who made this possible. for her leadership. for the hard work she has done to bring this summit together and i'm so glad to have her leadership for the republican party. this is not easy to put a

conference like this together. i had a really enjoyable moment in the back with the staff at the crowne plaza and we are talking about what it means to be a mom and multitasking and all of that so i just want to reach out to the staff here who are helping and serving us today and say thank you for being here. we appreciate what you do. as i look at all of you here today, i think this is a testament to the unique and important role new hampshire plays in the presidential process. we're celebrating a hundred year of the first in the nation primary and you know daniel webster once said in the mountains of new hampshire, god makes men. well, i'd like to add to that that in new hampshire, we pick presidents. one of the things new hampshire's so important is that everyone gets a fair shot. and we take very seriously our

responsibility to ask the hard questions. to go to the town halls, to really find out what these candidates stand for and what their vision is for the united states of america. and what they're going to do to turn this country around. from the failed policies of barack obama and where we have been over the last six or seven years. i want to make sure shah whoever wins this presidential nomination to represent the republican party that that candidate shares our common sense values here in new hampshire, our love of liberty in new hampshire, our commitment to our men and women in uniform. and our commitment to building a

brighter future for not only everyone in this room but my children, your children and our grandchildren. you've heard from a number of candidates. you're going hear after me from many more including into the evening, so what i thought i would talk to you about today, many of youp i serve on the armed services committee. i serve on the homeland security committee. and from my perspective, as your senator, i think one of the most important issues and challenges facing our next president is is how to keep america safe. we need a commander in chief, a commander in chief who is going to ensure that america leads in

a way that keeps this country safe radical islamic terrortists who would seek to harm us who would ensure that instead of where we are now our enemies around the world understand that you should not mess with the united states. and that our friends understand that we are a reliable friend and that we will stand with you and together, but today, where we are, i think we all understand that that's not what is happening. under the current administration. in fact, president obama promised when he ran for president in 2008 that he would